Since ASH can be confusing, especially the threshold starting over in the middle of the year versus benefits being per calendar year, I wanted to reiterate a response I had issued to help clarify this policy.
The ASH threshold actually DOES reset in July. I am quoting from ASH’s site, taken moments ago: “The Clinical Treatment Form Waiver is available for the first episode of care provided to a member who is a new or established patient (over 12 years of age) during the twelve month period of July 1st through June 30th. If there are additional services that may be necessary beyond the Clinical Treatment Form Waiver you will need to submit a Clinical Treatment Form (CTF) to ASH. Once a Clinical Treatment Form (CTF) has been submitted during the calendar year the Clinical Treatment Form Waiver is no longer available.”
You can find this by searching on a patients eligibility, and in the bottom left corner there is a blue button that says : This member has a Clinical Treatment Form Waiver. Display CTFW. When you click on the DISPLAY CTFW button, it will give you the terms of the threshold.
The way it works is this and believe me, it is very difficult to wrap your brain around: On January 1st, a patients ANNUAL benefits start over, say for example 20 visits per calendar year, HOWEVER, the THRESHOLD doesn’t start over until July. Basically, every July you catch a break in that you can now see a patient (as long as they are over 12 y.o.) for the amount of visits you have under your threshold without needing authorization. If the patient were to see a different provider, you are still entitled to your threshold, it’s relative to you specifically as the practitioner. Let me give a complete example: New 30 y.o. patient Betty comes in on January 15th, we look her up on ASH and see that she has 20 visits per calendar year and she hasn’t used any yet. Since this is the first time you are seeing her, you get 5 visits (if that’s your threshold #) where you can see her without needing authorization. The patient uses her 5 “free” visits and still needs more care. You complete a CTF and request more visits. You get the authorization you requested and she comes in. You are amazing and cure her, so she stops coming in for a while. Then, on July 15th, she has a new condition and comes to see you. At this time, you can once again see her for 5 “free” threshold visits because the threshold period restarted on July 1. After these 5 visits, you would again request authorization, if needed.
One last note. If, for example, a patient comes in on June 15th and you are out of threshold and have to request authorization and do so from June 15th THROUGH July 15th, your threshold restarts AFTER that July 15th expiration. So, on July 16th you can now have 5 “free” threshold visits. Just be weary that if a patient comes in on July 2nd and you forget about the threshold and complete a CTF requesting authorization, you have now forfeited your theshold because the threshold time period already restarted. So, it’s one thing for an existing authorization to start PRIOR to the threshold it’s another to request an authorization after the threshold time period has begun. I hope this clarifies things.