PRIOR AUTHORIZATION

Home Health Care fax request formProviders: you must get Prior Authorization (PA) for HHC. PA is not guarantee of payment. Payment is subject to coverage, patient eligibility and contractual limitations. Please use appropriate form for DME and Generic PA requests.

Date _______ /_______ /_______ Please check request type

¨ Standard request

Note: If the service has already been provided, please follow retro process and submit claim.

¨Expedited Requests-May take up to 72 hours.

I certify that waiting for a decision under the standard time frame could place the enrollee’s life, health, or ability to regain maximum function in serious jeopardy. ______________________________________________

Provider signature required

Patient nameAnd phone number

Requesting provider Provider NPI #

Patient ID # HHC Agency HHC NPI #

Patient birthdate Contact name

Initial care start date Contact phone # Contact fax #

Was patient discharged from hospital in past 30 days? ¨ No ¨ Yes, patient was discharged on _____/______/_______ Facility name ___________________________________________

Attending physician _____________________________________ Attending physician phone # ______________________

Is patient homebound? (leaving home is a considerable and taxing attributable to receive health care treatment)¨ No ¨ Yes. Please provide supporting documentation.

ICD-10 code

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. © 2018 Cigna INT_18_65729

Please attach a list of current medications to this form. You may submit pertinent clinical with the first page of this form or use the 3 page form. If submitting clinical separately, please remember to include: Evaluation/SN Notes, wound care measurements and pictures as available, history and physical, signed MD order, pertinent discharge information and notes.

Please provide total # of visits requested with date range for each

RN PT OT ST MSW HHA# of visits requested (frequency)Dates of Service

For additional visits: Please provide total # of visits that have already been completed

RN PT OT ST MSW HHA# of visits already completedDates of Service

Please fax this form and supportive clinical to Pre-Cert department below by market:

Market Phone # Fax #

IL, IN, No. MS, No. GA, AR 800.453.4464 866.287.5834

AL, FL, NC, SC, So. MS, Atlanta 800.962.3016 800.872.8685

TX, AR, OK 832.553.3456 888.205.8658

MA, PA, DE, DC, KC 888.454.0013 800.931.0145

TN HHC 866.913.0947 855.761.7326 or 615.401.4667

For a list of Cigna-HealthSpring services requiring PA, visit cigna.com/medicare/healthcare-professionalsor call your state’s Pre-Cert Department.

ICD 10 Code Diagnosis Description Plan of Care/Barriers to Success

Mental Status

¨ Oriented ¨ Forgetful ¨ Disoriented ¨ Agitated ¨ Depressed ¨ Lethargic ¨ Comatose ¨ Other

Skilled Needs Plan of Care (Please include instructions on when education occurred and to whom)

Interventions

HTN: BP Date: Diabetes: blood sugar Date: CHF/COPD- lung assessment:

Wound Assessment

(Please attach additional sheets for multiple wounds)

Size: Length Width Depth

Type: ¨ Pressure Ulcer (Stage ________ ) ¨ Diabetic ¨ Stasis ¨ Ischemic ¨ Surgical Wound ¨ Burn

Granulating % Slough % Necrotic % Raw/Red %

Raw/Pink % White %

Wound Edges: ¨ Fused ¨ Detached ¨ Tunneling (check for yes) ¨ Undermining (check for yes)

Exudate: ¨ None ¨ Small ¨ Moderate ¨ Large ¨ Copious ¨ Odor (check for yes)

Exudate Type: ¨ Serous ¨ Serosanguinous ¨ Purulent ¨ Bloody Tan ¨ Yellow/Green ¨ Clear

Surrounding Skin: ¨ Intact ¨ Erythematous ¨ Denuded ¨ Macerated ¨ Blistered ¨ Necrotic ¨ Edematous ¨ Indurate

Wound Care orders, treatments and goals Goals

Note changes in orders or visits to wound clinic MD Appointment Date:

OCN Visit Date:

Can Member or caregiver perform treatment? ¨ Yes ¨ No

Date of Education:

Comments Additional Details

Please indicate follow up appointment by PCP or Physician)

Safety Issues & Interventions Social Issues

PRIOR AUTHORIZATION - Home Health Care fax request form - Page 2 INT_18_65729

DME Equipment Being Used DME Functional Frequency Comments include dose /rate if applicable

Wound Assessment

(Please attach additional sheets for multiple wounds)

Size: Length Width Depth

Type: ¨ Pressure Ulcer (Stage ________ ) ¨ Diabetic ¨ Stasis ¨ Ischemic ¨ Surgical Wound ¨ Burn

Granulating % Slough % Necrotic % Raw/Red %

Raw/Pink % White %

Wound Edges: ¨ Fused ¨ Detached ¨ Tunneling (check for yes) ¨ Undermining (check for yes)

Exudate: ¨ None ¨ Small ¨ Moderate ¨ Large ¨ Copious ¨ Odor (check for yes)

Exudate Type: ¨ Serous ¨ Serosanguinous ¨ Purulent ¨ Bloody Tan ¨ Yellow/Green ¨ Clear

Surrounding Skin: ¨ Intact ¨ Erythematous ¨ Denuded ¨ Macerated ¨ Blistered ¨ Necrotic ¨ Edematous ¨ Indurate

Wound Care orders, treatments and goals Goals

Note changes in orders or visits to wound clinic MD Appointment Date:

OCN Visit Date:

Can Member or caregiver perform treatment? ¨ Yes ¨ No

Date of Education:

Comments Additional Details

Please indicate follow up appointment by PCP or Physician)

PRIOR AUTHORIZATION - Home Health Care fax request form - Page 3 INT_18_65729

Please fax this form and supportive clinical to Pre-Cert department below by market:

Market Phone # Fax #

IL, IN, No. MS, No. GA, AR 800.453.4464 866.287.5834

AL, FL, NC, SC, So. MS, Atlanta 800.962.3016 800.872.8685

TX, AR, OK 832.553.3456 888.205.8658

MA, PA, DE, DC, KC 888.454.0013 800.931.0145

TN HHC 866.913.0947 855.761.7326 or 615.401.4667

For a list of Cigna-HealthSpring services requiring PA, visit cigna.com/medicare/healthcare-professionalsor call your state’s Pre-Cert Department.