Fillable Precertification Form Durable Medical Equipment Diabetic Testing Supplies (Cigna Medicare Providers)

Fill Online, Printable, Fillable, Blank Precertification Form Durable Medical Equipment Diabetic Testing Supplies (Cigna Medicare Providers) Form

Use Fill to complete blank online CIGNA MEDICARE PROVIDERS pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Precertification Form Durable Medical Equipment Diabetic Testing Supplies (Cigna Medicare Providers)

On average this form takes 10 minutes to complete

The Precertification Form Durable Medical Equipment Diabetic Testing Supplies (Cigna Medicare Providers) form is 1 page long and contains:

  • 0 signatures
  • 7 check-boxes
  • 36 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Cigna Medicare Providers forms online.

BROWSE CIGNA MEDICARE PROVIDERS FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
MEDICARE ADVANTAGE DRUGS/BIOLOGICS PART B
PRECERTIFICATION FORM
DURABLE MEDICAL EQUIPMENT (DME) – DIABETIC TESTING SUPPLIES
Please attach all required documentation: recent clinical notes, copy of the prescription or physician order,
relevant diagnostic labs.
HCPCS codes Equipment name
(if applicable)
Quantity Limit
every 30 days
Duration
This precertication form applies to all Cigna Medicare markets except Arizona and Leon health plans.
This precertication form does not apply to Medicaid only and Medicare/Medicaid Plan (MMP) plans.
Please fax to: 1-877-730-3858 | Phone: 1-888-454-0013
Note: In an eort to process your request in a timely manner, please submit all pertinent clinical information.
Expedited – dened as may seriously jeopardize the life or health of the Customer or the Customer’s
ability to regain maximum function if not provided with 72 hours
Patient name: Patient date of birth:
Name of requesting provider: ID number:
Contact person: Date of service:
Address:
NPI number: Phone number: Fax number:
If referring to a (servicing) provider, the below stated information must be submitted:
Name of servicing provider: Phone number:
Contact person: Fax number:
Address: NPI number:
Please check if servicing provider is non-contracted
If servicing provider is non-contracted/out-of-network provider/facility, please explain why:
Who will supply the items?
Pharmacy
DME Provider
Other. Please specify:
Please select place of service by checking only one of the boxes:
Home
Other. Please specify:
Diagnosis codes: Diagnosis:
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna
Health and Life Insurance Company. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc.
INT_20_83310_C 936998 11/19 © 2019 Cigna
Q1: For non-preferred glucose monitor or test strip – Has the patient tried preferred glucose monitor or test strip?
If no, please indicate the need for non-preferred glucose monitor or test strip. Preferred meters are Abbott Meters
and Ascencia Meters.
Q2: For high utilization of test strips – Has the patient had an in-person visit with the provider within the past 6
months and provider certied the need for test strips greater than 200 test strips every 30 days that the plan allows?
Q3: For Talking glucose monitor – Does the patient have severe visual or manual dexterity impairment requiring use
of this special monitoring system?
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Precertification Form Durable Medical Equipment Diabetic Testing Supplies (Cigna Medicare Providers)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 16 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document