Forms
This
forms library contains information change request forms,
overpayment/voucher deduction request and more to come.
| Form |
Description |
Instructions |
| Participating Dental Provider Application (PDF) |
This form is used to apply for participation on our dental network. |
Complete and sign the form, attach required documentation, and mail the application to:
P.O. Box 21267 M/S S704
Seattle, WA 98111-3267 |
| Provider
Change of Information Form (PDF) |
Use this form to report and changes or additions
to the provider's demographics or tax ID.
A signature is required before the changes can take
effect. If the tax ID is changing, you must submit
a W-9 form. If the address is changing, you will
need to include proof of insurance for that location. |
- Complete the old information, if applicable.
- Indicate what is changing in the 'new
or additional' information section.
- Sign and date the form.
- Fax or mail the form to the addresses or number(s)
on the form.
|
| Voucher
Overpayment Refund Form (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. |
- 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.
|
Dental
Provider Manual
The Asuris
Northwest Health Dental Provider Manual is available
for download.
The Dental Policy Manual will shortly be available
online.
Asuris MedAdvantage Preventive Dental Services
Asuris MedAdvantage
is our Medicare Advantage PPO option for Medicare eligible
members. It includes benefits for preventive dental
services. Members may go to any dentist, and are covered
up to $500 annually for preventive dental services
such as routine cleanings, x-rays and exams.
The following is a list of benefited services:
D0120 Periodic oral evaluation
D0140 Limited oral evaluation. Problem focused
D0150 Comprehensive oral evaluation - new or established patient
D0160 Detailed and extensive oral evaluation. Problem focused
D0170 Re-evaluation, limited problem focused
D0180 Comprehensive periodontal evaluation
D0210 Intraoral - complete series (including bitewings)
D0220 Intraoral - periapical first film
D0230 Intraoral - periapical each additional film
D0240 Intraoral - occlusal film
D0270 Bitewing - single film
D0272 Bitewings - two films
D0274 Bitewings - four films
D0277 Vertical bitewings - 7 -8 films
D0330 Panoramic film
D1110 Prophylaxis - adult
D1120 Prophylaxis - child
D1201 Topical application of fluoride (including prophylaxis) - child
D1203 Topical application of fluoride ( prophylaxis not included) - child
D1204 Topical application of fluoride (prophylaxis not included) - adult
D1205 Topical application of fluoride (including prophylaxis) - adult
D1351 Sealant
D4910 Periodontal maintenance
Frequency limitations:
- Cleanings - 2 per calendar year (prophylaxis and/or perio maintanence)
- Bitewings - 2 per year (whatever combination)
- Panoramic film - once every 3 years
- Fluoride - 2 times per calendar year for members aged 17 years and under
- Exams - 2 per calendar year, any combo
- Intraoral complete series - once every 3 years
- Sealants, on permanent bicuspid and molars - only provided
for members aged 17 years and under
House Bill 1418 ‘ Overpayment
Recovery Practice’
On January 1, 2006, House Bill 1418 ‘Insurance
Overpayment Recovery’ (RCW 48.43.600), goes into
effect. This new law requires that carriers provide
prior written notification within 24 months after the
date that the payment was made to a health care provider
when the refund is requested or 30 months for a coordination
of benefits (COB) refund.
Effective January 1, 2006, written refund requests
will be sent to vouchered providers included in the
new legislation. In most cases Asuris Northwest Health
will notify the provider of a refund by displaying
the claim number(s) impacted for each member, on the
weekly voucher pend report that is included with your
remittance advice. The pend report is currently in
use and is used to notify your office of any claims
being held for additional information, such as preexisting
information or coordination of benefits. As of January
2006, the pend report will now include claim(s) holding
for refund notification, along with the dollar amount
of the refund and the reason we are requesting the
refund.
Refund requests for special circumstances, COB and
other party liability (OPL) claims will require a letter
to be sent instead of the pend report. For easy identification,
the letters will be mailed to your office in a goldenrod
envelope.
Once you have been notified of the refund, your office
will have 30 days to respond. To expedite the refund
process, please respond immediately.
- If Asuris Northwest Health has no response after
30 days, the refund will be released and automatically
deducted on a future voucher.
- If your office needs additional time to refund
the amount due, your office can contact us and make
arrangements for repayment. You may take up to six
months to complete the repayment.
If you have a question regarding the original claim
related to the refund request, you can also use Asuris
Online Service for Providers (ROS-P) to view a remittance
advice or check on the claim status.
Finalizing the refund request
To
help assist you in reducing the administrative burden
this new legislation may cause, you can advise Asuris
Northwest Health on how to proceed with the refund
request.
The following options are available:
Email our Refund Department(s)
asurisrecovery@asuris.com
Call Customer Service
1 (888) 344-5587
Fax the pend report. Indicate on
the pend report (per claim) how to handle the refund
(ok to process, or hold for repayment) and fax to Asuris
Northwest Health.
(206) 626-6227
Mail notification to:
P.O. Box
21267, Seattle WA 98111-3267
If you have any questions or concerns regarding this
new legislation, please call your professional
relations representative.
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