MassHealth Chiropractic Referral Requirements: begin today August 1, 2025

MassHealth Chiropractic Referral Requirements: begin today August 1, 2025

Background and Advocacy Efforts

We understand the frustration and concerns circulating throughout the profession regarding the reinstatement of referral requirements and the increased administrative burden placed on providers. MassHealth suspended referral requirements as part of the their Covid-19 response.

On July 21, 2025, Mass Chiro met directly with MassHealth leadership to voice our concerns about the new referral protocols and the requirement that all claims include the referring provider’s NPI, who must be actively enrolled with MassHealth. We expressed that while the intention may be to streamline oversight, these policies impose undue compliance burdens on chiropractic providers, particularly when responsibility is shifted onto the treating provider rather than the referring party.

To ensure your voice is heard, Mass Chiro joined with other affected provider groups in filing formal grievances with:

• The Secretary of State
• The Massachusetts Insurance Commissioner
• The Office of the Governor

We are pleased to report that these grievances have been accepted for review. While we await next steps, Mass Chiro remains steadfast in standing up for the chiropractic profession, ensuring we can continue to deliver high-quality, non-opioid care to the patients and communities who need it most.

🔹 What’s Changing on August 1, 2025?

Referrals will be required for chiropractic services, office visits, and certain radiology services for MassHealth members enrolled in:

• The Primary Care Clinician (PCC) Plan
• A Primary Care Accountable Care Organization (ACO)

✅ Chiropractor Action Checklist

1. Verify Eligibility
2. Use the Eligibility Verification System (EVS) to confirm the patient’s current MassHealth plan.
3. Check for Referral
4. For PCC Plan members, log into the MassHealth Provider Online Service Center (POSC) to verify whether a referral has been entered.
5. If No Referral Exists
6. Contact the patient’s Primary Care Provider (PCP) or PCC, as listed in the EVS, to request a referral.
7. Referral Rules

• The PCP/PCC must determine the service is medically necessary and
• Enter the referral into the POSC before the date of service.
• Retroactive referrals may be accepted if the service is later deemed medically necessary.

1. Claims Requirements

• Claims must include the referring provider’s NPI
• The referring provider must be actively enrolled with MassHealth or the claim will be denied.

🔍 Additional Notes

• Referral rules only apply to the PCC Plan and Primary Care ACOs.
• Other plans, including MCOs and Accountable Care Partnership Plans, may have different requirements, verify directly with the plan.
• Urgent care services do not require a referral.
• Providers must maintain accurate and thorough clinical documentation in compliance with MassHealth regulations.
• Prior authorization will continue to be required for patients under age 2 beginning January 1, 2025.

📄 Additional Resource

We’ve prepared a printable comparison flyer summarizing the key differences between the 2024 and 2025 referral requirements:

Download the flyer that is printable for your office to compare at the bottom

💬 Final Thoughts

Mass Chiro is committed to ensuring that chiropractors across the Commonwealth are equipped with the information and support needed to adapt to these changes—while continuing to advocate for meaningful reform.

As we continue these efforts, we invite you to stand with us.

If you are interested in joining our advocacy, we welcome your participation—whether through writing letters, attending key meetings, or helping raise awareness on behalf of the profession. Your voice and involvement matter.

We will continue to provide updates as our grievances progress and will remain a steadfast advocate for chiropractic care in Massachusetts.

For further details, visit www.mass.gov or contact MassHealth Customer Service at 800-841-2900 (TTY: 800-497-4648).

 

 

Timeline of Mass Health Referrals

• December 1, 2010: MassHealth eliminated the general primary care referral requirement for chiropractic services.
• October 1, 2016: MassHealth reinstated the referral requirement for chiropractic services specifically for members in the PCC Plan.
• MassHealth had suspended referral requirements for members enrolled in the PCC Plan or a Primary Care Accountable Care Organization (ACO) as part of their COVID-19 response through December 31, 2023
• August 1, 2025: MassHealth will reinstate referral requirements for PCC Plan and Primary Care ACO members, including for chiropractic care.

We are steadfast in our commitment to advancing and protecting the chiropractic profession, and will continue to advocate with determination on behalf of every chiropractor in Massachusetts