Non Participating Practitioner Claims Packets

 How to Obtain Verification of Medical Necessity for Podiatric Services Rendered by Non-Participating Practitioners

If your program requires verification of medical necessity for services rendered by non-participating practitioners, then coverage is limited to those services that are verified as medically necessary.

Pre-Certification

Under this program some services will require Pre-Certification. Pre-Certification is triggered by a practitioner or member contacting ASH prior to the provision of a service designated as requiring Pre-Certification. ASH has identified classes of podiatric services that are typically considered for Pre-Certification. Examples of such services for which ASH may require Pre-Certification include, but are not limited to:

  • All surgical procedures (CPT 20000 series codes; 20670-29906 and 35226) including, but not limited to:
    - Wound Care, Debridement, and Excision procedures
    - Incision and Drainage procedures
    - Osteotomy, Arthrotomy, Arthrodesis, Arthroplasty, Phalangectomy, Tenotomy/Tenolysis, Amputation, and Capsulotomy procedures
    - Open Treatment of Fracture and Closed Treatment of Joint Dislocations
    - Professional component of services to be rendered at a Health Plan contracted surgical center
    - Biopsy procedures
  • Injection procedures including, but not limited to:
    - Ultrasound-guided and Fluoroscopy-guided injection
    - Injection of neurolytic agents
    - Hyaluronan injections
  • Durable medical equipment (DME), supports, orthotics, ad/or prosthetics, including:
    - All devices with a maximum allowable fee schedule of $250 or more (podiatrists may, if they choose, request Pre-Certification for DMEs with a maximum allowable fee schedule of less than $250, in lieu of medical necessity review)
    - Foot and Ankle-Foot Orthoses (AFO)

Podiatrist may submit any podiatric service for Pre-Certification/pre-service review at any time.

 

  Send clinical documentation to verify the medical necessity of care to American Specialty Health Group, Inc. (ASH Group) for peer review.

You can do this by either:

Option A:

Obtain your medical records yourself for the dates of service you want verified as medically necessary and send that information by fax to the fax number below or by mail to ASH Group at the address below. The medical records should include any intake forms you completed in the practitioner’s office describing your condition as well as copies of any examination forms used in assessing your condition or progress. And, tell us what dates of service you want us to review. These dates should be the first and last visit dates on the claims submitted.

Option B:

Ask your non-participating practitioner to communicate directly with ASH Group to verify medical necessity. If your practitioner is willing to do this on your behalf, we have developed reporting tools for your practitioner to use. The practitioner can assist you in meeting your obligation to obtain medical necessity verification by:

  1. Completing the Medical Records Cover Sheet which communicates the number of dates of services, treatment/services rendered, x-rays, etc.
  2. Sending either the Clinical Information Summary Sheet or your medical records supporting your treatment plan for the dates of service to be reviewed. If your practitioner chooses to submit your medical records on your behalf, please ask him or her to attach the Medical Records Cover Sheet (and be sure to include the following elements: Patient Age and Gender; Chief Complaint; Pain Severity; Mechanism of Onset; and the pertinent findings from your Physical Examination ). He or she may fax the Medical Records Cover Sheet along with the forms to ASH Group at the number below or mail the forms to the address below.

ASH Group Customer Service Agents are available Monday through Friday from 5 a.m. to
6 p.m. Pacific Time at 800.972.4226 to assist you and answer any questions.

 

Send the necessary information to:
American Specialty Health Group, Inc.
Claims Department 
P.O. Box 509077
San Diego, CA 92150-9077


Fax : 877.248.2746

 

If your practitioner is willing to communicate directly with ASH Group on your behalf, the links below may be helpful. They include easy-to-use clinical forms and instructions for their use. ASH Group believes these forms present the most efficient means of ensuring that all required information is included in your submission. These forms are designed to be easily completed and follow a format that is consistent with standard medical record keeping practices.

Medical Necessity Instruction Guide and Forms