Precertification*/preauthorization Nonparticipating Provider Request

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Aetna
Precertification*/Preauthorization
PO Box 14079
Nonparticipating Provider Request
Lexington, KY 40512-4079
Fax: 859-455-8650
Instructions to the Primary Care Physician’s Office
Complete all fields and mail or fax form (address and fax information is in top right corner of this form).
IF THIS IS AN URGENT REQUEST, call the telephone numbers listed below and follow the prompts for precertification:
HMO: 1-800-624-0756
Traditional: 1-888-632-3862
A. Requesting Provider Information
1. Name (First, Ml, Last)
2. Provider ID Number
3. Provider Contact Name
4. Telephone Number
5. Physician’s Signature
6. Request Date
B. Patient Information
1. Name (First, Ml, Last)
2. Date of Birth
3. Patient’s ID Number
4. Address
5. Telephone Number
C. Nonparticipating Provider Information
1. Name (First, Ml, Last)
2. Telephone Number
3. Address
4. Fax Number
5. Specialty or Provider ID Number
6. Have you attempted to find an Aetna network provider?
Yes
No
7. Has patient seen this provider in the past?
Yes
No
If Yes, when was the last visit?
/
U
U
U
U
Month Year
D. Reason for Nonparticipating Provider Request
1. Service(s) Needed (for example, consultation, diagnostic testing, specific procedure, inpatient care, etc.)
2. Diagnosis Code(s)
3. Procedure/CPT Code(s)
4. Explain why the services listed above can only be provided by this particular specialist.
5. Does the member have out-of-network benefits he/she plans to use?
Yes
No
*The term precertification here means the utilization review process to determine whether the requested service, procedure,
prescription drug or medical device meets the company’s clinical criteria for coverage. It does not mean precertification as
defined by Texas law, as a reliable representation of payment of care or services to fully insured HMO and PPO members.
GR-67353-12 (5-10)

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