Commercial Provider

If you’re a member of our Medicare Advantage network through the Monterey Bay Independent Physicians Association (MBIPA),
click here for your resources.

Blue Shield Trio Prior Authorizations

Blue Shield has updated its list of services that require prior authorization (PA) for Blue Shield Trio HMO members. As a partner to Blue Shield in our local community, Aspire Health Plan has produced a document that includes codes for all services that require PA for timely claims payment. The list of categories requiring PA is effective July 1, 2024.
Blue Shield Trio Prior Authorization List – Updated 6/2024

Commercial Roster Information
Providers and facilities contracted under the Aspire Direct Commercial HMO network in Monterey County.

Commercial HMO Network Provider Manuals
Providers who care for members in one of our managed care commercial plans must abide by their provider manual requirements.
Please review the provider manuals of our health plan partners:

• Anthem Blue Cross HMO
• Blue Shield Trio HMO

Claims Submission

Claim Policies and Procedures
Aspire Health complies with all the claims payment requirements set forth in the Knox-Keene Health Care Service Plan Act of 1975. Aspire Health providers should review the policies and procedures regarding claims submission and processing, listed below, to ensure they are up-to-date on the current practices of the plan.

• AHP ASO CL001 AB1455 Claims Payment Guidelines
• AHP ASO CL002 Receipt and Acknowledgement of Claims
• AHP ASO CL005 Claims Turnaround Time
• AHP ASO CL006 Contested and Denied Claims Notification
• AHP ASO CL010 Misdirected Claims
• AHP ASO CL011 Interest Requirements for Late Payments, Appeals and PDRs
• AHP ASO CL015 Timely Filing of claim or PDR
• AHP ASO CL016 AB72 Payments to Non-Contracted Providers
• AHP ASO CL024 Non Contracted Provider RC Policy

Credentialing and Contracting
Provider Networks and Contracting Team
(831) 657-0700  For assistance, please email network_support@aspirehealthplan.org

Credentialing Policies and Procedures
Healthcare professionals who wish to join our managed care commercial HMO network will be subject to credentialing by Aspire Health. The Plan utilizes CAQH for submission of completed, signed and dated applications. Click here to for more information about CAQH.
Before you apply, please review our policies and procedures:

• AHP-PS001 Provider Network Credentialing Standards – CR1
• AHP-PS002 Provider Network Credentialing Committee – CR2
• AHP-PS003 Provider Network Credentialing – CR3
• AHP-PS004 Provider Network Recredentialing Cycle Length – CR4
• AHP-PS005 Provider Network Ongoing Monitoring and Interventions – CR5
• AHP-PS006 Provider Network Notification to Authorities and Practitioner Appeal Rights – CR 6

Health Care Coverage During a State of Emergency
Aspire Health, in coordination with its full-service commercial plan partners, must provide enrollees who have been displaced or whose health may otherwise be affected by a state of emergency, as declared by the Governor, or a health emergency, as declared by the State Public Health Officer, with access to medically necessary health care services. Learn more about Aspire Health’s commitment to Health Care Coverage During a State of Emergency. Should a declared state of emergency or health emergency arise, Aspire will activate its Disaster Relief Plan.

• Disaster Relief Plan
• Health Care Coverage During a State of Emergency

Medical Authorizations
(831) 657-1600
(831) 657-2669 Fax
Authorization Request Form
Submit authorization requests electronically at:  id.phtech.com.
If you do not have a portal account and would like to establish one, please call (503) 584-2169

Medical Policies and Clinical Utilization Management Guidelines
Providers who care for members in one of our managed care commercial plans must use these guidelines below as the first tier of the decision hierarchy.
Please review the clinical utilization management guidelines of our partner plans:
Anthem Blue Cross HMO
Blue Shield Trio HMO

Non-Pharmacological Pain Management Treatment
Aspire Health has worked alongside its full-service commercial HMO plan partners to provide resources related to non-pharmacological therapies. Health & Safety Code § 124962 requires health plans and their contracted providers to encourage the use of evidence-based non-pharmacological therapies for pain management.

Provider Customer Service

* UM decision making is based only on appropriateness of care and service and existence of coverage. Aspire Health does not specifically reward practitioners or other individuals for issuing denials of coverage or care. Financial incentives for UM decision makers do not encourage decisions that result in underutilization.

Utilization Management Policies and Procedures
Depending on the members you serve, you may need to obtain approval from Aspire Health before the patient undergoes a specific procedure and/or service. Please review our policies and procedures:

• 2023 – 2024 Utilization Management Program Description
• AHP HS081 Access to UM Staff and Communication Services
• AHP OP002 Standard and Expedited Medical Utilization Review Determination
• AHP ASO OP003 Disclosure of UM Criteria and Policies
• AHP ASO OP004 Emergency Services
• AHP HS027 Utilization Review Criteria
• AHP ASO HS053 Language Assistance for Limited English Proficient Members
• AHP ASO HS061 Non-Delegated Transplant Requirements
• AHP ASO HS064 Standing Specialist Referrals Including HIV AIDS
• AHP ASO HS065 Second Opinions
• AHP HS066 Cancellation/Withdrawal of Requests (Commercial HMO)
• AHP ASO HS067 Direct Access to OB GYN
• AHP ASO HS069 Coverage Denials for Members with Terminal Illnesses (Commercial HMO)
• AHP ASO HS070 Standing Specialist Referrals – Members without Life-Threatening, Degenerative, or Disabling Conditions (Commercial HMO)
• AHP HS071 Rescinding Authorizations
• AHP ASO OP005 Forwarding Grievances Complaints and Appeals to Health Plan (Commercial HMO)
• AHP HS026 Separation of Medical and Fiscal Decisions

Members and Providers may obtain a free of charge copy of the actual benefit provision, guideline, protocol or other similar criterion on which a denial decision is based, upon request, by calling Aspire Health at 1-888-893-4187 (TTY users should call 711).