Appeals
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Appeals

Appeals

There are several appeal processes available to Asuris providers.

  • Adverse determination and dispute process
  • External audit and investigation process
  • Provider contract termination process
  • Medical and reimbursement policy reconsideration process

Before submitting an appeal, please review the information about each process to ensure you are following the correct process for your specific issue.

View additional details about the processes in the Appeals for providers (PDF) section in our Administrative Manual.

Notes about other types of disputes:

  • Member appeal process (PDF) applies to:
    • Claims denied as member payment responsibility.
    • Services received from a non-participating provider and not governed by Washington House Bill 1065 Balance Billing Protection Act beginning January 1, 2020.
    • Claim denied for additional information that you are now submitting. Use the form available on our member website.
  • Medicare Advantage: The member must file the grievance within 60 days of the event or incident that precipitated the grievance. View information about appeals for Medicare Advantage members in the Medicare Advantage Plans (PDF) section of the Administrative Manual.
  • Disputes related to contractual pricing of a claim or claim line, contact Provider Relations
  • Disputes related to the following, contact Provider Contact Center:
    • Claim denied for timely filing
    • Additional information requests
    • Claim denied as duplicate claim and payment not received
  • Disputes governed by Washington HB 1065 Balance Billing Protection Act beginning January 1, 2020, from Washington non-contracted providers regarding payment or offer of payment must submit a dispute within 30 days to:

Asuris Provider Disputes
HB 1065 Disputes
Fax: 1 (855) 357-3172

Very large documents or documents sent by certified mail may be sent to:

Asuris Provider Disputes
HB 1065 Disputes
PO BOX 1248
Lewiston ID 83501-1248

Adverse determinations

Adverse Determination Appeal Process

The Adverse Determination Appeal Process (PDF) for our commercial members applies when a provider is at financial risk for the cost of a claim. The process is outlined in the Appeals for Providers section of our Administrative Manual. Appeals for hospital claims follow the process outlined in the hospital's current agreement with us.

Use the adverse determination appeal form (PDF) to disagree with our decision that:

  • Medical necessity criteria were not met
  • Pre-authorization was not obtained (dispute process)
  • NCCI or CCE coding rules apply to a claim or claim line
  • Admission notification was not provided (dispute process)
  • Line-item audit resulted in a reduced payment or denial (dispute process)
  • Items/services billed were not consistent with the medical records provided
  • Hospital acquired conditions (HAC)/never events charges were denied (dispute process)
  • Items/services billed were not consistent with our reimbursement/medical policies or contracts
  • Claim denied as a duplicate when services were performed more than one time, and payment does not reflect multiple service payment

The completed appeal form or a written description of the (issue(s) on the appeal must be submitted to us by facsimile to 1 (866) 273-1820.

Very large documents or documents sent by certified mail may be sent to:

Asuris
Attention: Provider Appeals
P.O. Box 1248
Lewiston, ID 83501-1248

The following information must be submitted with the Provider Appeal Form or the written description of the issue(s) on appeal:

a) A detailed description of the disputed issue(s);
b) The basis for disagreement with the decision; and
c) All evidence and documentation supporting your position.

A first internal level Adverse Determination Appeal or Dispute for our commercial members must be submitted in writing within the following timeframes based on the Plan in which the provider is contracted:

Washington providers: within 24 months after payment of the claim or notice that the claim was denied or 30 months for claims subject to coordination of benefits.

Please refer to the Administrative Manual for subsequent appeal processes beyond the first internal level of appeal or dispute.

Notification:

  • If an appeal is upheld or partially upheld, you will receive an appeal determination letter.
  • If an appeal is overturned, you will receive a provider voucher upon claims reprocessing.
External Audit and Investigation

External Audit and Investigation Appeal Process

The External Audit and Investigation Appeal Process is intended to give providers an opportunity to request reconsideration of audit findings issued by our External Audit and Investigation Department and to ensure we have reviewed all information relevant to the audit findings.

Provider contract termination

Provider Contract Termination Appeals

A contracted provider may initiate an appeal of a contract termination, adverse decision due to quality reasons or altering conditions of participation made by Asuris through the Provider Contract Termination Appeal Process.

Most of the appeal panel participants must be clinical peers of the provider. At least one panel participant must be a participating provider who is not involved in network management and who is a clinical peer of the participating provider. Other panel members may include, but are not limited to, the Asuris executive medical director, director of provider contracting and the director of provider network management.

Medical and reimbursement policy reconsideration

Medical and reimbursement policy reconsideration

Requests for review of a policy determination not related to a claim may be submitted using the:

  • Medical Policy Review Request process, or the
  • Reimbursement Policy Request for Review process

Additional information about these processes is available in the Policies (PDF) section of our Administrative Manual.