| 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.
| Contracting & Credentialing Forms |
| Form |
Description |
Instructions |
Practitioner Credentialing Criteria for Participation and Termination (PDF)
(effective 11/1/ 2007)
Organizational Provider Credentialing Criteria for Participation and Terminationn (PDF)
(effective 11/1/ 2007)
|
This document explains our organizational requirements for
requesting participation and continued participation with Asuris Northwest
Health. All practitioners and organizational providers must complete an application for participation
so we may perform a comprehensive review of the provider's credentials. Once the application is completed we will begin a review of
the practitioner's or organizational credentials using a variety of national and state data
sources. |
|
| Universal Facility Application (PDF) |
This form may be used for initial credentialing, or recredentialing of facilities. |
|
Complete this form in its entirety and attach all requested documentation and explanation. |
|
If a question does not apply to your facility, answer with “Not-Applicable” or “N/A”. |
|
If additional space is necessary to provide answers, attach additional sheet(s) of paper |
|
This application must be signed and dated where indicated. |
|
| 2007 Washington
Practitioner Application (PDF) |
This form must be completed to begin the process of credentialing. |
| |
Complete the form in its entirety using black or blue ink. |
| |
If a particular question does not pertain to you or your practice,
please check the box at the tops of that section. |
| |
Keep an unsigned and undated copy in your files for any future requests,
if necessary. |
| |
Attach copies of requested documents. |
|
If changes are made to the completed application, strike out the
information and write in the modification, initial and date. |
|
Document any ‘YES’ responses on the Attestation Question
page. |
|
Expect addendum’s from the requesting organizations for information
not included on this form. |
|
Send completed form to P.O. Box 21267, Mail Stop S916, Seattle WA
98111-3267 |
|
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
|
