Get General Coverage Determination Form - Cigna

Filling out the General Coverage Determination Form - Cigna online is a crucial step in obtaining necessary health coverage. This guide provides step-by-step instructions to help you navigate and complete the form with ease.

Follow the steps to effectively complete the coverage determination form.

1. Press the 'Get Form' button to access the General Coverage Determination Form and open it in your editor.
2. Begin by completing the provider information section. Fill in the fields for office contact, provider specialty, first and last name, phone, fax, address, license number, DEA number, and NPI number.
3. Next, provide the customer information. Enter the customer’s name, address, phone numbers (home and cell), customer ID, and date of birth.
4. In the prescription information section, specify the drug, dosage, frequency, whether it is a brand or generic medication, and the required quantity. Also indicate if it is a new medication or a continuation, and provide the starting date if applicable.
5. List the diagnosis or ICD-10 code(s) relevant to the request. Follow this by documenting all formulary alternatives the customer has tried, including the duration of each therapy.
6. Include any adverse reactions or intolerances the customer has experienced with the formulary alternatives.
7. Indicate whether the customer is currently receiving dialysis, if the medication request is for a transplant medication, and if the transplant was covered by Medicare. If applicable, provide a copy of the Medicare card and the date of the transplant.
8. Complete the section regarding nebulizer use, specifying where the medication will be used, such as at home or in a long-term care facility.
9. Note the customer's hospice enrollment status and provide the disenrollment date if necessary.
10. If the request is for an inpatient awaiting discharge, ensure that clinical documentation is included to support the request.
11. If requesting expedited review, check the relevant box and certify that the standard review timeframe may jeopardize the customer's health or ability to regain function.
12. Finally, ensure the provider signature and date are included before submitting the form.
13. You can now save changes, download, print, or share the General Coverage Determination Form as needed.

Complete the General Coverage Determination Form - Cigna online today to ensure your coverage needs are met efficiently.