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Asuris Northwest Health serves Yakima, Walla Walla and other communities in Eastern Washington with affordable medical and dental insurance plans.
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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.

    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.

    		 
    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.

    		 

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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 6/1/2010)

    		 Asuris Practitioner Application (PDF)

     

    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 Asuris Practitioner Application (PDF) and the TRICARE Supplemental Credentialing Questionnaire.  

    TRICARE Supplemental Credentialing Questionnaire

    Organizations

    Eligible organizational providers include:

    • Child Birthing Centers
    • 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

    Note:  Effective November 1, 2010, all organizational providers (facilities) are required to complete the credentialing process prior to contracting with Asuris. They will also be required to complete the recredentialing process 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 1/1/2010)     		Universal Organization Application (PDF)

    Hospital-Based Practitioner Information Form

    Practitioner who practices 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.

    Use this form when a provider is being added to a hospital-based facility.

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

    		 Hospital performs credentialing functions. Hospital-Based Practitioner Information Form (PDF)

    Dental

    Credentialing is not required

    Complete an application and the information request (if applicable).

    Return completed Dental Provider Application and Additional Provider Information form to:

    Asuris Northwest Health
    Dental Services M/S S513
    PO Box 21267
    Seattle, WA 98111
    Fax: 1 (800) 331-3505

    Dental Provider Application (PDF)

    Additional Provider Information form (PDF)

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    Medical Pre-authorization Forms
    Form Description Instructions

    Pre-authorization Request 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.

  		• Complete all fields online.
  		• Print the form and submit by fax to 1 (800) 453-4341.
  		• 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.

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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 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.  

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    Medicare Forms for Hospital, Skilled Nursing Facility or Home Health Discharges:

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

    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.

    Instructions - Home Health Agency NOMNC forms

    Instructions - Skilled Nursing Facility NOMNC forms

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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 6/1/2010)

    		 Asuris Practitioner Application (PDF)

     

    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 Asuris Practitioner Application (PDF) and the TRICARE Supplemental Credentialing Questionnaire.  

    TRICARE Supplemental Credentialing Questionnaire

    Organizations

    Eligible organizational providers include:

    • Child Birthing Centers
    • 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

    Note:  Effective November 1, 2010, all organizational providers (facilities) are required to complete the credentialing process prior to contracting with Asuris. They will also be required to complete the recredentialing process 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 1/1/2010)     		Universal Organization Application (PDF)

    Hospital-Based Practitioner Information Form

    Practitioner who practices 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.

    Use this form when a provider is being added to a hospital-based facility.

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

    		 Hospital performs credentialing functions. Hospital-Based Practitioner Information Form (PDF)

    Dental

    Credentialing is not required

    Complete an application and the information request (if applicable).

    Return completed Dental Provider Application and Additional Provider Information form to:

    Asuris Northwest Health
    Dental Services M/S S513
    PO Box 21267
    Seattle, WA 98111
    Fax: 1 (800) 331-3505

    Dental Provider Application (PDF)

    Additional Provider Information form (PDF)

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