PRIOR AUTHORIZATION - Cigna...PRIOR AUTHORIZATION Generic fax request form Providers: you must get...

1
PRIOR AUTHORIZATION 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 DME and, Home Health 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. © 2017 Cigna INT_17_53852 04212017 Please fax this form and supportive clinical to Pre-Cert department below by market: Market Phone # Fax # TN, IL, IN, No. MS, No. GA, AR 800.453.4464 866.287.5834 AL, FL, NC, SC, So. MS, Atlanta 800.962.3016 866.913.0940 TX, AR, OK 832.553.3456 888.205.8658 MA, PA, DE, DC, KC 888.454.0013 888.951.0144 • For a list of Cigna-Healthspring services requiring PA, visit cigna.com/medicare/medicare/healthcare-professionals/ 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 cigna.com/medicare and use the Provider SearchTool.

Transcript of PRIOR AUTHORIZATION - Cigna...PRIOR AUTHORIZATION Generic fax request form Providers: you must get...

Page 1: PRIOR AUTHORIZATION - Cigna...PRIOR AUTHORIZATION Generic fax request form Providers: you must get Prior Authorization (PA) for services before service is provided. PA is not guarantee

PRIOR AUTHORIZATION

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 DME and, Home Health 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. © 2017 Cigna INT_17_53852 04212017

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

Market Phone # Fax #

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

AL, FL, NC, SC, So. MS, Atlanta 800.962.3016 866.913.0940

TX, AR, OK 832.553.3456 888.205.8658

MA, PA, DE, DC, KC 888.454.0013 888.951.0144

• For a list of Cigna-Healthspring services requiring PA, visit cigna.com/medicare/medicare/healthcare-professionals/ or call your state’s Pre-Cert Department

• IfyouneedhelpfindingaPARfacilityorprovider,pleasecall800-230-6138orvisitcigna.com/medicareandusetheProviderSearchTool.

Musculoskeletal Prior Authorization for Highmark...This presentation contains CONFIDENTIAL and PROPRIETARY information. How to request prior authorization: Prior Authorization Requests

Musculoskeletal Prior Authorization for Highmark...This presentation contains CONFIDENTIAL and PROPRIETARY information. How to request prior authorization: Prior Authorization Requests

Electronic Prior Authorization (ePA) AMCP... · The New Standard for Electronic Prior Authorization: ... Tony is leader for the NCPDP electronic prior authorization (ePA) ... 17 Prior

Electronic Prior Authorization (ePA) AMCP... · The New Standard for Electronic Prior Authorization: ... Tony is leader for the NCPDP electronic prior authorization (ePA) ... 17 Prior

FORWARDHEALTH PRIOR AUTHORIZATION REQUEST FORM (PA · PDF filePRIOR AUTHORIZATION REQUEST FORM (PA/RF) ... (608) 221-8616 or by mail to: ForwardHealth, Prior Authorization, Suite 88,

FORWARDHEALTH PRIOR AUTHORIZATION REQUEST FORM (PA · PDF filePRIOR AUTHORIZATION REQUEST FORM (PA/RF) ... (608) 221-8616 or by mail to: ForwardHealth, Prior Authorization, Suite 88,

Prior Authorization Form Synagis® · Prior Authorization Form Synagis® Access this PA form at

Prior Authorization Form Synagis® · Prior Authorization Form Synagis® Access this PA form at

Marketplace Prior Auth (PA) Code Matrix Effective …...Marketplace Prior Auth (PA) Code Matrix Effective Q4, 2019 Any exceptions included in this Prior Authorization Code Matrix document

Marketplace Prior Auth (PA) Code Matrix Effective …...Marketplace Prior Auth (PA) Code Matrix Effective Q4, 2019 Any exceptions included in this Prior Authorization Code Matrix document

UnitedHealthcare Notification/Prior Authorization ... UHC...UnitedHealthcare Notification/Prior Authorization Requirements ... Notification/Prior Authorization Requirements Effective

UnitedHealthcare Notification/Prior Authorization ... UHC...UnitedHealthcare Notification/Prior Authorization Requirements ... Notification/Prior Authorization Requirements Effective

Alabama Medicaid Preferred Drug and Prior Authorization ......Preferred Drug and Prior Authorization Program DMARD/Biological Injectable Agents Prior Authorization (PA) Criteria Instructions

Alabama Medicaid Preferred Drug and Prior Authorization ......Preferred Drug and Prior Authorization Program DMARD/Biological Injectable Agents Prior Authorization (PA) Criteria Instructions

Prescription Drug Formulary Prior Authorization (PA) NQTL ...

Prescription Drug Formulary Prior Authorization (PA) NQTL ...

Saver Drugs That Require Prior Authorization (PA) …...Saver Drugs That Require Prior Authorization (PA) Before Being Approved for Coverage You will need authorization from Express

Saver Drugs That Require Prior Authorization (PA) …...Saver Drugs That Require Prior Authorization (PA) Before Being Approved for Coverage You will need authorization from Express

PRIOR AUTHORIZATION - Cigna · 2018. 8. 22. · PRIOR AUTHORIZATION Generic fax request form Providers: you must get Prior Authorization (PA) for services before service is provided.

PRIOR AUTHORIZATION - Cigna · 2018. 8. 22. · PRIOR AUTHORIZATION Generic fax request form Providers: you must get Prior Authorization (PA) for services before service is provided.

Molina Healthcare of Ohio Prior Authorization (PA) List · molina healthcare of ohio prior authorization (pa) list ... alinia 100 mg/5 ml suspensi lower cost alternatives alinia 500

Molina Healthcare of Ohio Prior Authorization (PA) List · molina healthcare of ohio prior authorization (pa) list ... alinia 100 mg/5 ml suspensi lower cost alternatives alinia 500

Outpatient Prior Authorization Requirements€¦ · Outpatient Prior Authorization Requirements . This document provides the services requiring prior authorization. ... E0202 E0301

Outpatient Prior Authorization Requirements€¦ · Outpatient Prior Authorization Requirements . This document provides the services requiring prior authorization. ... E0202 E0301

PRIOR AUTHORIZATION LIFELINE Desk Manual PA Desk Manual_Nov 2014... · 4. If there is only one Lifeline Prior Authorization the “Prior Authorization Information” panel and the

PRIOR AUTHORIZATION LIFELINE Desk Manual PA Desk Manual_Nov 2014... · 4. If there is only one Lifeline Prior Authorization the “Prior Authorization Information” panel and the

Prior Authorization of Extended Nursing Services...Objectives 1 Review the HUSKY Health program’s person-centered Prior Authorization (PA) process for determining the medical necessity

Prior Authorization of Extended Nursing Services...Objectives 1 Review the HUSKY Health program’s person-centered Prior Authorization (PA) process for determining the medical necessity

Prior Authorization / Preferred Drug List (PA/PDL) for ... ANTIEMETICS, CANNABINOIDS . Instructions: Type or print clearly. Before completing this form, read the Prior Authorization/Preferred

Prior Authorization / Preferred Drug List (PA/PDL) for ... ANTIEMETICS, CANNABINOIDS . Instructions: Type or print clearly. Before completing this form, read the Prior Authorization/Preferred

PRIOR AUTHORIZATION / “J” CODE ATTACHMENT (PA/JCA), · prior authorization / “j” code attachment (pa/jca) Providers may submit prior authorization (PA) requests with attachments

PRIOR AUTHORIZATION / “J” CODE ATTACHMENT (PA/JCA), · prior authorization / “j” code attachment (pa/jca) Providers may submit prior authorization (PA) requests with attachments

Prior Authorization: AMA Update · 2019. 12. 10. · Overview. Review of the Prior Authorization (PA) Landscape • 2018 AMA PA Physician Survey • The human face of PA: AMA grassroots

Prior Authorization: AMA Update · 2019. 12. 10. · Overview. Review of the Prior Authorization (PA) Landscape • 2018 AMA PA Physician Survey • The human face of PA: AMA grassroots

Prior Authorization Crosswalk Table - UHCprovider.com › content › dam › provider › docs › publi… · Prior Authorization Crosswalk Table May 2019 Prior Authorization given

Prior Authorization Crosswalk Table - UHCprovider.com › content › dam › provider › docs › publi… · Prior Authorization Crosswalk Table May 2019 Prior Authorization given

MIHMS Provider Community Training Prior … Training Information...2010/08/09  · MIHMS Provider Community Training Prior Authorization (PA) Version 1.2 Provider_Training_PA_v1.2_20100809.pptx

MIHMS Provider Community Training Prior … Training Information...2010/08/09  · MIHMS Provider Community Training Prior Authorization (PA) Version 1.2 Provider_Training_PA_v1.2_20100809.pptx

Blue Cross of Idaho Prior Authorization Criteria (Updated … · 2019-12-09 · Updated 12/01/2019 1 PA Criteria Prior Authorization Group ACITRETIN Drug Names ACITRETIN Covered Uses

Blue Cross of Idaho Prior Authorization Criteria (Updated … · 2019-12-09 · Updated 12/01/2019 1 PA Criteria Prior Authorization Group ACITRETIN Drug Names ACITRETIN Covered Uses