Non Participating Practitioner Claims Packets
How to Obtain Verification of Medical Necessity for Chiropractic 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.
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:
- Completing the
Medical Records Cover Sheet
which communicates the number of dates of services, manipulation services, adjunctive therapies, x-rays, etc.
- 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 including, at a minimum, Inspection and Palpation findings ). 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.
For the below client please send to the address on the back of the member's identification card:
Providence Health Plan - PEBB (Choice (EPO) & Statewide (EPO); Benefit Plan)
For all other clients send the necessary information to:
American Specialty Health Group, Inc.
Claims Administration
P.O. Box 509001
San Diego, CA 92150-9001
Fax
(California only): 877.427.4777
Fax
(All other states): 877.304.2746
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.