Applications and Addenda

For a copy of the W9 form and instructions please visit http://www.irs.gov/pub/irs-pdf/fw9.pdf.

Change in Participating Effective Date Policy

Effective April 1, 2008, all physicians and other health care professionals must be credentialed before they can participate in an Asuris Northwest Health provider network.

Beginning April 1, 2008, the following policy will apply to all participating providers:

• New provider agreements will have an effective date of the first day of the month in which the provider was credentialed (e.g., if credentialing was approved on June 14, the agreement will be effective on June 1).
• If Asuris does not receive a signed agreement in the same month as credentialing is completed, the agreement effective date will be the first of the month in which credentialing is approved or the signed agreement is received, whichever is later.
• A new provider joining a group or clinic agreement will have an effective date of the first day of the month in which he or she was credentialed (e.g., if credentialing was approved on June 14, the effective date of participation will be June 1).
• If a provider already participating with Asuris adds an additional network, the effective date of the new network will be the first day of the month the signed agreement is received.
• Asuris will no longer establish retroactive agreement effective dates.
• Claims submitted to Asuris for dates of service prior to the provider’s effective date will be processed as out-of-network.

If you have any questions regarding this policy, please contact your provider consultant.

About Applications and Addenda: Follow the instructions included on each form. Mail the completed documents back to Asuris Northwest Health at the following address:

Asuris Northwest Health
1800 Ninth Avenue
PO Box 21267
Mailstop S916
Seattle, WA 98111-3267

Phone: 1 (800) 562-2156