The conditions or procedures listed below are typically excluded under most of our contracts. However, some contracts do cover these, so the member should check his or her benefits booklet. This is not a complete list. Please verify member eligibility and benefits.
- Marital and family counseling
- Investigational services or supplies
- Conditions related to acts of war or military service
- Treatment or surgery for sexual dysfunction/impotence
- Hospitalization for diagnostic purposes when not medically necessary
- Drug or chemical substance addiction or abuse, unless otherwise specified
- Charges that in the absence of coverage there would be no obligation to pay
- Injuries related to semi-professional or professional athletics, including practice
- Acupuncture, except as specifically provided in the acupuncture and chemical dependency benefits
- Counseling services that are undocumented at the member's request, pursuant to WAC 246- 810-035
- Surgery, treatment, program or supplies that are intended to result in weight reduction, regardless of diagnosis
- Treatment related to the inability to conceive; artificial means of conception; fertility drugs; however, pregnancy resulting from such treatment will be covered
- Cosmetic surgery, unless related to illness or injury occurring while covered, for reconstructive breast surgery following mastectomies and for congenital anomalies
- Treatment for malocclusion or other abnormalities of the jaw, including service for myofascial pain syndrome or any related appliances unless coverage is specifically provided for temporomandibular joint disorders
- Benefits excluded to the extent covered under any automobile medical, personal injury protection, automobile no-fault, automobile uninsured or underinsured motorist, homeowner or commercial premises, medical or similar insurance
Physical or psychiatric examinations or psychological testing for the purpose of obtaining or continuing employment, licensure, legal proceedings, insurance, school admission or a sports activity.
We will not pay for services that are not covered under the member's health plan or for services that do not meet the requirements outlined in our Administrative Manual, the provider agreement or any other Asuris communication or publication.
Each participating physician or other health care professional has entered into an agreement with us. This agreement contains important information about your responsibilities as a participating provider.
Participating providers have agreed, at a minimum, to:
- Maintain confidentiality of our proprietary information.
- Submit claims and encounter data for services provided to members.
- Refer members only to participating providers unless one is not available.
- Provide consultation to other participating practitioners as reasonably requested.
- Allow onsite reviews and medical record reviews by us upon reasonable notice.
- Provide services during normal business hours with 24-hour, 7-day-a-week emergency coverage.
- Comply with our quality improvement, credentialing and utilization management programs, policies and procedures.
- Notify our Provider Network Management department in writing at least 60 days prior to limiting or closing their practice to members.
- Maintain all required licenses, certifications, credentials and liability insurance, as defined by our credentialing program policies and procedures.
- Accept our reimbursement as payment in full for covered service rendered to eligible members. The provider cannot seek additional reimbursement from the member for covered services.
Promptly notify us when an agreement between the provider and another entity is made that states monies owed to the provider by us are assigned to that entity. Please call our Provider Contact Center if this situation is applicable to your office.
Please refer to your agreement for more complete information about your responsibilities. The above list is a summary of some of your responsibilities for reminder purposes only. It is not intended to replace or redefine the responsibilities in your agreement.