Tag: #medicalnecessity

I am getting a lot of request from PT/OT providers, regarding the new Oscar Insurance “medical necessity” review process. So, I decided to write a FAQ blog post on this subject.

Are you a PT or OT provider? Do you accept patients with Oscar Insurance? Then this blog post is for you!

What you will learn in this blog post?

1. Know who to contact to get your authorization on the first submission.

2. Avoid unnecessary denials!

3. Keep yourself and your staff current on the most updated medical billing/authorizations guidelines.

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Let’s begin.

Recently Oscar Insurance announced that effective 07/15/2021, the “medical necessity for Physical and Occupational Therapy”, will be handled by the American Specialty Health Group, Inc. (ASH Group).

For the purposes of this blog “medical necessity” is interchangeable with “prior authorization”

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Below are the most frequently asked questions and their answers:

1. I am a participating OT/PT provider; how do I submit an authorization?

As a participating provider, you have several ways to submit medical notes for prior auth.

1. Provider portal: www.ASHLink.com
2. Fax: 877-248-2746
3. Mail: American Specialty Health (ASH) PO Box 509077, San Diego, CA 92150-9077

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2. Where can I find information regarding clinical documentation?

The clinical information guidelines are available on the website : www.ASHLink.com . On the website you need to click Resources then Providers then Physical , Occupational and Athletic Training and then click on Practitioner Claims Packet-Oscar.

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3. Do I need to register with ASH in order to view the necessary information?

Yes, in order to access any information regarding the prior authorization criteria and documentation requirements, you have to register with ASH and/or activate your account.

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4. I am a participating Provider (with Oscar), where should I go to verify patient’s eligibility?

A participating provider should go to hioscar.com/provider or call 1855-oscar-55 to verify the member eligibility, before requesting a PT/OT medical necessity review.

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5. Will my claim will be denied if I do not obtain a prior authorization (PT/OT) before sending the claim for processing?

Yes, it will be. As a participating provider it is the responsibility to obtain a “medical necessity review” prior to submitting claims for payment.

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6. Where do I submit PT/OT claims to?

As a participating PT/OT provider you will submit the claims directly to Oscar at:

Oscar Insurance Corporation

PO Box 52146

Phoenix, AZ 85072-2146

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7. How do I file an appeal?

If the PT/OT services are denied, as a participating provider you have the right to file an appeal. That information is going to be included in the determination documentation.

8. If I am a participating provider who can I contact for more information?

Please contact Oscar Provider Services at 1-855-OSCAR-55

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Find this content helpful? Support me by following my blog. Here you will find the most current medical billing and coding guidelines, prior authorization and reimbursement changes/updates.

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Do yo need more hands on help: training or consulting? Please contact me via email:

Consulting: kr2medialbilling@gmail.com or for educational/training at cskr2billing@gmail.com

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