Prior Authorization Request Form–OUTPATIENT
Prior Authorization Request Form ? OUTPATIENT
Please fax to: 1-800-931-0145 (Home Health Services) 1-866-464-0707 (All Other Requests) | Phone: 1-888-454-0013
* Required Field ? please complete all required fields to avoid delay in processing
Note: In an effort to process your request in a timely manner, please submit any pertinent clinical information (i.e. progress notes, treatment rendered, test/lab results or radiology reports) to support the request for services. Any request for a non-contracted provider must include documentation to substantiate the reason for the request. (When all required information has been submitted we will complete your request within 5 business days.)
Expedited ? defined as danger to a member's health if not provided within 72 hours. Please explain:
Member Information:
*Member Name:
*Member DOB:
/
/
* Member ID:
*Date of Service:
/
/
Requesting Provider Information:
*PCP/Requesting Provider:
Contact Person:
*Phone #:
*Fax #:
Referring to (servicing) provider information: if below fields are not answered, Cigna-HealthSpring will automatically assign Cigna-HealthSpring's participating provider network to the member:
*Servicing Provider: Non-contracted
Tax ID #:
*Facility: Non-contracted
Tax ID #:
NPI#: NPI#:
Contact Person: *Phone #: *Fax #: Contact Person: *Phone #: *Fax #:
If requesting a non-contracted provider/facility, please explain why:
*Type of Service: Please check only one of the boxes:
ASC Elective Inpatient Admit MRI/MRA/CT PET PT/OT/ST Cosmetic/Reconstructive
Elective Outpatient Surgery Office Procedure Transplant Evaluation DME Medication
Prosthetics/Orthotics Home Health Ambulance Other___________________ __________________________
Clinical Information: *Diagnosis Code:
Diagnosis:
*Procedure/Service Requested: Procedure/Service Description: Number of visits: Frequency of visits:
CPT Code:
Duration: Number of previous visits:
HCPCS Code:
*Is supporting Clinical Information Attached?
Yes No - Please summarize clinical information below
INT_13_11381 09242013 28
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