928176b Rev. 07/2021
Intensive Outpatient Program (IOP)
Request Form
This form should be completed by the clinician who has a thorough knowledge of the Cigna customer's current
clinical presentation and his/her treatment history. Please note: The information contained in this form may be released
to the customer or the customer's representative.
To help expedite processing of this request, please complete all sections as specifically and clearly as possible.
Typed responses are preferred.
Please do not send encrypted messages.
Omissions, generalities, and illegibility will result in this request being returned for completion or clarification.
Initial request Continued Stay request
1. Customer name:
Customer date of birth:
Cigna ID #: Policyholder Social Security number (SSN)
2. Facility name:
Taxpayer Identification Number (TIN):
Service address:
Utilization Reviewer name: UR phone: Ext.:
Requested start date for treatment, if authorization is granted:
Diagnosis (F codes):
Previous authorization number
Billing Code: 905 MH IOP/S9480
906 CD IOP/H0015
Number of visits requested: 30 18 12
Number of visits per week: Number of hours per day:
Last substance use date (optional): N/A (optional): Planned discharge date:
Current functional impairment (optional):
Aftercare plan
or Other:
All fields are required unless marked as '(optional)'.
Network Exception Request
CPT Code 90853 does not require authorization, do not submit this form.
3. Authorization Request
UR FAX Number (to Receive Return Faxes):
928176b Rev. 07/2021
5. Please provide any additional/relevant information (do not attach extra pages) (optional):
6. State Specifics:
Please complete this form, save it to your computer, then submit by:
Fax: 1.833.213.9211**(Recommended for more timely response)
”Cigna Behavioral Health” refers to Cigna Behavioral Health, Inc. and subsidiaries of Cigna Behavioral Health, Inc., including Cigna
Behavioral Health of California, Inc., and Cigna Behavioral Health of Texas.
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including
Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Cigna Behavioral Health, Inc., and HMO
or service company subsidiaries of Cigna Health Corporation. The Cigna name, logo, and other Cigna marks are owned by Cigna
Intellectual Property, Inc.
© 2020 Cigna. Some content provided under license.
4. Eating disorder IOP ONLY (optional):
Current height: Ideal body weight: Current weight:
Body Mass Index (BMI):
Eating disorder behaviors/symptoms:
** Please note that Cigna assumes no responsibility for the protection of electronically transmitted information prior to its actual
receipt of that information. It is your responsibility to take any steps necessary to protect the email or documents prior to receipt
by Cigna.
Is the treatment facility licensed by the Department of Pennsylvania Insurance AND is there a certification/referral from
a physician or psychologist licensed by the Pennsylvania Department of Health?
If yes, please submit any supporting documentation if possible.
Yes No