Forms
Visit asurisdental.com for helpful resources, including:
- Dental Manual and Guidelines
- Updates to your directory information
- CDT Guide, including dental policies and procedure codes
Claims and payments
Pricing disputes
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.
Appeals
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
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)
- Claim timely filing denial
- Claim denied as duplicate claim and payment not received
- Other additional information requests
Coordination of benefits
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.
Cover sheets
- Supporting Documentation (PDF)
Complete this cover sheet when submitting information to support a claim. This ensures documentation is 'attached' to the correct claim.
Overpayment recovery
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).
Contracting and credentialing
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.
Medical management
- 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.
Medicare forms
- 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.