Original Medicare (type A or B) programs need for your acupuncture provider to have a MD, NP or PA to sign on with the treatment to become an "overseeing provider". Acupuncturists cannot bill directly to original Medicare A or B programs.
If you have a Medicare Advantage (type C) program, then acupuncturists may not need an "overseeing provider" like a MD, DO, NP or PA. This still will vary from plan to plan and patients need to find out what their options are.
Acupuncture inclusion to Medicare has parameters and is currently limited to chronic lower back pain (cLBP). The Centers for Medicare & Medicaid Services (CMS) will cover acupuncture for chronic low back pain under section 1862(a)(1)(A) of the Social Security Act. Up to 12 visits in 90 days are covered for Medicare beneficiaries under the following circumstances:
For this Medicare decision, chronic low back pain is defined as pain:
For those patients demonstrating an improvement, an additional eight visits will be allowed, but no more than 20 acupuncture treatments may be administered annually. Treatment must be discontinued if the patient is not improving or is regressing.
You can get acupuncture from a doctor, nurse practitioner or physician assistant who has both of these:
Currently, only providers accepting the Medicare "assignment" may submit claims directly to Medicare. Acupuncturists are not on the list of providers who may register and as a consequence cannot submit a claim to Medicare.
Follow the instructions on the form for the type of claim you're filing. Generally, you’ll need to submit:
State Health Insurance Assistance Program (SHIP): Visit shiphelp.org to get the Medicare claims must be filed no later than 12 months (or 1 full calendar year) after the date when the services were provided unless an exception applies. If a claim isn't filed within this time, Medicare won't pay its share. How can I check the status of a claim once I've filed it? Example: If you see your doctor on March 22, 2019, your doctor must have filed the Medicare claim for that visit by March 22, 2020. Check the "Medicare Summary Notice" (MSN) you get in the mail, log into your secure Medicare account, or check your plan's claims statements to make sure claims are being filed in a timely way.
If you have Original Medicare, you'll need to mail your claim form, itemized bill and supporting documents to the address for your state, which is listed on the Medicare Administrative Contractor Address Table within the claim form.
Being a small medical office, we focus our time on great treatment. This means that our medical providers do not directly bill to insurance providers because we do not have the resources to keep up with billing and administrative responsibilities.
Most privatized insurance plans provide patient portals to submit their own claims. Many insurance providers now have benefits for acupuncture. In order to find out if you have acupuncture benefits attached to your insurance plan, you will have to contact your insurance provider or read your explanation of benefits (EOB) for your specific insurance plan. Benefits will vary greatly from plan to plan, so make sure you know the requirements and limits of your plan.
We are labeled as "out-of-network providers". This means that you have the ability to find reimbursement for our services is your have "out-of-network benefits". These benefits, which include all types of out-of-network providers, will often have a deductible or set amount of treatments before any reimbursement kicks in. So, please check your specific explanation of benefits.
If you do have acupuncture benefits, we are able to furnish you with a "superbill", which is a receipt that has all the insurance coding that you will need for patient submission. Just ask us at the end of your treatment and we will be happy to provide you with one.
Medicare Patient Reimbursement CMS-1490S (pdf)
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