STEP 1
Client Information
Date of Request:
Client Name:
Name of Person Referring:
Email:
Phone:
Fax :
 ( )
Principal Reinsurer:

TPA Name

(If Different):
Phone:
Fax :
 ( )
Group or Plan Name:
Group/Policy No.:
Effective Date:
Contract Type:
Specific Deductible:
    
Patient Information
Patient Name:
Diagnosis:
Employee Name:
SSN:
- -
Facility/Physician:
Tax ID Number:
Dates of Service:
         Total Charges:
Is Provider in a Network?:

Name of Network:
Expiration Date of Discount:
Discount:
   
If yes, has policyholder authorization and cooperation agreement been obtained?  
If we obtain a discount, can benefits be treated as if in-network?
If yes, at what percentage are benefits payable?
Please provide the following information prior to submitting for negotiation:
Claim is payable at:
Deductible / Out-of-pocket (owed)
When are checks cut for group? Other:
Has any payment been made on this bill? |   If yes, amount paid:
 
Comments including any applicable benefit limitations:
Services Requests
Negotiation
Network Repricing
Bill Review (w/out Medical Record)
Bill Audit (with Medical Record)
For Bill Review and Audits, please check the following boxes:
Quality of care issue Over Threshold - Days
Excessive charges Inconsistencies in charges
Excessive Length of Stay Multiple Diagnosis Charge Split
Non-covered condition “carve out” Others:
 
Agreement: Client represents that it has verified the patient’s eligibility for benefits and availability of benefits under the Group’s plan (and Excess Loss/ Reinsurance coverage, if applicable) and agrees to pay the Provider(s) the discounted amount within the time frame agreed upon between ASERT and the Provider(s). If a discount is lost due to non-payment of the bill or payment outside the terms agreed upon between ASERT and the Provider(s), ASERT’s fee remains due and payable. Client agrees to pay Asert for Bill Review/Screening if Client: 1) requests this service or 2) if Client prevents Asert from initiating or completing a requested negotiation. Client agrees that the above information is accurate and that ASERT can rely on this information and shall not be responsible for any losses resulting from inaccurate information. Network discounts must be reported on this form and must be valid and accepted by the Provider(s) to be recognized for net savings calculation. ASERT does not guarantee payment of benefits under any Benefit Plan or Reinsurance/Excess Loss coverage and does not review the medical necessity of the services or appropriateness of the charges submitted for negotiation or Network Repricing.  
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ASERT's FAX Number : 305-670-0760
I agree to the above terms