Navigating the landscape of healthcare needs and insurance coverage can be both daunting and complex. At the heart of this process, the Initial A form, specifically the CareAllies Initial Pre-Certification Request Form, serves as a crucial stepping stone for ensuring that patients receive the necessary approval for healthcare services. By requesting detailed information about the employer or fund supporting the patient, alongside the member or patient's personal and contact details, this form initiates a thorough review process aimed at facilitating care provision. Healthcare professionals and facilities are also integral to this process, with their information forming the backbone of the service verification. The documentation demands diverse data, including diagnostic and procedure codes, service dates, and levels of care, which are essential for accurately assessing the request's validity. Moreover, additional guidelines available online offer a roadmap for navigating these requests, embodying a transparent approach designed to streamline the approval process. Confidentiality and restricted access underscore the form's sensitive nature, emphasizing its role in the broader healthcare ecosystem as a confidential document limited to authorized personnel, reflecting its importance in the meticulous journey towards obtaining pre-certification for healthcare services.
| Question | Answer |
|---|---|
| Form Name | Initial A Form |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | careallies prior authorization, cigna careallies prior authorization, careallies prior auth, care allies pre certication |
CareAllies Initial
Please provide the following information for review of services. Fax request to
If clinical information is available, attach with this form.
Employer/Fund Information:
Employer/Fund Name:
Member/Patient Information:
Member/Patient |
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Name: |
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ID: |
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Street
Address:
City:
State: ZipCode:
Phone#:
Servicing Health Care Professional Information:
Provider Name:
Phone#:
Street
Address:
City:
State:
Fax #
ZipCode:
Facility Information:
Facility Name:
Street
Address:
City:
Phone#:
Fax #
State:
ZipCode:
JANUARY 2011
Review Request Detail Information:
Level of Care:
CPT Code/s: |
Date of
Service:
Further Guideline Information:
For Further guideline information, please visit us at:
http://www.careallies.com/healthcare_professionals.html
Confidential, unpublished property of CIGNA. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. Copyright 2011 by CIGNA
JANUARY 2011