Get You May Also Ask Us For A Coverage Determination By Phone At 18884079977 Or Through Our

Navigating the coverage determination process can be straightforward with the right guidance. This guide provides step-by-step instructions on how to effectively fill out the coverage determination request form to ensure your needs are met.

Follow the steps to successfully complete your coverage determination request.

1. Click ‘Get Form’ button to obtain the form and access it for editing.
2. Begin by entering the enrollee's information. Fill out the enrollee's name, date of birth, address (including city, state, and zip code), and phone number. Ensure that the Enrollee’s Member ID is accurate.
3. If someone other than the enrollee or prescriber is making the request, complete the requestor's information section. This includes the requestor's name, relationship to the enrollee, address, city, state, zip code, and phone number.
4. If applicable, attach documentation showing authority to represent the enrollee. This may include the Authorization of Representation Form CMS-1696.
5. Specify the prescription drug you are requesting, including its strength and quantity per month, if known.
6. Indicate the type of coverage determination request by selecting the appropriate option that best fits your situation. Provide any required supporting information if indicated.
7. If you're requesting an expedited decision, check the designated box and ensure you have a supporting statement from your prescriber, which should be attached.
8. Sign the form to certify the accuracy of the information provided. Include the date of your signature.
9. Complete the prescriber’s information section, including their name, address, office phone number, and fax number. The prescriber must also sign and date the form.
10. Provide any relevant medical information, including medication details, diagnosis, rationale for request, and any other explanations necessary.
11. Review all entries for accuracy and completeness. Save changes, and then you can download, print, or share the completed form as needed.

Complete your coverage determination request online today for a streamlined experience.