Out-of-Network Packets
Many of our health plan clients offer both In-Network and Out-of-Network benefits.
Verification of medical necessity by Out-of-Network providers may be required.
The below links provide you with a Procedure guide and Out-of-Network Forms Packet
for each ASH Networks client who offers an Out-of-Network benefit to their Members.
ASH Networks believes that these forms present the most efficient means of ensuring
that all required information is included in your communication. These forms are
designed to be easily completed and follow a format that is consistent with standard
medical record keeping practices. You are encouraged to use these forms and they
are provided for your convenience.
ASH Networks' Provider Services representatives are available Monday through Friday
from 5 am to 6 pm Pacific Time to assist you and answer any questions.
To access these PDF files, you must have
Acrobat Reader
installed on your computer.
Anthem Blue Cross - Out-of-Network (CA-Acupuncture)
Anthem Blue Cross - Out-of-Network (CA-Chiropractic)
Anthem Blue Cross SISC Members – Out-of-Network (CA-Physical Medicine Services)
Materials for this new plan are not available at this time. Please check back after 1/1/10 for additional information.
Anthem HealthKeepers - Out-of-Network (Chiropractic)
Capital BlueCross - Out-of-Network (Chiropractic)
Use this packet for Capital BlueCross Members who are not employees of the Pennsylvania
Employee Benefit Trust Fund (PEBTF)
Capital BlueCross for Pennsylvania Employee Benefit Trust Fund (PEBTF) Employees
- Out-of-Network (Chiropractic)
Use this packet for Pennsylvania Employee Benefit Trust Fund (PEBTF) Employees who
are eligible with Capital BlueCross and are seeking services with a provider within
the Capital BlueCross 21 county service area
Capital BlueCross for Pennsylvania Employee Benefit Trust Fund (PEBTF) Employees
- Out-of-Area (Chiropractic)
Use this packet for Pennsylvania Employee Benefit Trust Fund (PEBTF) Employees who
are eligible with Capital BlueCross and are seeking services in Pennsylvania with
a provider outside of the Capital BlueCross 21 county service area
Pennsylvania Employee Benefit Trust Fund (PEBTF) Employees - Out-of-Network (Chiropractic)
Use this packet for Pennsylvania Employee Benefit Trust Fund (PEBTF) Employees who
are not eligible with Capital BlueCross and are seeking services in a state outside
of Pennsylvania
Empire BlueCross and Empire BlueCross BlueShield - Out-of-Network (Chiropractic Services)
Empire BlueCross and Empire BlueCross BlueShield - for Empire In-Network Providers
(Physical Therapy/Occupational Therapy)
Use this packet for Empire BlueCross and Empire BlueCross BlueShield Members who
are being seen by a provider who is an Empire BlueCross and Empire BlueCross BlueShield
In-Network Provider
Empire BlueCross and Empire BlueCross BlueShield - Out-of-Network (Physical Therapy/Occupational
Therapy)
Use this packet for Empire BlueCross and Empire BlueCross BlueShield Members who
are being seen by a provider who is NOT an Empire BlueCross or Empire BlueCross
BlueShield Provider
Health Net Health Plan of Oregon, Inc. and Health Net Life, Inc. - Out-of-Network
(Acupuncture)
Health Net Health Plan of Oregon, Inc. and Health Net Life, Inc. - Out-of-Network
(Chiropractic)
Health Net Health Plan of Oregon, Inc. and Health Net Life, Inc. - Out-of-Network
(Massage Therapy)
Health Net Health Plan of Oregon, Inc. and Health Net Life, Inc. - Out-of-Network
(Naturopathy)
Health Net Life Insurance Company - Out-of-Network (CA - Acupuncture)
Health Net Life Insurance Company - Out-of-Network (CA - Chiropractic)
Optima Health - Out-of-Network (Chiropractic)