Fillable Prior Authorization Request Form (Cigna Medicare Providers)

Fill Online, Printable, Fillable, Blank Prior Authorization Request Form (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.

Prior Authorization Request Form (Cigna Medicare Providers)

On average this form takes 6 minutes to complete

The Prior Authorization Request Form (Cigna Medicare Providers) form is 1 page long and contains:

  • 1 signature
  • 6 check-boxes
  • 18 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
 
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 Durable
Medical Equipment (DME) and Home Health Care 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. 936620 b 03/20 © 2020 Cigna INT_20_85095_C
Please fax this form and supportive clinical to Pre-Cert department below by market:
Market Phone # Fax #
TN, IL, IN, No. MS, No. GA, East 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, CO, NJ 888.454.0013 800.931.0145
• For a list of services requiring PA, visit MedicareProviders.Cigna.com or call your state’s Pre-Cert Department
• If you need help finding a PAR facility or provider, please call 800-230-6138 or visit MedicareProviders.Cigna.com and
use the Provider Search Tool.
MEDICARE ADVANTAGE PRIOR AUTHORIZATION
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>
click to sign
signature
click to edit
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

Prior Authorization Request Form (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