ASH Threshold time for California providers….

Just a reminder to all of you California ASH providers that the most wonderful time of the year is upon us….threshold time!  You should have recently received a letter about your tier status, hopefully you went up or at least didn’t go down….To recap what this means, most of you are at a 5 visit threshold. If your tier status increased, you may be at 8 now or even better 12 or the elusive unlimited (never need authorization).  It can take a very long time to move up in tier status and you all start out with 5.

If you are a terrible documenter, you can be dropped down to needing an authorization for each and every visit, so it does get worse than 5. What all of this means is that each July 1, you can see a patient for this amount of visits without needing authorization. If you see Kaiser patients, they do not fall under this luxury time, nor do patients 12 years old and under, but all others qualify. If you had gotten an authorization prior to this time but it spans July, so for example in June you got an auth for 6/15-7/15, then your threshold begins AFTER 7/15.  If, however, you request an authorization after 7/1, you FORFEIT your threshold and must now abide by the authorization time frames (requesting authorization during the threshold time supercedes it and says to ASH, no thank you, I do not want my threshold visits I would much rather do paperwork).  Remember too that the threshold time has nothing to do with the patient’s annual visits, they still apply.  This is what I always find confusing.  In January, the patient’s benefits start over, maybe they get 20 visits per calendar year for example, but the threshold starts over every July. Make sure to keep track of visits used on an annual basis but remember to take advantage of this wonderful threshold time, it’s the only paperwork breather you get from ASH. One last note, your threshold applies to you the provider.  If  a patient saw a different provider before you, they had their threshold and now that the patient is coming to see you, you have your threshold.  It isn’t a combined thing among providers, you each get your own special ASH time.

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4 Responses to ASH Threshold time for California providers….

  1. This information is incorrect. The time period for which the treatment form waivers are in effect is from January 1st to December 31st. It does not reset in July. It is spelled out in their acupuncture provider services agreement, attachment K.

    • tandersen says:

      Hi Christi. The 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.

  2. ChristiRaunig says:

    When I go to a patient’s eligibility and display the CTF it most definitely says the 12 month period of January 1st to December 31st. I’m guessing that all states are different. I’m in Oregon, not California. You definitely need to make note of this on your site.

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