Pre-Cert Request

Please fill out the form below to submit your request for pre-certification. Required fields are underlined and marked with an asterisk (*).
Your Info
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Patient Info
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Insured Info
Only enter the insured's name if it is different than the patient name.
Service Info
Please enter the primary diagnosis description and/or code. You may also add additional diagnoses if necessary.
Please enter the primary procedure description and/or code. You may also add additional procedures if necessary.
Admit date, date of service, or EDC if OB notification
Provider Info
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This information is required on all Ancillary Claims.
Facility Info Copy Provider Info to Facility
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Clinical Info
Your pre-certification request must be submitted with the appropriate clinical information in order to be processed. Please select an option below.
Additional Notes
Please enter any additional instructions, comments, or notes below.
Disclaimer: We are certifying for medical necessity. We advise you to call the claims payor regarding benefits, eligibility and how this claim will be paid.