Practitioner Claims Packet

Empire BlueCross for Empire In-Network Providers

American Specialty Health Group, Inc. (ASH Group) has been contracted to provide medical management for the physical therapy and occupational therapy benefit for this Payor. In addition to information regarding this benefit, below are links to helpful instructions on how to obtain approval and reimbursement for covered services through ASH Group.

This program requires verification of medical necessity for all necessary services rendered by providers, but reimbursement will be limited to those covered services that are determined to be medically necessary through the ASH Group evaluation process.

How to Obtain Approval/Verification of Medical Necessity

Send clinical documentation to verify the medical necessity of care to ASH Group for peer-review. This documentation requirement may be met by:

Completing the appropriate Medical Necessity Review Form (MNR Form) listed below. (Please note that for a pediatric patient with an orthopedic condition please use the MNR Form for Orthopedic conditions instead of the MNR Form for Pediatric patients.)
Or sending copies of your medical records supporting your treatment plan for the dates of service to be reviewed.

The MNR Forms and instructions on how to obtain approval and reimbursement for covered services are provided as a convenience to you to help ensure all necessary information is included. 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.

It is important to include all necessary information. Services may not be approved for reimbursement if you do not provide adequate information. Properly completing the MNR Form helps ensure that we receive adequate information. The MNR Forms listed below have the fill-in feature for your convenience. They are the most efficient way to communicate your clinical information.

ASH Group will respond within one week of receipt of the completed form. Notification of the clinical decision will be mailed or faxed directly to you and will include the name and phone contact information of the peer-clinician who rendered the decision. Services rendered during the review period will be reimbursed if they are approved by ASH Group.

ASH Group representatives are available Monday through Friday from 5 AM to 6 PM Pacific Time at 800.972.4226 to assist you and answer any questions.

Members covered under this program: MediBlue HMO and PPO members
Medical necessity review: To be eligible for reimbursement this plan requires verification of medical necessity for all services performed by Empire In-Network providers after the sixth (6th) visit per member per calendar year
Send Medical Necessity Review Forms or Medical Records to:
American Specialty Health Group, Inc.
P.O. Box 509077
San Diego, CA 92150-9077
Fax: 877.248.2746
Send Claims to:
Empire BlueCross
Attn: Claims Department
P.O. Box 1407
Church Street Station, New York, NY 10008-1407

Be sure to include the treating practitioner's NPI number on your claim form.

For eligibility, benefit, and claims information: Call Empire BlueCross Provider Services at 800.552.6630

For member questions: Call Empire Member Services at the number on the back of the member's identification card

Other information: Use these materials for Empire BlueCross members who are being seen by a provider who is an Empire BlueCross In-Network Provider.