MEDICARE ADVANTAGE PRIOR AUTHORIZATION
Durable Medical Equipment (DME) fax request form
Providers: you must get Prior Authorization (PA) for DME before DME is provided. PA is not guarantee of payment. Payment
is subject to coverage, patient eligibility and contractual limitations. Please use appropriate form for Home Health Care
and Generic PA 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 enrollees life, health, or ability to
regain maximum function in serious jeopardy.
___________________________________________________
Provider signature required
Patient name Ordering Provider NPI #
Patient ID # Provider of Service NPI #
Patient birthdate Contact name
Diagnosis with ICD 10 Contact phone # Contact fax #
Date of service ________/_________/__________
Check DME type
¨
Purchase ¨ Rental
Rental dates of service
Start date _________/__________/___________
End date _________/__________/___________
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. 936619 b 03/20 © 2020 Cigna INT_20_85300_C
Please fax this form and supportive clinical including MD order and CMN 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 states Pre-Cert Department.
Equipment Quantity HCPCS code Cost NU RR
Formula # calories # cans
Nutrition % /
ml per day
Check how formula is
administered
¨
Bolus ¨ Gravity ¨ Pump
MM
DD
YYYY
<Patient name>
<Ordering Provider>
<Ordering Provider #>
<Patient ID Number>
<Provider of Service>
<MM / DD / YYYY>
<Contact name>
<Contact phone>
<Contact fax>
MM
DD
YYYY
MM
DD
YYYY
MM
DD
YYYY
<Equipment A>
<Qty>
<code>
<Cost>
<NU>
<RR>
<Equipment B>
<Qty>
<code>
<Cost>
<NU>
<RR>
<Equipment C>
<Qty>
<code>
<Cost>
<NU>
<RR>
<Equipment D>
<Qty>
<code>
<Cost>
<NU>
<RR>
<Equipment E>
<Qty>
<code>
<Cost>
<NU>
<RR>
<Formula>
<#>
<#>
<#>
click to sign
signature
click to edit
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