Referrals to Other Providers

Section 3.5 of the Participating Chiropractic Agreement states that chiropractors are expected to refer patients to other Participating Chiropractors or Participating Providers. Included are Participating Durable Medical Equipment (DME) providers, Preferred Physical Therapy and Occupational Therapy providers, Preferred Medical Doctors (PMD), and any other specialty for which there is a network. Find a provider in their respective network, with "Find a Doctor." 

Professional Courtesy and Collection of Copayments and Deductibles

Professional courtesy and the requirement to collect copayments and deductibles is addressed in section 4.5 of the Agreement. Chiropractors may waive a particular copayment or coinsurance amount for reasons of professional courtesy. If the chiropractor, except in cases of professional courtesy, does not bill the patients these amounts or does not make a reasonable good faith effort to collect, or if the chiropractor waives or represents that he waives these amounts, the Agreement has been breached and participation may be immediately terminated.

Professional courtesy may apply when a chiropractor treats his own employees or family members of his employees, or other healthcare providers. This list is not intended to be all-inclusive, but providers should use professional courtesy at his/her own discretion. It should not be used as a marketing tool by applying it to selected "groups" of people. When professional courtesy is extended, the fees for the physician treating the patient is usually made at a reduced rate, or the copayment may be waived.

Treating Family Members

Professional courtesy does not apply when a provider is treating his/her own family members. Blue Cross and Blue Shield of Alabama does not provide benefits for the professional services of a provider rendered to a member who is related to the physician by blood or marriage or who lives in the provider's household. Payments made in error on these claims are subject to refund recovery.

Temporary/Locum Tenens Coverage

As a general policy, the chiropractor rendering a service should bill with his or her individual provider NPI. In temporary coverage/locum tenens arrangements, the chiropractor should make an effort to ensure the covering chiropractor is part of the Participating Chiropractic Network.

Chiropractors should keep in mind the following:

• If a non-participating chiropractor must be used, the participating chiropractor may bill for the non-participating chiropractor under his/her provider NPI if the services are provided on a temporary/non-routine basis such as locum tenens.
• If the locum tenens (or covering chiropractor) replaces the chiropractor for more than two weeks, or on a regular, ongoing basis (for example, every weekend), the covering chiropractor should be credentialed through Blue Cross to bill (file claims) under his or her own provider NPI. In this situation, the patient’s medical record should reflect this signature style: “Doctor X covering for Doctor Y.”

The modifiers below may be submitted with the procedure codes on a claim to indicate that someone other than the primary chiropractor is involved in patient care. Although we do not require these modifiers on the claim, any information that can communicate involvement by another provider is helpful in processing.

Modifiers:

• Q5 - Service Furnished By Substitute Physician Reciprocal
• Q6 - Service Furnished By a Locum Tenens Physician