Pricing Dispute Form

Use this form to disagree with our decision on how a claim processed according to your provider agreement.

Important notes:

Pricing disputes are not appeals and do not follow the appeal process or timeline.
Any dispute or appeal that is not a pricing dispute and/or is from a non-contracted provider will be returned to follow the appropriate appeal process.
Appeals will not be forwarded using this submission channel.

Before submitting this form:

We require you to validate your pricing dispute using all available resources, including but not limited to:

Your reimbursement schedule
Your most recent agreement terms
Provider website resources, including:
- Coding Toolkit
- Billing guidelines
- Administrative Manual
- Reimbursement policies
Provider Contact Center
Availity Essentials resources

Facility diagnosis related group (DRG) pricing is applied per the grouper version indicated in your agreement. Please verify your current grouper version matches what is indicated in your agreement prior to submitting a DRG dispute.

Fields marked with an asterisk (*) are required fields.

Your details

First name*

Last name*

Phone*

Email*

NPI number*

Tax ID number*

Rendering provider/Facility name(s)*

Fax number

Contract ID

The Contract ID is found in the footer of your agreement document.

Are you a third-party billing company?*

Yes

Claim details

Has this claim been disputed with Asuris before?*

Yes

Does this dispute impact more than five Asuris members?*

Yes

Add up to five claims and their related details in the following fields.

Claim 1

Claim 2

Claim 3

Claim 4

Claim 5

Pricing dispute details

Please provide a detailed explanation.

Documentation

If documentation examples are not included in support of this pricing dispute, this request will be considered invalid and will be returned without review. Please complete all applicable fields below. If a specific field is not applicable, it can be left blank.

Asuris provider website

Please include description and URL of content.

Specific agreement terms

Include agreement name, effective date and page number, as well as the rationale being used for the dispute, such as RVU year, base rate, conversion factor, percentage, etc.

Administrative manual

Include the manual section and page number.

Reimbursement schedules

Include schedule name, effective date and page number.

Reimbursement policy

Include policy name and number or website link.

Desired outcome and expected additional payment amount*

We process updates within 30 business days.

If you have questions after 30 days, please call the Provider Contact Center.

Please DO NOT submit duplicate requests.