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Coverage Determination (FOR PROVIDER USE ONLY) MEMBER INFORMATION REQUIRED (Please Write Legibly) Customer Name:Customer ID:Customer DOB:Customer Address:Phone (Home):Phone (Cell):PROVIDER INFORMATION

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What is coverage determination form cigna-healthspring?

It is a form used to request coverage decision for certain medications or medical services under Cigna-HealthSpring insurance plan.

Who is required to file coverage determination form cigna-healthspring?

Any member or their authorized representative who wishes to receive coverage for specific medications or services is required to file the form.

How to fill out coverage determination form cigna-healthspring?

The form can be filled out online through the insurance provider's website or by contacting their customer service. Required information includes personal details, prescription details, and justification for coverage request.

What is the purpose of coverage determination form cigna-healthspring?

The purpose is to request a decision on coverage for specific medications or services, based on medical necessity and coverage guidelines.

What information must be reported on coverage determination form cigna-healthspring?

Information such as patient's details, healthcare provider information, prescription details, medical justification, and any supporting documents must be included.

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