Triage: Patient responsibility with waiver, or write off
The plan does not pay a chiropractor for this particular service. The provider type wall does not move, so resubmitting the same claim is pointless.
Classic examples: plans that cover CMT from a DC but not exams, X-rays, or therapies. With a proper waiver on file the PR version is patient billable. The CO version means the payer holds the provider responsible, usually because no valid waiver existed.
A Medicare patient receives an adjustment, an exam, and electrical stimulation. Medicare pays the CMT line and denies the exam and the therapy with 170 style provider type logic, because Medicare pays chiropractors for spinal manipulation and nothing else. With a proper notice on file the excluded services are billable to the patient at the practice’s rate; without one, they are the practice’s loss.
Medicare’s coverage of chiropractors extends only to manual manipulation of the spine to correct a subluxation, per the Benefit Policy Manual, Chapter 15, section 240. Exams, X-rays, and therapies furnished by a chiropractor are statutorily excluded, which is why they deny regardless of documentation quality.
Cervica distinguishes the PR and CO versions in the worklist so staff bill or write off correctly, and the intake flow captures the waivers that make these balances collectible.
General information for billing teams, not legal or payer specific advice. CARC definitions belong to X12; payer policies vary and control. Verify against the payer contract before acting on any individual claim.