Get the free Precertification Fax Request Form

A form used to request precertification for medical procedures or treatments, requiring supporting medical documentation.

How to fill out precertification fax request form

How to fill out Precertification Fax Request Form

1. Obtain the Precertification Fax Request Form from your insurance provider or health plan.
2. Fill out the patient's information, including full name, date of birth, and insurance policy number.
3. Provide the provider's contact information, including name, phone number, and mailing address.
4. Describe the procedure or service that requires precertification in clear terms.
5. Include any relevant medical history or documentation that supports the precertification request.
6. Sign and date the form where indicated, certifying that the information provided is accurate.
7. Fax the completed form to the specified number provided by the insurance company or health plan.
8. Keep a copy of the fax transmission confirmation for your records.

Who needs Precertification Fax Request Form?

1. Patients requiring prior authorization for specific medical procedures or services.
2. Healthcare providers submitting requests for medical necessity on behalf of their patients.
3. Insurance companies that mandate precertification before certain treatments or procedures are performed.

People Also Ask about

How are prior authorizations submitted?

The Prior Authorization Process Flow The healthcare provider must check a health plan's policy or prescription to see if Prior Authorization is needed for the prescribed treatment. The healthcare professional must sign a Prior Authorization request form to verify the medical necessity claim.

What is a precertification form?

During the precertification process, medical professionals review the planned medical services against standard medical criteria to ensure that the services are within accepted medical standards and are medically necessary. Precertification may be initiated by you, your representative or your medical provider.

How do I submit a prior authorization to Cigna?

Sometimes, your health care provider will start and coordinate the prior authorization process for you. However, you may be responsible for getting the prior authorization yourself.

Can I submit a prior authorization for myself?

Who's Responsible for Getting the Prior Authorization? Sometimes, your health care provider will start and coordinate the prior authorization process for you. However, you may be responsible for getting the prior authorization yourself.

Why are providers dropping Cigna?

Jefferson Health said rising costs made its previous contract with Cigna unsustainable. "Since 2020, Cigna's reimbursement rates have increased only around 3%, while the costs of providing care have increased more than 20%," said Dr. Edmund Pribitkin, Jefferson Health's Chief Physician.

How to submit prior authorization for Cigna?

If you are unable to use electronic prior authorization, you can call us at 1 (800) 882-4462 to submit a prior authorization request.

What is the fax number for Medicare prior authorization?

For Standard requests, complete this form and FAX to 1-877-808-9362. Determination made as expeditiously as the enrollee's health condition requires, but no later than 14 calendar days after receipt of request. For Expedited requests, please CALL 1-800-977-7522.

For pdfFiller’s FAQs

What is Precertification Fax Request Form?

The Precertification Fax Request Form is a document used by healthcare providers to obtain prior approval from an insurance company before rendering certain medical services or procedures.

Who is required to file Precertification Fax Request Form?

Healthcare providers, including physicians and facilities, are required to file the Precertification Fax Request Form when they seek authorization for specific services that require precertification from insurance payers.

How to fill out Precertification Fax Request Form?

To fill out the Precertification Fax Request Form, providers must provide patient information, details of the requested service, medical necessity rationale, and relevant clinical information. It's essential to follow specific guidelines provided by the insurance company.

What is the purpose of Precertification Fax Request Form?

The purpose of the Precertification Fax Request Form is to streamline the process of obtaining prior authorization for medical services, ensuring that they are medically necessary and covered by the patient's insurance plan.

What information must be reported on Precertification Fax Request Form?

The Precertification Fax Request Form must report information including the patient's demographic details, insurance information, details of the requested procedure or service, the diagnosis, and any supporting medical documentation that justifies the request.