Guide

Billing chiropractic through ASH carve outs

By Dr. Daniel Turner, DC · Reviewed September 2, 2026

Carve outs are the least documented corner of chiropractic billing: the patient's card says one insurance company, the money and the rules live at another. This guide explains the machinery from a practice that bills through it, in a way no payer handbook quite does.

What a carve out actually is

Many health plans do not manage chiropractic themselves. They delegate it, the network contracts, the clinical review, the authorizations, and often the claims, to a specialty benefits organization, of which American Specialty Health is by far the largest in chiropractic. The patient carries the health plan's card; the chiropractic benefit lives at the carve out. Everything confusing about these arrangements flows from that split: two organizations, one benefit, and a claim that must find the right one.

The forwarded claim trap

Bill the health plan on the card when chiropractic is carved out, and the plan hands the claim to the carve out entity, reporting it on the remittance with code B11, claim forwarded to another processor. This is the single most misread event in carve out billing: it looks like a denial, it is not one, and rebilling the health plan manufactures duplicates that arrive at the carve out behind the original. The full playbook for that moment is on the B11 page of the denial library; the short version is calendar a follow up and do not rebill.

Authorization, tiers, and medical necessity review

Carve out arrangements commonly work on a tiered trust model. Providers are assigned a tier under the entity's clinical review system, and the tier decides how much care flows without paperwork: an initial allowance of visits, then submission of clinical information, exam findings, functional measures, the treatment plan, for continued care. In our practice's direct experience the operational keys are unglamorous: know your current tier, track authorized visits against what has been used the way you track any plan cap, and submit the continued care paperwork before the visit that needs it rather than after the denial that follows it. Missing authorizations surface in the denial library as CO-197.

Where the claim actually goes

Once you know a plan carves chiropractic out, bill the carve out entity directly through its own portal and payer ID rather than bouncing claims off the health plan. First claims for a new patient are the moment of truth: run eligibility, note who administers the chiropractic benefit, and set the patient's payer routing accordingly so every future claim goes straight to the right processor. Software that stores payer routing per plan makes this a one time discovery instead of a recurring surprise.

The denial codes carve outs produce

  • →B11 · the forwarded claim itself, hold and follow up, never rebill
  • →CO-197 · authorization absent, attach the auth number or request retro review
  • →CO-109 · wrong payer billed, fix the routing so it sticks
  • →CO-22 · coordination questions when other coverage is in play

How Cervica handles carve outs

Per payer routing sends carved claims to the right processor from the first claim, forwarded B11 claims are held with a follow up clock instead of queued for rebilling, visit counts track against authorizations, and the denial worklist routes each carve out denial to its specific fix.

General information reflecting public materials and our own practice's direct billing experience as of 2026, not advice for any specific claim. Carve out arrangements vary by plan, state, and contract; your provider agreement and the payer's current policies control. American Specialty Health and ASH are trademarks of their owner; Cervica is not affiliated with ASH.

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Common questions

What is ASH in chiropractic billing?
American Specialty Health is a specialty benefits organization that many national and regional health plans delegate their chiropractic networks and claims to. When a plan carves chiropractic out to ASH, the network contract, the clinical review, the authorizations, and often the claim itself run through ASH rather than the health plan on the patient’s card.
Why did my claim to the health plan come back as forwarded?
When a plan has carved chiropractic out, a claim sent to the plan gets handed to the carve out entity, and the remittance reports it with code B11, claim forwarded to another processor. It is not a denial. The claim is in flight at the carve out, and rebilling the health plan only creates duplicates downstream.
Do ASH claims need prior authorization?
Often, beyond an initial allowance. Carve out arrangements commonly grant a number of visits without review, then require submission of clinical information for continued care, with the required paperwork and thresholds varying by the provider’s tier in the clinical review system. The practical rule is to know your tier, know your allowance, and calendar the submission before the visit that needs it.
How do I avoid ASH related denials?
Three habits cover most of it: learn which of your payers carve chiropractic out so first claims go to the right place, track authorized visit counts against what has been used, and never rebill a forwarded claim to the original plan. The denials the arrangement produces, forwarded claims, missing authorizations, and coordination questions, each have specific fixes in our denial library.