Follow the steps to complete the precertification request form.

1. Click ‘Get Form’ button to obtain the Medicare Advantage General Precertification Request form and open it for completion.
2. Begin filling in the member's information, including their name, date of birth, insurance identification number, and phone number.
3. Enter the ordering provider's information, including their name, specialty, provider ID number, office address, phone number, and fax number.
4. Provide the rendering provider's details by filling in their name, specialty, provider ID number, office address, phone number, and fax number.
5. Complete the facility information section by entering the facility name, ID number, and address.
6. Specify the date or date range of service and the services requested, including any relevant CPT codes if available.
7. Indicate the place of service, selecting from options such as observation, outpatient, inpatient, or other.
8. Provide the diagnosis related to the request, including ICD-9 codes if known, in the designated fields.
9. Detail the service being requested by entering descriptions and associated codes in the appropriate sections.
10. Explain the member’s condition related to the request, ensuring to include relevant ICD-9 codes.
11. Attach appropriate supporting clinical information and confirm whether this request is a pre-claim or post-claim submission.
12. Complete the attestation section by signing with the name and title of the provider or representative, along with the date.
13. Finally, save your changes, and choose to download, print, or share the completed request form.

Ensure a smooth submission process by completing your Medicare Advantage General Precertification Request form online today.