MEDICARE ADVANTAGE PRIOR AUTHORIZATION · Generic fax request form Providers: you must get Prior...

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Generic fax request form Providers: you must get Prior Authorization (PA) for services before service is provided. PA is not guarantee of payment. Payment is subject to coverage, patient eligibility and contractual limitations. Please use appropriate form for Durable Medical Equipment (DME) and Home Health Care requests. Date _______ /_______ /_______ Please check request type ¨ Standard request Note: If the service has already been provided, please follow retro process and submit claim. ¨ Expedited Requests-May take up to 72 hours. I certify that waiting for a decision under the standard time frame could place the enrollee’s life, health, or ability to regain maximum function in serious jeopardy. ____________________________________________________ Provider signature required Patient name Requesting provider Patient ID # Provider NPI # Patient birthdate Contact name Contact phone # Contact fax # Date of service _____/______/_______ Name of facility/place of service/specialist __________________________________ MA ONLY: Is provider part of a regulated facility? ¨ Yes ¨ No Diagnosis with ICD 10 ¨ Inpatient ¨ Outpatient Service or procedure, including codes Quantity or number of visits requested All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. 936620 b 03/20 © 2020 Cigna INT_20_85095_C Please fax this form and supportive clinical to Pre-Cert department below by market: Market Phone # Fax # TN, IL, IN, No. MS, No. GA, East AR 800.453.4464 866.287.5834 AL, FL, NC, SC, So. MS, Atlanta 800.962.3016 800.872.8685 TX, AR, OK 832.553.3456 888.205.8658 MA, PA, DE, DC, KC, CO, NJ 888.454.0013 800.931.0145 • For a list of services requiring PA, visit MedicareProviders.Cigna.com or call your state’s Pre-Cert Department • If you need help finding a PAR facility or provider, please call 800-230-6138 or visit MedicareProviders.Cigna.com and use the Provider Search Tool. MEDICARE ADVANTAGE PRIOR AUTHORIZATION

Transcript of MEDICARE ADVANTAGE PRIOR AUTHORIZATION · Generic fax request form Providers: you must get Prior...

Page 1: MEDICARE ADVANTAGE PRIOR AUTHORIZATION · Generic fax request form Providers: you must get Prior Authorization (PA) for services before service is provided. ... PA, DE, DC, KC, CO,

Generic fax request formProviders: you must get Prior Authorization (PA) for services before service is provided. PA is not guarantee of payment. Payment is subject to coverage, patient eligibility and contractual limitations. Please use appropriate form for Durable Medical Equipment (DME) and Home Health Care requests.

Date _______ /_______ /_______ Please check request type

¨ Standard request

Note: If the service has already been provided, please follow retro process and submit claim.

¨Expedited Requests-May take up to 72 hours.

I certify that waiting for a decision under the standard time frame could place the enrollee’s life, health, or ability to regain maximum function in serious jeopardy. ____________________________________________________

Provider signature required

Patient name Requesting provider

Patient ID # Provider NPI #

Patient birthdate Contact name

Contact phone # Contact fax #

Date of service _____/______/_______ Name of facility/place of service/specialist __________________________________

MA ONLY: Is provider part of a regulated facility? ¨ Yes ¨ No

Diagnosis with ICD 10 ¨ Inpatient ¨ Outpatient

Service or procedure, including codes Quantity or number of visits requested

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. 936620 b 03/20 © 2020 Cigna INT_20_85095_C

Please fax this form and supportive clinical to Pre-Cert department below by market:

Market Phone # Fax #

TN, IL, IN, No. MS, No. GA, East AR 800.453.4464 866.287.5834

AL, FL, NC, SC, So. MS, Atlanta 800.962.3016 800.872.8685

TX, AR, OK 832.553.3456 888.205.8658

MA, PA, DE, DC, KC, CO, NJ 888.454.0013 800.931.0145

• For a list of services requiring PA, visit MedicareProviders.Cigna.com or call your state’s Pre-Cert Department

• If you need help finding a PAR facility or provider, please call 800-230-6138 or visit MedicareProviders.Cigna.com and use the Provider Search Tool.

MEDICARE ADVANTAGE PRIOR AUTHORIZATION

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