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Claims & Billing Forms
Form Description Instructions
Appeal Form for Provider Billing Dispute and Medical Necessity Denial (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.

 

Automatic Deposit (EFT/ACH Credits) Authorization and Contact Information (PDF)

  		• Enroll in electronic funds transfer to have claim payments deposited directly into your bank account.
  		• Enrollment will require that you also receive your remittance advices electronically.
  		• Print and complete all fields on the form
  		• Return to Asuris using one of the methods listed on the form
    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.
    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.
    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.
    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.
    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..
    Overpayment Recovery Process and Overpayment/Voucher Deduction Request

    Complete the Overpayment/ Voucher Deduction Request forms as outlined in the Overpayment Recovery process.

    		  
    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.
    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.
    Miscellaneous    
    Annual Wellness Visit Program Enrollment Form (PDF) Asuris TruAdvantage contracted primary care specialty-type providers may enroll in the Annual Wellness Visit Program.  
    Sample – Non-covered Member Consent Form (PDF)

    Use this sample form as a guideline when developing a member consent form. You may wish to consult with your legal counsel before adopting this format.

    Participating providers must hold harmless any amount determined by Asuris to be not medically necessary. Asuris will consider a member consent form obtained by the provider of the primary service valid for all associated claims (e.g., anesthesia, pathology, laboratory, hospital) if the primary provider indicates a consent form has been signed.

    		 

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    Contracting and Credentialing Forms

    Type Instructions Criteria Forms

    Practitioners

    Physicians and other health care professionals.

     

    Review the credentialing criteria and complete an application.

    Return completed applications to:

    Asuris Northwest Health
    Credentialing Department M/S S555
    P.O. Box 21267
    Seattle, WA 98111-3267

    Fax: 1 (888) 335-3002

    Email

    Practitioner Credentialing Criteria for Participation and Termination (PDF)
    (Effective 1/1/2012)

    		 Washington Practitioner Application (PDF)

    ProviderSource® is a free service hosted by OneHealthPort™ to help Washington healthcare providers manage provider data used for credentialing and privileging.  You may use ProviderSource to submit your application online. Note: If you use ProviderSource to submit an application please notify our credentialing department.

    TriWest/TRICARE

    TriWest Healthcare Alliance (TriWest) is contracted with the U.S. Department of Defense for the administration of the TRICARE program in the West Region.

    		    

    Complete the following forms:

    Organizations

    All organizational providers (facilities) are required to complete the credentialing process prior to contracting with Regence. The recredentialing process must also be completed at a minimum of every three years.

     

    Review the credentialing criteria and complete an application.

    Return completed Universal Facility Applications to:

    Asuris Northwest Health
    Credentialing Department M/S S555
    P.O. Box 21267
    Seattle, WA 98111-3267

    Fax: 1 (888) 335-3002

    Email

    Organizational Provider Credentialing Criteria for Participation and Termination (PDF)
    (Effective 1/1/2012)

    Organizational Provider/Facility Credentialing/Recredentialing Application (PDF)

    Hospital and Free-Standing Facility Based Practitioner Information Form

    Practitioner who practices exclusively within a hospital setting, inpatient setting or free-standing facility setting, meets our credentialing and contracting criteria and provides care for Asuris members only as a result of members being directed to the hospital or other inpatient setting.

    Use this form when a provider is being added to a hospital, inpatient or free-standing facility location.

    Return completed Hospital and Free-Standing Facility Based Practitioner Information Form to the address or fax number listed on the form.

    		   Hospital and Free-Standing Facility Based Practitioner Information Form (PDF)

    Dental

    Review the credentialing criteria and complete an application.

    Return completed Practitioner Credentialing applications to:

    Fax: 1 (800) 331-3505

    or

    Asuris Northwest Health
    Dental Services M/S S513
    PO Box 21267
    Seattle, WA 98111

    Practitioner Credentialing Criteria for Participation and Termination (PDF)
    (Effective 1/1/2012)

    Washington Practitioner Application (PDF)

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    Medical Pre-authorization Forms
    Form Description Instructions

    Pre-authorization Request Form

    Medical, surgical or DME services:

    		 This form is used when a condition requires a pre-authorization. A limited number of services require a pre-authorization.

    Submit completed forms:

    • Securely online, or
    • By Fax to:
           
        •

    1 (877) 663-7526 for Uniform Medical Plan (UMP) members
        •

    1 (800) 453-4341 for all other members
    Pre-authorization Fax Cover Sheet (PDF) This form is used when faxing the Pre-Authorization Request Form Use the Pre-Authorization Fax Cover Sheet to fax your Request form.

    Statement of Medical Necessity for Oncotype DX (PDF)

    This form is used to facilitate medical necessity for Oncotype Dx® Breast Cancer Assay. Codes include S3854 and 84999.

    		 Fax completed forms to 1 (800) 453-4341.
    Behavioral Health Pre-authorization Forms
    Form Description Instructions

    Behavioral Health Treatment Plan Request

    This form is for members who require an authorization for behavioral health outpatient treatment, including chemical dependency.

    Submit this form to Asuris for authorization of continued services.

    Please call Asuris Behavioral Health Customer Service at 1 (800) 780-7881 for any authorization questions. 

    Complete the Treatment plan request form securely online or you may download the form (PDF) and submit by fax to Asuris Behavioral Health 1 (888) 496-1540.

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    Provider Information Forms
    Form Description Instructions
    Notification of Covering Provider 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.
    Provider Information Update Form Use this online form to report any changes or additions to the provider’s demographics or tax ID. You may also submit your NPI to Asuris using this form. NOTE: "Tax ID changes of Clinic Agreements may require updating of contracts, please contact your provider representative for clarification." Thank you.
  		• Complete the old information, if applicable.
  		• Indicate new or changed information and submit.

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    Case Management Forms
    Form Description Instructions

    Case Management Request Form

    		Case Management is a service that is available to all members, from birth through the golden years, who may have complex or chronic medical condition(s) or event(s). Case Managers can also assist members who have a potential for future medical conditions. Complete the online referral request form or call 1(866) 543-5765.

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    Behavioral Health Forms
    Form Description
    Alcohol Use Disorders Identification Test (AUDIT) (PDF)

    The Alcohol Use Disorders Identification Test (AUDIT) was produced by the National Institute on Alcohol Abuse and Alcoholism, a component of the National Institutes of Health, and is endorsed by the World Health Organization (WHO) as a screening tool to identify heavy alcohol use.
    Zung Self-Rating Depression Scale (PDF)

    The Zung Self-Rating Depression Scale, is a screening tool to identify symptoms of depression in adults. The first page contains the screening questions; the second page contains the scoring key.

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    Medicare Forms for Hospital and Skilled Nursing Facility Discharges:

    Medicare requires specific forms to be issued for every discharge from a hospital or skilled nursing facility.

    Hospital discharge notice

    The An Important Message From Medicare About Your Rights form, along with additional information can be obtained from Centers for Medicare & Medicaid Services (CMS).

    Notice of Medicare Non-Coverage (NOMNC) forms

    It is important to use the correct Asuris form based upon your geographic location. Use of another health plan’s notification form for Asuris members is not considered valid by CMS.

    Note: The name, address and telephone number of the provider that delivers the notice must appear above the title of the form.

    Instructions - Skilled Nursing Facility NOMNC forms

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