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. (1) A licensee reviewing chiropractic billing and medical records for the purposes of determining the adequacy or sufficiency of chiropractic treatments, or the clinical indication for those treatments, must be certified to do so if the purpose for such review is to assist any health insurance or managed care entity 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 regulation. The requirements contained within this regulation must be met prior to engaging in insurance consulting.

   1. (A) Application shall be made on a form provided by the board and accompanied by the required fee.
   2. (B) Prior to obtaining certification, the applicant shall submit proof of meeting the requirements of section 376.423, RSMo.
   3. (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 them to the board upon request.
2. (2) No licensee may receive compensation from a third-party payor based in whole or in part upon the amount of fees the licensee recommends be reduced or denied when the licensee is performing services as an insurance consultant pursuant to this regulation.

3. (3) In order to maintain a valid certification in insurance consulting, a licensee holding a certificate at the time of license renewal shall certify to the board completion of a minimum of twelve (12) hours of continuing education in insurance consulting, approved by the board. 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:

   1. (A) Provide the number of claim reviews conducted during the biennial renewal cycle, the percentage of their income derived from claims review when compared to total income, and the percentage of income derived from the clinical practice of chiropractic; and
   2. (B) The continuing education shall apply toward attainment of the twelve (12) required hours of continuing education pursuant to 20 CSR 2070-2.080(5), in the general studies category of continuing education.
4. (4) Continuing education in the area of insurance consulting may also be submitted to the board for approval as formal continuing education hours.

5. (5) A certification in insurance consulting may be reinstated upon submitting an application, provided by the board, paying the required fee, and documenting twelve (12) hours of formal continuing education approved by the board. For the purpose of reinstatement of the insurance consultant certification, continuing education shall consist of the following:

   1. (A) Four (4) hours Medicare requirements, coding, and reimbursement; and
   2. (B) Four (4) hours Subjective Objective Assessment Plan (SOAP) notes; and
   3. (C) Four (4) hours billing and/or coding.
6. (6) A licensee applying for reinstatement may submit other topics of formal continuing education to the board for review. The licensee shall be responsible for providing all documentation requested by the board and shall have the burden of demonstrating that the topics contribute to the licensee’s knowledge of insurance consulting.

AUTHORITY: sections 331.060 and 376.423, RSMo 2000 and sections 331.050 and 331.100.2, RSMo Supp. 2008.* 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.

*Original authority: 331.050, RSMo 1939, amended 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; and 376.423, RSMo 1990, amended 1992, 1993, 1997. 20 CSR 2070-4