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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?

The coverage determination form cigna-healthspring is a form used to request coverage for certain medical services or medications under a Cigna-HealthSpring insurance plan.

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

Members who are seeking coverage for specific medical services or medications are required to file the coverage determination form cigna-healthspring.

How to fill out coverage determination form cigna-healthspring?

To fill out the coverage determination form cigna-healthspring, members must provide their personal information, details of the medical service or medication being requested, and any supporting documentation as required.

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

The purpose of the coverage determination form cigna-healthspring is to determine if a specific medical service or medication is covered under a member's Cigna-HealthSpring insurance plan.

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

The coverage determination form cigna-healthspring must include details of the member's personal information, the requested medical service or medication, and any supporting documentation or medical records.

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