1. This completed
compliance cover sheet
2. The short summary compliance form obtained from the PAP device manufacturer’s software
Member Name:
DOB:
Univera ID#:
Physician Name:
NPI:
Address:
City / Zip:
Phone:
Fax:
DME Provider:
TIN:
Address: City / Zip:
Phone:
Fax:
RSPLY Request: Select one type of mask and one tubing
Page 1 of 1
PAP Resupply Cover Sheet
Please fax the following documents to the corresponding number at the bottom of the page to request
authorization for PAP Supplies:
Mask
Tubing
A7037 Standard PAP Tubing
A4604 Heated PAP Tubing
A7027 Combination Oral / Nasal Mask
A7030 PAP Full Face Mask
A7034 Nasal Mask
A7044 PAP Oral Interface
eviCore healthcare | www.eviCore.com | 400 Buckwalter Place Blvd • Bluffton, SC • 29910 | 800.918.8924
Please fax information to the corresponding fax number below:
General (Including Excellus, Univera, Universal American,
Wellcare, and YourCare health plans):
Oscar:
Harvard Pilgrim and Tufts Health Plan:
For general sleep inquiries, please call 888-511-0401.
866-999-3510
855-252-1118
888-511-0403
