Overpayment/voucher deduction request

This form is to be used to request a deduction on a future remittance advice (voucher) in response to a recent recoupment request from Asuris, or as a result of an overpayment discovered by your internal claims review process. Please use the comment section for additional information.

Asuris Northwest Health has our permission to automatically deduct the requested amount for the following claim(s):

*Asterisks indicate required fields.

Please complete all fields of this form to ensure your request is processed quickly and accurately.

Member ID*

Claim number(s)*

In the comments section below:

Indicate the amount to be deducted
Indicate if this is in response to a recoupment request from Asuris, or
If the result of your own overpayment discovery, indicate if the error was:
- Not our patient
- Duplicate payment
- Other insurance primary
- Third party responsiblity (please explain)
- Other (please explain)

Comments*

Office name*

Tax ID and/or NPI number*

Office contact name*

Email*

Phone*

Submission of this form serves as notification on how to proceed with your deduction request and/or Regence's recent recoupment request. Any claim(s) processed as a result of this request will be reflected in a future remittance advice.

The proposed overpayment amount is based on the current claim status within our system and any adjustments could affect patient responsibility, which may include copayment, deductible amounts and coinsurance amounts.