Provider Home Contact Site Map Search
Asuris Northwest Health serves Yakima, Walla Walla and other communities in Eastern Washington with affordable medical and dental insurance plans.
For Physicians, Other Health Care Professionals and Facilities
Admin. Simplification »
Care Management
Claims & Billing »
Contact Us »
Contracts/Credentialing »
Cost & Quality »
Dental Professionals »
Educational Tools »
Secured Site
 Provider Center »
Products »
Provider Directory »
Provider Library »
RegenceRx Pharmacy »
TriWest »
Pre-authorization

Medical Pre-authorization Lists

 

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.

    Back to top

     

    Note: To print a PDF document, you need Adobe® Reader®. Download it now for free.
     

     

     

     

     
    Asuris Northwest Health. All rights reserved.
    Asuris Ethics  Privacy Policy  Fraud and Abuse  Site Feedback