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It directs providers not to use the form to initiate requests, but to attach it to an existing Availity case when asked, or submit via provider portal, confidential fax, or mail. It outlines next steps for clinical review, coverage determination, and member-specific policy sources, plus required contact and request details.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/precertification-information-request-form-what-to-include-and-how-to-submit/288451/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/precertification-information-request-form-what-to-include-and-how-to-submit/288451.png","ImageObject",442,249,{"name":88,"@type":89},"Fahsai","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-22","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":79},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"Can this form be used to initiate a precertification request?","Question",{"text":108,"@type":109},"No. Do not use this form to initiate a precertification request. Initiate electronically on Availity or by calling the Precertification Department.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What should I submit with the precertification case?",{"text":113,"@type":109},"Submit the requested medical records and any requested clinical information with your electronic submission. 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(Banner | Aetna)  \nAetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company and its affiliates (Aetna) . Aetna provides certain management services on behalf of its affiliates.  \nAbout this form  \nDo not use this form to initiate a precertification request. To initiate a request, submit electronically on Availity or call our Precertification Department. Submit your medical records to support the request with your electronic submission.  \nWe’ve made it easy for you to authorize services and submit any requested clinical information. Just use our provider portal on Availity® . Register [today at](today at Availity.com/aetnaproviders. Once your account)[ ](today at Availity.com/aetnaproviders. Once your account)[Availity.com/aetnaproviders](today at Availity.com/aetnaproviders. Once your account)[. Once your account](today at Availity.com/aetnaproviders. Once your account) is ready, you can start submitting authorization requests right away.  \no For additional information on Availity, go to [https://www.aetna.com/health-care-professionals/resource](https://www.aetna.com/health-care-professionals/resource)center/availity.html  \nRequesting authorizations on Availity is a simple two-step process  \nHere’s how it works:  \n1. Submit your initial request on Availity with the Authorization (Precertification) Add transaction.  \n2. Then complete a short questionnaire, if asked, to give us more clinical information.  \no If you receive a pended response, then complete this form and attach it to the case electronically.  \nThis form will help you supply the right information with your precertification request. Typed responses are preferred. Failure to complete this form and submit all medical records we are requesting may result in the delay of review or denial of coverage.  \nHow to fill out this form  \nAs the patient’s attending physician, you must complete all sections of the form. You can use this form with all Aetna health plans, including Aetna’s Medicare Advantage plans. You can also use this form with health plans for which Aetna provides certain management services.  \nWhen you’re done  \nOnce you’ve filled out the form, submit it and all requested medical documentation to our Precertification Department by:  \n􀂃 If your request was submitted via telephone, you can either:  \n• Access our provider portal via Availity; enter the Reference number provided and attach this form and all  \nrequested medical documentation to the case or  \n• Send your information by confidential fax to:  \no Precertification-Commercial and Medicare using FaxHub: 1-833-596-0339  \no The fax number above (FaxHub) is for clinical information only. Please send specific information that supports your medical necessity review. Please continue to send all other information (claims etc) to appropriate fax numbers.  \n• If you do not have fax or electronic means to submit clinical:  \no Mail your information to: PO Box 14079  \nLexington, KY 40512-4079  \n(Please note mailing will add to the review response time)  \nPCFX  \nPrecertification Information Request Form  \nWhat happens next?  \nOnce we receive the requested documentation, we’ll perform a clinical review. Then we’ll make a coverage determination and let you know our decision. Your administrative reference number will be on the electronic precertification response.  \nHow we make coverage determinations  \nIf you request precertification for a Medicare Advantage member, we use CMS benefit policies, including national coverage determinations (","cbCaieZWdr2EK3zY","https://ap.wps.com/l/cbCaieZWdr2EK3zY","pdf",881271,8,"English","# Requesting authorizations on Availity\n## Two-step process and when to attach the form\n# How to fill out this form\n## Provider responsibilities and preferred typed responses\n# When you’re done\n## Submission methods: Availity, FaxHub, or mail\n# What happens next?\n## Clinical review and coverage determination\n# How we make coverage determinations\n## Medicare Advantage vs other members\n# Section 1: General information for all requests\n# Section 2: General information","[{\"question\":\"Can this form be used to initiate a precertification request?\",\"answer\":\"No. Do not use this form to initiate a precertification request. Initiate electronically on Availity or by calling the Precertification Department.\"},{\"question\":\"What should I submit with the precertification case?\",\"answer\":\"Submit the requested medical records and any requested clinical information with your electronic submission. Typed responses are preferred, and failure to complete the form and submit all requested records may delay review or lead to denial of coverage.\"},{\"question\":\"How are precertification requests submitted if electronic or fax options are not available?\",\"answer\":\"If you do not have fax or electronic means to submit clinical, mail your information to PO Box 14079, Lexington, KY 40512-4079, noting that mailing may add to the review response time.\"}]","Precertification Information Request Form - What to Include and How to Submit | PDF",1789633497]