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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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How to fill out coverage determination form cigna-healthspring

01
To fill out the coverage determination form for Cigna-HealthSpring, follow these steps:
02
Obtain a copy of the form. You can usually find it on the Cigna-HealthSpring website or by contacting their customer service.
03
Read the instructions carefully to understand the purpose of the form and the information required.
04
Provide your personal information, including your name, date of birth, and contact details.
05
Enter your Cigna-HealthSpring policy number and any other relevant identification numbers.
06
Specify the details of the drugs or medical services for which you are seeking coverage determination.
07
Include any supporting documentation, such as prescriptions or medical reports, to support your request.
08
Indicate the reason why you believe coverage should be provided and provide any additional details or explanations.
09
Review the filled form for accuracy and completeness.
10
Sign and date the form.
11
Submit the completed form as instructed, either by mail, fax, or online.
12
Keep a copy of the form for your records.

Who needs coverage determination form cigna-healthspring?

01
Anyone who is a member of Cigna-HealthSpring and requires coverage determination for certain drugs or medical services needs to fill out the coverage determination form.
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Coverage determination form cigna-healthspring is a document used to request coverage or approval for a specific medical service or prescription drug.
Members or healthcare providers may be required to file the coverage determination form depending on the situation.
The form can be filled out online or submitted by mail, following the instructions provided by Cigna-Healthspring.
The purpose is to request coverage or approval for medical services or prescription drugs to ensure they are eligible for benefits under the plan.
The form typically requires information such as member details, healthcare provider information, details of the service or drug being requested, and supporting medical documentation.
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