Asuris Northwest Health - For Providers

Medical Pre-authorization Lists

Group and Individual Products (Asuris HSA Healthplan 2.0^SM, Asuris Embark^SM, Vantage^SM and Motivate^SM)
Medicare and Medicaid Products (Asuris TruAdvantage, Medicare Part D, Healthy Options)
Pharmacy

Medical Pre-authorization Forms

Form

Description

Instructions

Pre-authorization Form (PDF)

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

	Indicate which product the member has.
	Indicate if original request.
	Complete part II of the form, including all procedures/HCPCS codes AND diagnosis.
	If supporting documentation is attached, mail the form to the addresses listed.
	If no supporting documentation, fax the form (PDF) and cover sheet (PDF) to the number(s) indicated on form.

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.