Non Participating Practitioner Claims Packets

 How to Obtain Verification of Medical Necessity for Physical, Occupational, and Speech Therapy and Athletic Training Services Rendered by Non-Participating Practitioners

If your program requires verification of medical necessity for services for physical, occupational, and speech therapy and athletic training services rendered by non-participating practitioners (out-of-network/OON), 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 (ASH) 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 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 evaluation 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 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, the services you received, 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. Be sure to include the following elements: Patient and practitioner demographics, services submitting for review, services rendered, patient complaints or response to care, appropriate diagnoses, any pertinent history and appropriate outcome assessment results, along with the clinical findings to support any diagnoses and proposed plan of care. He or she may fax the Medical Records Cover Sheet along with the forms to ASH at the number below or mail the forms to the address below.

ASH Customer Service Agents are available Monday through Friday from 5 a.m. to 6 p.m. Pacific Time at 800.972.4226, option 2, to assist you and answer any questions.

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

Fax: 877.248.2746

If your practitioner is willing to communicate directly with ASH on your behalf, the links below may be helpful. They include easy-to-use clinical forms and instructions for their use. ASH 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