Complementary and Alternative Medicine Benefit Fact Sheet

Brief Description: Oxford Health Plans, Inc. was one of the first managed care organizations to offer a complementary and alternative medicine program with a credentialed network. Oxford continues to develop its program as new changes in this field occur.
Year Founded: 1997
Management Team:
•   James Dillard, M.D., D.C., C.Ac., medical director,
complementary and alternative medicine
Specialist Network: Approximately 2,400 providers offer complementary and alternative therapies in:
•   Acupuncture
•   Chiropractic
•   Naturopathy (only in Conn.)
•   Nutrition
•   Massage therapy
•   Yoga instruction
  The most commonly used complementary and alternative medicine benefit is chiropractic care.
•   Oxford has more than 1,600 chiropractors, 200 acupuncturists, 80 yoga instructors, 400 massage therapists and 100 nutritionists in its complementary and alternative medicine network of providers.
•   Nearly 35,000 members have access to complementary and alternative medicine specialists through Oxford's complementary and alternative medicine rider.
Credentialing: Alternative medicine providers must:
•   Meet state licensing requirements
•   Meet clinical experience requirements
•   Commit to continuing education in a specialty area
•   Have specialty certification, when necessary
•   Maintain malpractice insurance coverage
•   Be credentialed every three years
Access: Depending on plan design and region, members can access this network in three ways:
•   Contracted rate - Oxford has negotiated contracted rates with all of the complementary and alternative medicine providers in our network, including acupuncturists, chiropractors, naturopaths, massage therapists, yoga instructors and nutritionists. These rates vary by specialty and region. The Oxford contracted rate allows all Oxford commercial and Oxford Medicare AdvantageSM members to go directly to a participating complementary and alternative medicine provider at any time and pay a specially negotiated contracted rate directly to the provider. This is not an insured benefit so there is no need for a PCP referral, reimbursement, or paperwork. You simply select a participating complementary and alternative medicine provider, schedule an appointment, and pay the Oxford-negotiated rate directly to the provider at the time of your visit. In most instances, this rate reflects a discount from the provider's normal fee.
•   Standard In-Network Benefits - Members whose plan includes standard benefits for medically necessary chiropractic and naturopathic coverage, can access participating Oxford providers upon obtaining a referral.

Precertification is required for any visits after the initial visit. Members are responsible for a copayment at the time of the visit. Those with non-gated plans are not required to obtain referrals to participating chiropractors or naturopaths.

For members with out-of-network coverage, access to chiropractic care through a non-participating provider must be reviewed for medical necessity. Members and providers can either:

  1. Request prior approval through TRIAD by submitting the Voluntary Prior Approval Agreement Form along with an Initial Care Plan Form; or
  2. Submit clinical notes for medical necessity review to TRIAD after services are rendered and claims are submitted.
•   Alternative medicine rider - Members whose plan includes the alternative medicine rider can make medically necessary initial visits (subject to a copayment) to participating chiropractors, acupuncturists and naturopaths without a PCP referral. Precertification is required for any visits after the initial visit. The rider replaces any applicable standard in-network chiropractic or naturopathic benefit. Rider availability differs by region, employer, company size and plan design.