Proper Use of the BCBSM Advance Notice of Member Responsibility Form

Also: Use of the ANMR Form and Massage Therapy Benefits

Transitioning Patients to Chiropractic Maintenance Care? Use the ANMR Form

By:       Stephanie Davidson, MAC Insurance Relations Manager

Many chiropractic patients rely on chiropractic maintenance care to prevent recurrences, remain pain-free, and maintain wellness and/or a higher quality of life. Maintenance care reflects a shift in treatment to a preventive approach designed to prevent new episodes and maintain current levels. As practice management consulting and coaching expert Mark Sanna, DC, put it in an article in Chiropractic Economics magazine:

“Acute care has, at its core, the expectation of significant improvement in both subjective and objective symptoms, and that’s according to Medicare… Maintenance care, on the other hand, is a level of care at which we do not expect any type of symptoms to significantly improve; our acute care has achieved its maximum effect, and once we have reached that plateau and patients level off, it is maintained at that particular level… Chiropractors have to learn when patients are showing significant improvement in signs and symptoms and when they have reached that plateau for benefits in acute care. That’s when it is time to move to maintenance care.”

Transitioning From Acute to Maintenance Care: Using the BCBSM ANMR Form

Unfortunately, while maintenance care can be extremely beneficial for patients, there are very few Michigan insurance companies that will actually cover it. These companies sometimes call it “routine” or “Medicare non-covered spinal adjustment” care. No Blue Cross Blue Shield of Michigan policies cover such care. The Blue Cross Advance Notice of Member Responsibility (ANMR) Form should be provided when the patient transitions from medically necessary care to non-medically necessary (active chiropractic to maintenance care). 

Please note: The ANMR form can also be provided when the patient has Therapeutic Massage (97124) benefits, but the service is not covered and payable when delegated and performed by an LMT. Please see the accompanying article below for use of the ANMR form in this situation.

Active to Maintenance Care Transition Steps

1. New patient (or established patient with a new complaint) comes into the office.
2. Active care treatment plan developed. This should include:
   1. Diagnosis including functional decline in objective measures
   2. Recommended level of care (duration/frequency of visits)
   3. Specific treatment goals
   4. Specific treatment methods (adjustments, exercise, traction, etc.)
   5. Objective measures to evaluate treatment effectiveness
3. Once symptoms remain stable or progress in reducing symptoms is no longer shown, transition patient to maintenance care.
   1. Discuss further care options with the patient.
   2. If the patient wishes to continue care, they must pay out of pocket.
   3. Be sure to have the patient sign the ANMR form before any subsequent care begins.
4. Maintenance care plan commences.

Transitioning Back to Active Care

If the patient sustains future injury/loss of function, and his or her condition once again meets the criteria for active care, follow the steps above.

Documentation

The MAC Insurance Relations team recommends following Medicare documentation standards, and BCBSM documentation guidelines that can be found on Availity in the BCBSM provider manuals. The Medicare guidelines are as follows:

New Patient / Established Patient with New Complaint (initial visit)

1. History
2. Present Illness, including:
   1. Mechanism of trauma
   2. Quality/character of symptoms
   3. Onset, duration, intensity, frequency, location, and radiation of symptoms
   4. Aggravating or relieving factors
   5. Prior interventions, treatments, medications, secondary complaints
   6. Symptoms causing patient to seek treatment
3. Physical Exam (P.A.R.T evaluation)
4. Diagnosis
5. Treatment Plan, including
   1. Recommended level of care (duration/frequency of visits)
   2. Specific treatment goals
   3. Objective measures to evaluate treatment effectiveness

Subsequent Visits

1. History
2. Physical Examination, including:
   1. Examination of area of spine involved in diagnosis
   2. Assessment of change in patient condition since last visit
   3. Evaluation of treatment effectiveness
3. Documentation of treatment given on day of visit

Additional Information

For more information about Medicare billing and documentation requirements for active care:

• Medicare Documentation Job Aid for Chiropractic Doctors
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/se1601.pdf
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/se1602.pdf
• https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/se1603.pdf

For the BCBSM (and BCN) Provider Manuals:

• https://digsauth.bcbsm.com/secureprovider/publications/manuals.shtml?fromLogin=true

For more information on chiropractic maintenance care:

• Axén et al., Chiropractic & Manual Therapies, Chiropractic Maintenance Care – What’s New? A Systematic Review of the Literature, (2019) 27:63
• Chiropractic Economics Article, “The Status of Chiropractic Maintenance Care,” March 1, 2021
• Chiropractic Economics Article, “What Maintenance Care Can Mean for Your Patients and Your Practice,” Posted March 31, 2017

For more information on active care vs. maintenance care:

• KMC University Blog, “Active vs. Maintenance Care with Medicare,” August 3, 2022
• KMC University Blog, “De-Mystifying Active vs. Maintenance Care with Medicare,” Posted May 27, 2021
• KMC University Blog, “Medicare Gives You the Rules: Just Follow Them (Part 1) (Part 2),” Posted July 16, 2021

Use of the ANMR Form and Massage Therapy Benefits

As you are no doubt aware, Blue Cross consistently sells health insurance policies that state they provide massage therapy services as part of the patient’s chiropractic benefit, but in fact only provide them when performed by the chiropractic physician him- or herself. This can cause confusion among BCBSM contract holders, especially those who have moved from MESSA, where massage therapy is able to be delegated to a licensed massage therapist, to another Blue Cross product in which it is not.

The MAC has created a handout that members can put on their letterhead and use to explain this situation to their patients with Blue Cross contracts that will not pay chiropractors for delegated massage therapy services. This handout can be used when a new patient comes into the office for the first time, or when an established patient gets new insurance, such as when a MESSA patient changes insurance to a new contract that does not pay for delegated massage therapy services.

1. 1. Contact BCBSM Provider Inquiry at (800) 344-8525 to determine whether the patient’s contract allows delegation of MT services or not. BCBSM’s automated interactive voice response system provides benefit information. However, if you can’t get this information through the automated system and you need additional information, transfer to a customer service representative (available during business hours, 8:30am – 5:00pm, Monday through Friday).
      1. Ask specifically: “Is massage payable under this contract when performed by a licensed massage therapist, and under the direct supervision of a DC?”
      2. Be sure to then note in the patient’s file that you checked, the date you checked, and the person you talked to.
   2. If Blue Cross does not pay for delegated massage therapy services, discuss this with the patient. Give them the MAC “Understanding Your Blue Cross Massage Therapy Benefit” handout. Explain that if they wish to receive MT services in your office, they will have to pay for them out-of-pocket moving forward.
   3. If they agree to pay out of pocket, make sure they sign the BCBSM AMNR form before providing any further care.