Asuris Northwest Health - For Providers


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Claims & Billing
Contracting and Credentialing Forms
McKesson Specialty Rx Forms (located on the RegenceRx Physician Web site)
Asuris TruAdvantage
Hospital-Based Practitioner Information Form
Medical Pre-authorization
Medication Prior Authorization Forms (now located on the RegenceRx Physician Web site)
Provider Information Forms
Case Management
Behavioral Health

Claims & Billing Forms

Form

Description

Instructions

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.

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.

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.

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.

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.

Contracting and Credentialing Forms

Provider	Definition	Criteria	Forms
Practitioners Return completed applications to: Asuris Northwest Health Credentialing Department P.O. Box 21267 Mail Stop S555 Seattle, WA 98111-3267 Fax: 1 (888) 335-3002 Email	Physicians and other health care professionals.	Practitioner Credentialing Criteria for Participation and Termination (PDF) (Effective 1/1/2010)	Washington Practitioner Application (PDF)
Organizations Return completed applications to: Asuris Northwest Health Credentialing Department P.O. Box 21267 Mail Stop S555 Seattle, WA 98111-3267 Fax: 1 (888) 335-3002 Email	Eligible organizational providers include: Ambulatory Surgery Centers Hospital Medical Centers Home Health Agencies Hospice Care Centers Skilled Nursing Facilities Behavioral Health Care Organizations, including those that provide mental health, chemical dependency, alcohol and drug rehabilitation services	Organizational Provider Credentialing Criteria for Participation and Termination (PDF) (Effective 1/1/2010)	Universal Organization Application (PDF) W9 form and instructions
Dentists and dental professionals Fax or mail completed Application and Additional Provider Information form to: Asuris Northwest Health Dental Services PO Box 21267 Mail Stop S513 Seattle, WA 98111 Fax: 1 (800) 331-3505			Dental Provider Application (PDF) Additional Provider Information form (PDF)

Medical Pre-authorization Forms

Form

Description

Instructions

Pre-authorization Form (PDF)

Pre-authorization Fax Cover Sheet (PDF) (for use when faxing the form)

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

View a list of services and supplies requiring pre-authorization

	Indicate which product the member has.
	Indicate if original request.
	Complete part II of the form, including all procedures/HCPCS codes AND diagnosis.
	If supporting documentation is attached, mail the form to the addresses listed.
	If no supporting documentation, fax the form (PDF) and cover sheet (PDF) to the number(s) indicated on 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.

Provider Information Forms

Form

Description

Instructions

Notification of Covering Provider

	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.

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.

Behavioral Health Forms
Form	Description	Instructions
Asuris Behavioral Health Outpatient Treatment Plan Request (PDF)	This form is for members with Asuris Northwest Health coverage who require an authorization for behavioral health outpatient treatment. Please call Asuris Behavioral Health Customer Service at 1 (800) 780-7881 for any authorization questions.

Hospital-Based Practitioner Information Form
Hospital-Based Practitioner Information Form (PDF)	Use this form when a provider is being added to a hospital-based facility. Asuris defines Hospital Based Practitioners as, “Practitioners who practice exclusively within a hospital 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."

Medicare Forms
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).
Asuris TruAdvantage Forms
Notice of Medicare Non-Coverage (NOMNC) Forms for home health and skilled nursing facilities.
Audience	Form	Description
Skilled Nursing Facilities	Notice of Medicare Non-Coverage (NOMNC) (PDF)	Skilled Nursing Facilities have unique requirements related to the Notice of Medicare Non-Coverage (NOMNC). See our NOMNC Fact Sheet (PDF) for more information. 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.
Home Health Agencies	Notice of Medicare Non-Coverage (NOMNC) (PDF)	Home Health Agencies have unique requirements related to the Notice of Medicare Non-Coverage (NOMNC). See our NOMNC Fact Sheet (PDF) for more information. 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.

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