계약된 제공자(Practitioner)는 Fee Schedule 금액을 기준으로 청구해야 하며, ASH가 승인한 금액 이상으로 청구하면 초과 금액은 지급되지 않음.
각 주(State)에서 허용된 면허 범위(scope of licensure) 내에서만 청구 가능.
CPT 코드 사용 시 National Correct Coding Initiative(NCCI) 규칙 준수 필수.
2️⃣ 청구 제출 기한
서비스일 기준 365일 내 청구 제출 필수.
예외:
정보 불완전으로 거절 → ASH Remittance Advice 받은 날 기준 180일 또는 서비스일 기준 365일 중 늦은 날짜까지 재청구 가능.
MNRF 관련 → 발행일 기준 30일 또는 서비스일 기준 365일 중 늦은 날짜까지 제출 가능.
ASH가 secondary payer → primary EOB 받은 날 기준 180일 내 제출 + 전송 시 EOB 팩스 필요.
제3자 책임(Third Party Liability) 거절 → 거절 통보일 기준 180일 내 제출 가능.
제출 방법: ASHLink, 승인된 clearinghouse, CMS-1500 양식 우편
3️⃣ CPT + ICD 코드 사용 (만성 요통)
적격 ICD 코드와 함께 CPT 1137F, 99080 필수 제출.
1137F → 만성 요통(>12주) 표시
99080 → 특별 보고서 제출 표시
CPT 1137F, 99080는 보고용 코드로, 수가 없음($0.00)
E&M 또는 침술 방문 CPT 코드와 반드시 함께 제출
제출 시 Medical Attestation Form 수집 사실 확인
4️⃣ 기타
청구 처리 및 지급은 ASH가 담당
제출 시 정확한 환자 정보와 제공자 정보 기재 필수
Covered Services & Fee Schedule
Contracted Practitioner is financially responsible to bill usual and customary rates according to the CPT codes in the fee schedule and agrees to accept the Fee Schedule Amounts as payment in full less applicable member responsibility. If Contracted Practitioner bills a procedure code greater than what was originally approved by ASH, ASH will reimburse based on the level of care approved. Contracted Practitioner is responsible for billing services according to the scope of licensure in their state. ASH reimbursement is subject to coding rules adopted by the National Correct Coding Initiative edits as published on the Centers for Medicare & Medicaid Services website.
CLAIMS
IPP (Incentive Payment Program) Requirements
Incentive Payments and Administrative Processing Fees apply for this plan.
Submissions (Where to send claims)
Submit all claims through ASHLink, or an approved clearinghouse, or on the current CMS 1500 Claim Form and mail to:
All claims must be submitted and received by ASH within 365 days after the date of service. Refer to the “Submitting Claims” section of the Practitioner Operations Manual for additional information. The following are exceptions to the 365 days submission timeline:
1. If a claim is denied due to incorrect or incomplete information, you may re-bill within 180 days of the date of an ASH Remittance Advice or 365 days after the date of service, whichever is later.
2. If the claim is submitted and received within thirty (30) days from the MNRF date or within 365 days after the date of service, whichever is later.
3. If ASH is the secondary Client, you should submit the claim, along with a copy of the primary Client's Explanation of Benefits (EOB), within 180 days of the date of the primary Client's EOB. If submitting your claim electronically through ASHLink or ASH Clearinghouse, fax a copy of the primary Client's EOB to 877-740-2746 when submitting the claim. Be sure the Practitioner's name and patient's identifying information are clear on the fax to allow ASH to match the EOB to the appropriate transaction. Your claim may be denied if you do not fax a copy of the EOB when submitting a claim.
4. If there is a third party liability and the third party liability denies reimbursement, you may submit the claim to ASH until within 180 days of the third party denial.
American Specialty Health Claims Department P.O. Box 509002 San Diego, CA 92150-9002
Billing Requirements
You must use an eligible ICD code in conjunction with CPT codes 1137F and 99080 when submitting claims for each date of service.
To identify that you are submitting services for reimbursement under this Medicare required coverage for chronic low back pain you must use an eligible ICD code. To specify that the low back pain is chronic, and as an attestation that you have collected a Medical Attestation Form that verifies the member meets the criteria for Covered Conditions for this plan, you must bill the applicable CPT codes for E&M and/or Acupuncture Office Visit found in the Fee Schedule and add the additional non-reimbursable CPT codes 1137F and 99080 for each date of service. CPT code 1137F is a CPT Category II code, a supplemental tracking code, related to the Patient History that specifically identifies the Low Back Pain as being chronic - greater than 12 weeks. CPT code 99080 is a CPT code that identifies that you have completed or are submitting a “special report more than the information conveyed in the usual medical communications or standard reporting”. Under this Medicare required coverage benefit, ASH requires you to use these codes to attest that you have collected a completed Medical Attestation Form including medical provider contact information that verifies that the member meets the coverage criteria. Payment for CPT codes 1137F and 99080 are for reporting purposes only and will not be separately reimbursed. You should list the fee for CPT codes 1137F and 99080 as $0.00 when submitting claims.
Processing and Payment
Claims will be processed and payment will be made by ASH.
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