Get Aetna Viscosupplementation Precertification Request

The Aetna Viscosupplementation Precertification Request is an essential document for obtaining approval for injection therapy. This guide provides step-by-step instructions to assist users in completing the form online accurately and efficiently.

Follow the steps to complete your precertification request with ease.

1. Press the ‘Get Form’ button to obtain the Aetna Viscosupplementation Precertification Request form and open it in your preferred document editor.
2. Begin by filling out the 'Patient Information' section. Provide the first and last name, address, phone numbers, date of birth, allergies, current weight, and height. Ensure all entries are clear and complete.
3. In the 'Insurance Information' section, enter the Aetna Member ID and indicate if the patient has additional insurance coverage. If applicable, provide the details of the other coverage, including the carrier name and group number.
4. Complete the 'Prescriber Information' section by entering the prescriber's first and last name, professional designation, contact information, and specialty.
5. In the 'Dispensing Provider/Administration Information' section, specify where the treatment will take place and provide details about the dispensing provider, including phone numbers and the necessary administration codes.
6. Complete the 'Product Information' section by indicating which medication is being requested for precertification.
7. Fill out the 'Diagnosis Information' section by entering the primary ICD code and any additional codes as necessary.
8. In the 'Clinical Information' section, answer all questions regarding the patient's condition and treatment history. This includes confirming the need for the procedure and providing details on past treatments.
9. If requesting an additional series, indicate the date of the last injection and answer the relevant follow-up questions.
10. Review your completed request for accuracy. Once satisfied, save your changes. You may also download, print, or share the completed form as needed.

Start completing your Aetna Viscosupplementation Precertification Request online now!