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Outpatient Behavioral Health (BH) Request –
TMS Requests: Transcranial Magnetic Stimulation
Precertification Information Request
PRECERTIFICATION only. DO NOT use this form for EXTENSION requests.
About this form
Do not use in Maryland or Massachusetts for commercial plans. The form may be used for Aetna
Medicare Advantage plans in these states.
You can’t use this form to initiate a precertification request. To initiate a request, you have to
submit your request electronically. Or you can call our Precertification Department. Failure to
complete this form and submit all of the medical records we are requesting may result in the
delay of review or denial of coverage.
Effective August 1, 2020, this form replaces all other Transcranial Magnetic Stimulation precertification
request documents and forms. Failure to complete this form and submit all of the medical records
we are requesting may result in the delay of review.
Once completed, this form contains confidential information. Only the individual or entity it’s
addressed to can use it. If you’re not the intended recipient, or the employee or agent responsible for
delivering the form to the intended recipient, you can’t disseminate, distribute or copy the completed
form. If you received the completed form in error, call us at 1-800-624-0756 or 1-888-632-3862.
How to fill out this form
As the patient’s attending physician, you must complete Sections 1 through Section 6 of the form.
You can use this form with Aetna’s Medicare Advantage plans. You can also use this form with health
plans for which Aetna provides certain management services. This includes Innovation Health Plan, Inc.
and Innovation Health Insurance Company. You can’t use the form with Traditional Choice/Indemnity
plans or other commercial plans. For commercial plans, call the number on the member’s card to
pre-certify the care.
When you’re done
Once you’ve filled out the form, submit it and all requested medical documentation to our Precertification
Department by one of the following:
(Preferred) Upload your information electronically on our secure provider website on the Provider
Portal at www.Availity.com.
Send your information by confidential fax to:
o Aetna Leap Plans: 888-934-7941
o Medicare Plans: 959-282-8799
o Commercial Plans: 888-463-1309
Note: Aetna Leap Plans have a unique ID number starting with the number "10".