Asuris Northwest Health - For Providers


	Admin. Simplification »
	Care Management »
	Claims & Billing
	Contact Us »
	Contracts/Credentialing »
	Dental Professionals »
	Online Services »
	Patient Feedback »
	Products »
	Provider Directories »
	Provider Library »
	RegenceRx Pharmacy »
	TriWest »
	Workshops »

Claims & Billing Forms

Form

Description

Instructions

Billing Dispute Form (PDF)

This form is to be used when an office has a billing dispute, with a specific claim, that was NOT resolved by contacting Provider Customer Service. The billing dispute process should only be initiated when the member has no interest in the outcome.

	Complete all applicable information on the form.
	Include the name of the person to contact in the office if there are questions.
	Include the information listed within the form, on the dispute letter.
	Fax or mail the billing dispute form and letter to the appropriate numbers located on the form.

Corrected Claim Cover Sheet (PDF)

This form was designed to facilitate the submission of a claim. Simply complete the form; attach a copy of the original claim. Submit to our Seattle post office mailing address. Using this form will help us quickly identify this as a corrected billing and forward it on to the appropriate area for reprocessing.

	Complete all applicable fields on the form.
	Make sure you include the claim number that needs correcting.
	Indicate the reason(s) the claim should be corrected (corrected charges, diagnosis, patient information, etc.)
	Indicate if submitting supporting documentation.

Hospital-Based Practitioner Application (PDF)

Use this form when a provider is being added to a hospital-based facility. Asuris Northwest Health defines Hospital Based Practitioners as, “Practitioners who practice exclusively within a hospital setting, meets our credentialing and contracting criteria and provides care for Asuris Northwest Health members only as a result of members being directed to the hospital or other inpatient setting.”

	Complete the practitioner information.
	Sign the form.
	Include requested copies of State Professional License, DEA Certificate and proof of insurance.
	Submit to the appropriate address.

Incident Report (PDF)

Asuris Northwest Health members will receive this form if the condition being treated requires investigation for third party liability. The member has 45 days to complete, sign, and return the form to Asuris Northwest Health. If the member does not return the form within the required time period and the services are being denied, the providers’ office can bill the patient for services.

	Check to see if the condition is one we investigate. If yes, the member will need to complete the form.
	If the condition is one we do NOT investigate, the form is not necessary.
	Member must complete and sign the form.
	Do not copy completed form and send in for every claim.
	Submit the form only when requested- see voucher for message code indicating one is needed.

Notification of Covering Provider (PDF)

Use this form when you have providers within your office or from another location, that you have arrangements with to be ‘on-call’ or covering for a provider within your office. This form should ONLY be used if the Tax ID’s are different. Locum Tenens, Temporary Providers, or PCP’s under the same TAX ID are excluded. By using this form, our system can be updated to recognize the on call or covering provider without requiring a referral.

	Complete the covering provider information. This person(s) will be on call or covering for you.
	Complete the information for who is requesting this change.
	Sign and date the form.
	Fax or mail the form to the addresses or number(s) on the form..

Supporting Documentation Form (PDF)

This is a standard cover sheet for submitting medical information in support of a claim. Using this cover sheet will ensure that documentation is “attached” to the right claim(s) and will expedite processing.

You may also use this form when you know in advance that Asuris Northwest Health requires a report (such as an unlisted procedure code). If you have the claim number, you may also use this form to submit supporting documentation. If we have requested supporting documentation the voucher will indicate when we require additional information.

	Complete all fields on the form.
	Include claim number on form when submitting.
	Do not use for corrected billings or billing disputes.
	Indicate if claim was submitted electronically if applicable.
	Complete all member information.
	Include the office contact information.
	Identify in the comment section, what type of documentation you are attaching.

Multiple Coverage Inquiry (PDF)

Members will periodically receive this form to notify Asuris Northwest Health of any other medical insurance coverage for themselves or any of their dependents. Members must return the form within the required period or the charges will be denied as patient responsibility for this claim and any future claims until the form is submitted.

	Member must complete and sign the form.
	Ask for other insurance information periodically and update your records.
	Have blank copies in office. If member neglects to complete and sign, at next visit ask the member to complete and sign so you can submit.

Coordination of Benefits (PDF)

Coordination of Benefits (COB) enables your patients to receive benefits from all health insurance plans they are covered under. Completion of this form will help us process claims corrrectly.

	Member must complete and sign the form.
	Send the completed form to us.

Native American Provider Data Form (PDF)

Use this form when a provider is being added to a tribal health facility. Asuris Northwest Health defines Indian Health Practitioners as: “Providers practicing at a recognized tribal health facility that meets our contracting criteria and is billing under that facility’s tax identification number.

Indian or Tribal Health Clinic credentialing requirements
Effective January 1, 2009 Asuris will require that all Indian/Tribal Health Clinic providers complete the credentialing process prior to contracting. Indian/Tribal Health Clinic providers will also be required to go complete the recredentialing process at a minimum of every three years.

	Complete the practitioner information.
	Sign the form.
	Include requested copies of State Professional License and DEA Certificate.
	Submit to the appropriate address.

Overpayment/Voucher Deduction Request (PDF)

Typically, this form is used when Asuris Northwest Health has made an overpayment to your office and you are notifying Asuris Northwest Health of the error and asking for a correction.

Online notification:

Overpayment/Voucher Deduction Request

	Complete all fields on the form.
	Complete the member information.
	Indicate the claim number and reason for deduction(s).
	Your office contact information.
	Make a copy for your records and submit a copy to the appropriate address listed at the bottom of the form.

Standard CHITA Referral Form (PDF)

This is a standard referral form used by providers statewide. You can find this form on the Washington Healthcare Forum, or on our Web site. Your office can use this form or your own, when submitting referrals. If you prefer, the referral can be mailed, faxed or telephoned in for easy submission.

	Complete the referring to and from information.
	Complete the member’s information.
	Indicate what action is requested.
	Check ‘Assume Management’ if applicable.
	List any restrictions or itemizations of procedures if applicable.
	Sign form and submit.

Sample - Non-covered Services Waiver Form (PDF)

Complete this form when services requested from a member are non-covered, excluded, or investigational/experimental.

Provider Billing Dispute and Medical Necessity or Investigational Denial Appeal Form (PDF)

Form used by physicians and other health care professionals to appeal a claim payment decision. Note: Do not use this form to submit a corrected claim or a member appeal.

For Pharmacy-related forms, visit the Pharmacy section.

For other forms, visit the Provider Library.