Both in-network and out-of-network chiropractic services for Empire health plans are managed by American Specialty Health (ASH) Networks.
ASH is a company that specializes in the management of chiropractic services. ASH’s review of chiropractic services helps ensure that these services are medically necessary and are performed in such a way, so that they are coverable under the member’s plan. This review includes the evaluation and management of clinical services such as treatment methods, manipulations, and X-rays.
Every provider, whether in-network or out-of-network, must submit a treatment plan and/or medical records to ASH for review after the first five treatments per calendar year. This review includes evaluating clinical services such as treatment methods, manipulations and X-rays. ASH will apply the same process that they use for in-network chiropractic services to out-of-network care, to validate that these services are medically necessary in accordance with the member’s health plan provisions.
For chiropractic services from in-and out-of network providers:
After a member’s fifth visit, providers must submit clinical treatment documentation to ASH Networks for review and determination of the medical necessity of further visits.
It is the provider’s responsibility to request the authorization and approval for additional services.
Both the member and the provider will be notified of ASH Network’s decision.
While not required, providers are welcome to submit a request for authorization prior to rendering service.
Please note: Members will be responsible for the cost of any chiropractic services, whether in- or out-of-network, that are not deemed medically necessary. Therefore, members may wish to ask that their providers request prior authorization for these chiropractic visits, to ensure that they are getting the maximum allowable benefits.
IMPORTANT differences to note:
For chiropractic services from an in-network provider:
If the provider fails to submit services for review and obtain authorization for covered services and additional treatment takes place, the provider will be held financially responsible.
For chiropractic services from an out-of-network provider:
If the provider fails to submit services for review and obtain authorization OR if services are not deemed medically necessary, the services will not be eligible for payment under the member’s benefit plan, and the cost of those services will be the member’s responsibility..
The determination notification will include the member’s rights and instructions on how to formally appeal this denial.
Although it’s not required, members may want to ask their providers to request prior authorization for these visits. A prior authorization may help offset any costs incurred if the services are not determined to be medically necessary.
Chiropractic services may not be covered by all plans. Please be sure to check your health plan benefit materials for more details.