Fillable (Scooters) Wheelchairs and Power Operated Vehicles Precertification Information (Aetna Health Insurance)

Fill Online, Printable, Fillable, Blank (Scooters) Wheelchairs and Power Operated Vehicles Precertification Information (Aetna Health Insurance) Form

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

(Scooters) Wheelchairs and Power Operated Vehicles Precertification Information (Aetna Health Insurance)

On average this form takes 15 minutes to complete

The (Scooters) Wheelchairs and Power Operated Vehicles Precertification Information (Aetna Health Insurance) form is 4 pages long and contains:

  • 1 signature
  • 58 check-boxes
  • 29 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Aetna Health Insurance forms online.

BROWSE AETNA HEALTH INSURANCE 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
 
PCFX
Wheelchairs and Power Operated Vehicles
(Scooters)
Precertification Information Request Form
Applies
to:
Aetna plans
Innovation Health® plans
He
alth benefits and health insurance plans offered, underwritten, and/or
administered by the following:
Allina Health and Aetna He
alth Insurance Company (Allina Health | Aetna)
Banner Health and Aetna Health Insurance Company and/or Banner H
ealth and
Aetna Health Plan Inc. (Banner | Aetna)
Sutter Health and Aetna
Administrative Services LLC (Sutter Health | Aetna)
Texas Health + Aetna Health Plan Inc. and Texas Health + Aetna Health Insurance
Company (Texas Health Aetna)
Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including
Aetna Life Insurance Company and its affiliates (Aetna). Aetna provides certain management services on behalf of its affiliates.
Page 1 of 4 GR-68970-2 (5-20)
PCFX
Wheelchairs and Power Operated Vehicles
(Scooters)
Precertification Information Request Form
About this form
You can’t use this form to initiate a precertification request. To initiate a request, please call our Precertification Department or
you may submit your request electronically. Failure to complete this form and submit all medical records we are
requesting may result in the delay of review or denial of coverage.
Effective April 1, 2020, this form replaces all other Wheelchairs and Power Operated Vehicles (Scooters) precertification information
request documents and forms. This form will help you supply the right information with your precertification request. You don’t have to
use the form. But it will help us adjudicate your request more quickly.
How to fill out this form
As the patient’s attending physician, you must complete all sections of the form. You can use this form with all Aetna health plans,
including Aetna’s Medicare Advantage plans. You can also use this form with health plans for which Aetna provides certain
management services.
When you’re done
Once you’ve filled out the form, submit it and all requested medical documentation to our Precertification Department by:
• (Preferred) Upload your clinical information electronically on our secure provider portal at www.Availity.com.
• Send your clinical information via confidential fax to: Precertification – Commercial and Medicare (including
expedited) using FaxHub: 1-833-596-0339
o The fax number above (FaxHub) is for clinical information only. Please send specific information that
supports your medical necessity review. Please continue to send all other information (claims etc) to
appropriate fax numbers. Thank you.
• Mail your information to: PO Box 14079
Lexington, KY 40512-4079
What happens next?
Once we receive the requested documentation, we’ll perform a clinical review. Then we’ll make a coverage determination and let
you know our decision. Your administrative reference number will be on the electronic precertification response.
How we make coverage determinations
If you request precertification for a Medicare Advantage member, we use CMS benefit policies, including national coverage
determinations (NCD) and local coverage determinations (LCD) when available, to make our coverage determinations. If there
isn’t an available NCD or LCD to review, then we’ll use the Clinical Policy Bulletin referenced below to make the determination.
For all other members, we encourage you to review Clinical Policy Bulletin #271: Wheelchairs and Power Operated
Vehicles (Scooters), before you complete this form.
You can find the Clinical Policy Bulletins and Precertification Lists by visiting the website on the back of the member’s ID card.
Questions?
If you have any questions about how to fill out the form or our precertification process, call us at:
• HMO plans: 1-800-624-0756
• Traditional plans: 1-888-632-3862
Page 2 of 4 GR-68970-2 (5-20)
Wheelchairs and Power Operated Vehicles
(Scooters)
Precertification
Information Request Form
Section 1: Provide the following general information
If submitting request electronically, complete member name , ID and r
eference number only
Member
name: Reference number (required):
Membe
r ID: Member date of birth:
Requesting provider/facility name:
Requesting provider/facility NPI:
Requesting provider/facility phone number: 1
- - -
Requesting provider/facility fax number: 1- - -
Assistant/co-surgeon name (if a
pplicable): TIN:
Section 2: Provide the following patient-specific information
Does the patient have a mobility limitation that significantly impairs the ability to participate in one or more mobility-related activities of daily
living (MRADLs) (e.g., toileting, feeding, dressing, grooming, bathing) in customary locations in the home that would be alleviated by the
requested mobility device?
Yes No
Is the patient ambulatory? Yes No
If yes, how many feet can
the patient ambulate with and without an assistive device (e.g., cane or walker)?
Can the patient’s mobility limitation be sufficiently resolved by the use of an appropriately fitted cane or walker?
Yes No
Is it anticipated the patient’s condition will not resolve within 3 months? Yes No
Is the patient able to se
lf-propel a manual wheelchair? Yes No
If no, please document why the pati
ent is unable to self-propel.
Has the patient shown th
e ability to safely operate the requested mobility device? Yes No
Does the patient’s home provide adequate acce
ss between rooms, maneuvering space and surfaces for the operation of the requested
device? Yes No
Is the requested devi
ce for use primarily outside the patient’s home? Yes No
Does the patient currently own a wheelchair?
Yes
No
If yes, provide the following information about the current wheelchair:
Manual Power operated
Specify t
he features on the power wheelchair
Tilt Recline Power legs Seat Elevator
Other, please specify
Specify the age of the current wheelchair
Detailed list of repairs, including cost, needed for the current wheelchair:
Explain why the current device is not adequate to meet the patient’s needs:
Page 3 of 4 GR-68970-2 (5-20)
Wheelchairs and Power Operated Vehicles
(Scooters)
Precertification Information Request Form
Member ID: Reference Number:
Sec
tion 2 Continued: Provide the following patient-specific information
Adj
ustable
arm-height option
Anti-ro
llback device
and anti-tip device
Arm trough
Batteries: U-1 battery,
22 NF deep-cycle lead
acid battery, gel battery or
Group 24 battery
Chin control
Electronic interface
control lights or other
electrical devices
Elevating leg rests
Enha
nced joystick
Gear r
eduction drive
wheel
Headrest
Lap tray wheelchair
attachment
Lever activated wheel
drive
Manual fully reclining
back option
Mechanical or power
shear reduction
features
Mechanical linked leg
elevation feature
Non-powered or
powered seat
elevator or standing
device
Non-standard seat
width, depth, or
height
One-arm drive
attachment
Power add-ons to
manual wheelchairs
Power leg elevation
feature
Power stander
attachment
Power tilt and/or
recline seating
systems
Power wheelchair
drive control systems
Push-rim activated
power assist device
Reinforced back
upholstery or
reinforced seat
upholstery
Safety belt/pelvic strap
Semi-reclining back
option
Shoe holder
Side guard
Solid seat insert or
other custom seating
option(s)
Swingaway
retractable, or
removable hardware
Tilt-in-space
Rotation-in-space
Section 3: Provide the following documentation for your request
• Itemized invoice for the requested mobility device and all accessories
• Current history and physical
• Current evaluation from the durable medical equipment (DME) vendor for the requested mobility device
Section 4: Read this important information
Any person who knowingly files a request for authorization of coverage of a medical procedure or service with the intent to injure, defraud
or deceive any insurance company by providing materially false information or conceals material information for the purpose o
f misleading,
commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
Section 5: Sign the form
Just remember: You can’t use this form to initiate a precertification request. To initiate a request, please call our Precertification
Department or submit your request electronically.
Signature of person completing form:
Date: / /
Contact name of office personnel to call with questions:
Telephone number: 1- - -
Page 4 of 4 GR-68970-2 (5-20)
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

(Scooters) Wheelchairs and Power Operated Vehicles Precertification Information (Aetna Health Insurance)

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 7 February 2022

Message

View Audit Log
Print With Audit Log
Duplicate Document