Forms

• Authorization to Disclose Protected Health Information (PDF)
• Authorization to Disclose Protected Health Information - Spanish (PDF)
• Behavioral Health Practitioner Areas of Clinical Focus form
  The information you share about your areas of clinical focus and modalities helps our members make informed decisions about their health care and who they select for services.

• Anxiety: Screening and treatment in the primary care setting (PDF)
• Depression: Screening and treatment in the primary care setting (PDF)

Visit asurisdental.com for helpful resources, including:

• Dental Manual and Guidelines
• Updates to your directory information
• CDT Guide, including dental policies and procedure codes

If you disagree with the contracted allowable rate applied to a claim or claim line items, please follow the pricing dispute process.

Contracted providers: Use the Pricing Dispute Form to submit your dispute.

Out-of-network (OON) providers: Follow our pricing dispute process for OON providers.

Use the Provider Appeal Form (PDF) to disagree with our decision that:

• Pre-authorization was not obtained
• No admission notification was provided
• NCCI or CCE coding rules apply to a claim or claim line
• A claim denied as a duplicate when services were performed more than one time, and payment does not reflect multiple service payment
• Claim denied for not meeting our medical necessity criteria
• Unlisted procedure codes paid a certain amount

• Additional reimbursement denied for the use of a payment enhancing modifier (modifier 22)

Note: Any dispute relating to how a claim or claim line was processed must be submitted via the pricing dispute process.

Use this guide to submit medical records via secure file transfer protocol (SFTP) to Appeals.

Other disputes may include:

• Claim denied as member's payment responsibility. The Member appeal process (PDF) applies.
• Claim denied for additional information that you are now submitting:
  • Coordination of Benefits (PDF)

• Call our Provider Contact Center for disputes relating to:

  • Claim timely filing denial
  • Claim denied as duplicate claim and payment not received
  • Other additional information requests

Coordination of Benefits (COB) enables your patients to receive benefits from all health insurance plans they are covered under.

• Coordination of Benefits (PDF)
  Members should complete this form to help us process claims correctly.
• Incident Report (PDF)
  Our members receive an incident report if the condition being treated requires investigation for third party liability.
  

• Supporting Documentation (PDF)
  Complete this cover sheet when submitting information to support a claim. This ensures documentation is 'attached' to the correct claim.
  

Payments are occasionally recouped due to a duplicate or adjusted claim. Learn more about the overpayment recovery process.

• To request a deduction to a future voucher:
  • Complete the online form. This is the preferred method for responding, especially if there are no attachments. If you need a copy of the completed form, please print the page before selecting Submit.
  • To attach documentation print and fax the Overpayment/Voucher Deduction Request (PDF).

• To refund the overpayment to us complete a Refund Notification (PDF)

We contract with physicians, dentists, other health care professionals and facilities to form provider networks essential for delivery of health care and dental services to our members. All providers and facilities, except locum tenens, must be credentialed before they can participate in our provider networks.

Would you like to join our networks as a contracted provider? Use our provider onboarding resource to quickly get started.

• View a step-by-step Guide to contracting (PDF).

• Use the Electronic Contracting Registration form to add or update details about your legal contract signatory.

• Case management Referral Request
  The case management referral request allows members to receive assessment from our care management staff. Case Management is a service that is available to all members 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.
• NICU/PICU Notification of Admission Form (PDF)
• Medical Peer-to-Peer Review Request form
  A peer-to-peer (P2P) review is a telephone conversation between a licensed Asuris physician and the physician or other health care professional requesting authorization for coverage. A P2P is not an appeal and is not intended to overturn the denial. The purpose is to further understand the reason for the denial based on our medical policies. Submit this form to request a review.
• Pharmacy Peer-to-Peer Review Request form (for provider administered medications)
  If you would like to speak with a clinical reviewer about the denial of a provider-administered medication pre-authorization request, please complete this form to arrange for a peer-to-peer (P2P) discussion. For retail (self-administered) medications, please call Pharmacy Customer Service at 1 (844) 765-6827.
  Note: All medication-related calls will be routed to an Asuris clinical pharmacist. If there are questions that the clinical pharmacist is unable to answer, the clinical pharmacist will schedule a call with an Asuris medical director.
  

• In-network Benefits to an Out-of-Network Provider (PDF)
  Request an organizational determination for an Asuris TruAdvantage PPO member to receive in-network benefits for services rendered by a provider out of the member's Asuris TruAdvantage PPO network.
  

The Centers for Medicare & Medicaid Services (CMS) requires specific forms to be issued for specific situations.

• Waiver of liability for appeals
  • A non-participating provider may become a party to an appeal only if the provider has executed a waiver of liability form. (See the downloads section.) This form ensures that the enrollee will not be held financially responsible for any charges should the provider lose the appeal.
• Medicare Outpatient Obervation Notice (MOON)
  • CMS requires all hospitals and critical access hospitals (CAHs) to provide written notification via the Medicare Outpatient Observation Notice (MOON) and an oral explanation to Medicare beneficiaries who are receiving observation services as outpatients for more than 24 hours. All hospitals and CAHs are required to provide this notice.
• Hospital discharge notice
  • An important message from Medicare about your rights, along with additional information can be obtained from CMS.

• Notice of Medicare non-coverage (NOMNC)

  • We provide the skilled nursing facility (SNF) with the member-specific form at least two days prior to the end of approved services. The form instructions and requirements are listed in the Medicare Advantage Plans section of our Administrative Manual.

View medication pre-authorization forms.

The Patient review feature gives our members the ability to provide feedback on their experiences with the health care system. You can respond to your patient's comments about their experience with you by completing the Provider Response Form (PDF).

• View our pre-authorization lists for forms and instructions for submitting a pre-authorization request.

• Pre-authorization requests can also be submitted online via the Availity Provider Portal. Some requests may receive automatic approval.

• Notification of Covering Provider (PDF)
  Submit 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.
• Electronic Contracting Registration - submit this form to register for electronic contracting, or update information about the invididual designated with the authority to review and sign agreement documents on your behalf (your legal contract signatory).
• Provider Information Update Form - Complete this form when you need to let us know about one of the following changes:
  • Specialty
  • Phone number
  • Organization's address
  • Accepting new patients
  • Offering telehealth services
  • eContracting email address
  • Changing organization ownership
  • Practice data validation email address
  • National Provider Identifier (NPI) number
  • Providers joining or leaving your clinic or practice
  • Changing where your payments should be directed
  • Changing your tax ID number (include a copy of your 147c letter from the IRS)

Dental providers - Visit asurisdental.com to update your practice information.

The following changes must be submitted in writing via certified mail:

• Terminating a network affiliation
  • Removing one provider from a group contract only requires a Provider Information Update Form be submitted

• Closing a practice

• Confidential Communication Request Form (PDF)
  Request that we use an alternative location when communicating with you about your Protected Health Information (PHI).
• Sample Consent for Disclosure of Patient Identifying Information and Substance Use Disorder Patient Records form (PDF)
  Use this sample form as a guideline disclaimer when Part 2 information is shared (e.g. from provider to health insurer).
• Sample non-covered services 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 Notification of a Deceased Member form
  Notify us of the passing of one of our members.