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 »
Educational Tools »
Secured Site
 Provider Center »
Products »
Provider Directory »
Provider Library »
RegenceRx Pharmacy »
TriWest »
Pre-authorization

Medical and Behavioral Health Pre-authorization Lists

 

Medical Pre-authorization Forms
Form Description Instructions

Pre-authorization Request Form

Medical, surgical or DME services:

 This form is used when a condition requires a pre-authorization. A limited number of services require a pre-authorization.

Submit completed forms:

• Securely online, or
• By Fax to:
       
    •

1 (877) 663-7526 for Uniform Medical Plan (UMP) members
    •

1 (800) 453-4341 for all other members
Pre-authorization Fax Cover Sheet (PDF) This form is used when faxing the Pre-Authorization Request Form 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

Behavioral Health Pre-authorization Forms
Form Description Instructions

Behavioral Health Treatment Plan Request

This form is for members who require an authorization for behavioral health outpatient treatment, including chemical dependency.

Submit this form to Asuris for authorization of continued services.

Please call Asuris Behavioral Health Customer Service at 1 (800) 780-7881 for any authorization questions. 

Complete the Treatment plan request form securely online or you may download the form (PDF) and submit by fax to Asuris Behavioral Health 1 (888) 496-1540.

 

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