Name of Manual - Blue Cross and Blue Shield of Minnesota

Coding Policies and Guidelines (Chiropractic)
Compliance Audits Your provider service agreement includes certain quality assurance
requirements. Pursuant to this agreement, Blue Cross may conduct
audits to evaluate a provider’s compliance with medical necessity
guidelines and standards of practice in the community. Such an
audit could include post-service claims review using provider
utilization thresholds established by Blue Cross which may result
in provider liability if care is determined to be not medically
necessary or medically inappropriate.
11-12
Medical necessary services are directed toward a diagnosis or
condition that is supported by documented subjective and objective
findings. Medically necessary care means health care services are
appropriate, in terms of type, frequency level, setting and duration,
to the member’s diagnosis or condition, and diagnostic testing and
preventive services (Minnesota Rules 4685.0100 Subp.5). The
intensity of treatment must be consistent with the severity or acuity
of the patient’s current level of impairment and/or
symptomatology. Additionally, there must be documentation of
reasonable progress consistent with the intensity of treatment and
the severity/acuity of the patient’s condition.
Blue Cross Blue Shield of Minnesota Provider Policy and Procedure Manual (03/06/12)