Fillable PRIOR AUTHORIZATION Generic fax request form (Cigna Medicare Providers)

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PRIOR AUTHORIZATION Generic fax request form (Cigna Medicare Providers)

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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 10242017
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 800.872.8685
TX, AR, OK 832.553.3456 888.205.8658
MA, PA, DE, DC, KC 888.454.0013 800.931.0145
• 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ndingaPARfacilityorprovider,pleasecall800-230-6138orvisitcigna.com/medicareandusetheProviderSearchTool.
MM
DD
YYYY
<Patient name>
<Requesting provider>
<Patient ID Number>
<Provider NPI #>
<MM / DD / YYYY>
<Contact phone>
<Contact fax>
MM
DD
YYYY
<Facility/place/specialist name>
<notes>
<notes>
<notes>
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PRIOR AUTHORIZATION Generic fax request form (Cigna Medicare Providers)

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Completed 15 June 2022

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