Chiropractic Insurance Consultant

PURPOSE: This rule sets out procedures for chiropractic physicians to become certified as chiropractic insurance consultants to perform third-party reviews, compensation for thirdparty reviews, and biennially reporting and renewal of the certification. (1) Any licensee reviewing chiropractic billing and treatment records for the purpose of determining the adequacy or sufficiency of chiropractic treatment(s) provided to a patient, or the clinical indication for the quantity or type of such treatment(s), must first be certified by the board to do so if the purpose for such review is to assist any health insurance entity, managed care entity, or any third party payor in making a determination regarding coverage or benefits. Any licensee engaging in such practice shall be deemed an insurance consultant and shall be subject to the provisions of this rule. The requirements contained herein must be met prior to engaging in insurance consulting or acting as an insurance consultant for any health insurance entity, managed care entity, or other third party payor. (A) Application shall be made on a form provided by the board and accompanied by the required fee pursuant to 20 CSR 20702.090. (B) Prior to obtaining the certification, the applicant shall submit satisfactory proof of meeting the requirements of section 376.423, RSMo. (C) Upon approval of the application for certification, the licensee shall keep copies of records reviewed proving compliance with section 376.423, RSMo for two (2) years following review and shall submit copies of the records to the board upon request. (2) No licensee may receive compensation from a third party payer based in whole or in part upon the amount of fees the licensee recommends to be reduced or denied when the licensee is performing services as an insurance consultant pursuant to this rule. (3) In order to maintain a valid certification in insurance consulting, the licensee shall maintain a current Missouri license and document completion of a minimum of twelve (12) hours of formal continuing education in insurance consulting, approved by the board, for each biennial licensure cycle. Failure of the licensee to receive the renewal form shall not relieve the licensee of the duty to renew the certification. To renew the certification the licensee shall— (A) Provide the number of claim reviews conducted during the biennial renewal cycle, the percent of their income derived from claims review when compared to total income, and the percent of income derived from the clinical practice of chiropractic; and (B) Complete the continuing education required for the renewal of the insurance consultant certification. The continuing education hours shall apply to the required formal continuing education hours for licensure renewal. (4) A certification in insurance consulting may be reinstated upon submitting an application provided by the board, paying the required fee pursuant to 20 CSR 2070-2.090 and documenting completion of the twelve (12) hours of formal continuing education programs, seminars, and/or workshops approved by the board for insurance consulting. (5) A licensee applying for reinstatement may submit other topics of formal continuing education to the board accompanied by a request that those hours be counted toward attainment of the twelve (12) hours of continuing education required for reinstatement of the certification. The licensee shall be responsible for providing all documentation requested by the board and shall have the burden of demonstrating the topics contribute to the licensee’s knowledge of insurance consulting. The application of such hours toward reinstatement of a certification insurance consulting shall be at the discretion of the board. AUTHORITY: sections 331.050, 331.060, 331.100.2, and 376.423, RSMo 2016.* This rule originally filed as 4 CSR 70-4.010. Emergency rule filed Dec. 21, 1990, effective Dec. 31, 1990, expired April 29, 1991. Original rule filed Oct. 16, 1990, effective April 29, 1991. Amended: Filed Dec. 15, 2003, effective June 30, 2004. Moved to 20 CSR 2070-4.010, effective Aug. 28, 2006. Rescinded and readopted: Filed Aug. 27, 2009, effective Feb. 28, 2010. Rescinded and readopted: Filed Oct. 4, 2018, effective April 30, 2019. *Original authority: 331.050, RSMo 1939, amended 1945, 1947, 1969, 1981, 1987, 1999, 2001, 2004; 331.060, RSMo 1939, amended 1969, 1971, 1972, 1981, 1987; 331.100, RSMo 1939, amended 1949, 1969, 1980, 1981, 2008, 2013; and 376.423, RSMo 1990, amended 1992, 1993, 1997.