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Coverages are determined after a claim is received based on eligibility and plan provisions at the time the service is rendered, following clinical review and coverage determination.",{"@graph":14,"@context":72},[15,34,55],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/letters/","Letters",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/request-for-infusion-drug-authorization-instructions-for-submitting-predeterminations/288655/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/request-for-infusion-drug-authorization-instructions-for-submitting-predeterminations/288655.png","ImageObject",442,249,{"name":42,"@type":43},"Sage","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-09-19","2026-09-17",true,{"@type":52,"interactionType":53,"userInteractionCount":30},"InteractionCounter",{"@type":54},"ViewAction",{"@type":56,"mainEntity":57},"FAQPage",[58,64,68],{"name":59,"@type":60,"acceptedAnswer":61},"Is a predetermination request the same as pre-certification of benefits?","Question",{"text":62,"@type":63},"No. The document states it is a courtesy review and not a pre-certification of benefits.","Answer",{"name":65,"@type":60,"acceptedAnswer":66},"What information is required to prevent delays in the predetermination process?",{"text":67,"@type":63},"All applicable fields are required; submissions without the member/patient’s group number, ID number, and date of birth cannot be completed and may be returned.",{"name":69,"@type":60,"acceptedAnswer":70},"How should fax submissions and supporting documentation be handled?",{"text":71,"@type":63},"Fax each patient separately using the fax number indicated on the form, do not send duplicate requests, place the Predetermination Request Form on top of supporting documentation, and mail any required photos instead of faxing them.","https://schema.org",{"og:url":32,"og:type":74,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":76,"canonical":32},"index,follow",{"doc_id":78,"site_id":7},288655,1789633748,{"code":4,"msg":81,"data":82},"success",[83,88,93,98,103,108,113,117,122],{"id":84,"doc_module":22,"doc_module_name":25,"category_name":85,"show_sort_weight":86,"slug":87},11,"Presentations",90,"presentations",{"id":89,"doc_module":22,"doc_module_name":25,"category_name":90,"show_sort_weight":91,"slug":92},12,"Resumes",80,"resumes",{"id":94,"doc_module":22,"doc_module_name":25,"category_name":95,"show_sort_weight":96,"slug":97},14,"Invoices",70,"invoices",{"id":99,"doc_module":22,"doc_module_name":25,"category_name":100,"show_sort_weight":101,"slug":102},15,"Posters",60,"posters",{"id":104,"doc_module":22,"doc_module_name":25,"category_name":105,"show_sort_weight":106,"slug":107},16,"Social Media",50,"social-media",{"id":109,"doc_module":22,"doc_module_name":25,"category_name":110,"show_sort_weight":111,"slug":112},17,"Forms",40,"forms",{"id":114,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":115,"slug":116},18,30,"letters",{"id":118,"doc_module":22,"doc_module_name":25,"category_name":119,"show_sort_weight":120,"slug":121},21,"Paper Templates",5,"papers-templates",{"id":123,"doc_module":22,"doc_module_name":25,"category_name":124,"show_sort_weight":4,"slug":125},158,"General","general-158",{"code":4,"msg":81,"data":127},{"doc_id":78,"user_id":128,"nickname":42,"user_avatar":129,"doc_module":22,"category_id":114,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":30,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":26,"language":135,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":12,"update_tm":79,"read_time":22},687197207057,"https://ap-avatar.wpscdn.com/davatar_29158cc5080c5b710cf443261637dec0","Instructions for Submitting Requests for Predeterminations  \nComplete and return to:  \nMeritain Health®  \nP.O. Box 853921  \nRichardson, TX 75085-3921  \nFax: 1.716.541.6735  \n[Email:](Email: predetermination@meritain.com)[ ](Email: predetermination@meritain.com)[predetermination@meritain.com](Email: predetermination@meritain.com)  \nREQUEST FOR INFUSION DRUG AUTHORIZATION  \nTHIS IS A COURTESY REVIEW AND NOT A PRE-CERTIFICATION OF BENEFITS  \nPLEASE NOTE: sending anything other than a predetermination request will delay the review of your information.  \nIMPORTANT PREDETERMINATION REMINDERS  \n1. Always verify eligibility and benefits first.  \n2. All applicable fields are required. If all information is not provided, this may cause a delay in the predetermination process. (Inquiries received without the member/patient’s group number, ID number, and date of birth cannot be completed and may be returned to you to supply this information.)  \n3. Fax information for each patient separately, using the fax number indicated on the form.  \n4. Always place the Predetermination Request Form on top of other supporting documentation. Please include any additional comments if needed with supporting documentation.  \n5. Do not send in duplicate requests, as this may delay the process.  \n6. If photos are required for review, the photos should be mailed along with the Predetermination Request Form and not faxed. Faxed photos are not legible and cannot be used to make a determination.  \nPlease note: The fact that a guideline is available for any given treatment or that a service or treatment has been preauthorized or predetermined for benefits, is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and plan provisions in effect at the time the service is rendered.  \nPlease note: Attach all clinical documentation to support medical necessity. The patient’s plan document supersedes this and Aetna® clinical policy bulletin criteria.  \nHow to fill out this form  \nAs the patient’s attending physician, you must complete all sections of the 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.  \n\n| SECTION 1: PROVIDE THE FOLLOWING GENERAL INFORMATION |  |\n| --- | --- |\n| MEMBER NAME | MEMBER DATE OF BIRTH |\n| MEMBER ID NUMBER |  |\n| REQUESTING PROVIDER/FACILITY NAME | PROVIDER ADDRESS |\n| PROVIDER PHONE NUMBER | PROVIDER FAX NUMBER |\n\n\n| SECTION 2: PROVIDE THE FOLLOWING PATIENT-SPECIFIC INFORMATION |  |\n| --- | --- |\n| PATIENT’S PLAN DOCUMENT SUPERSEDES THIS AND AETNA CLINICAL POLICY BULLETIN CRITERIA |  |\n| MEMBER NAME | MEMBER ID NUMBER |\n| GROUP NAME | GROUP NUMBER |\n| PATIENT NAME | PATIENT DATE OF BIRTH |\n| PROCEDURE CODE(S) | PRICE (INDICATE IF PER UNIT OR FULL PRICE) |\n| DIAGNOSIS CODE(S) |  |\n| PLEASE SELECT WHICH IS APPLICABLE\u003Cbr> HOME INFUSION\u003Cbr> OFFICE/INFUSION CENTER\u003Cbr> REQUESTING BUY AND BILL |  |","cbCaiuxhKSFOdcf3","https://ap.wps.com/l/cbCaiuxhKSFOdcf3","pdf",74827,"English","# Instructions for Submitting Requests for Predeterminations\n## REQUEST FOR INFUSION DRUG AUTHORIZATION\n## IMPORTANT PREDETERMINATION REMINDERS\n## How to fill out this form\n## What happens next\n## Section 1: Provide the following general information\n## Section 2: Provide the following patient-specific information","[{\"question\":\"Is a predetermination request the same as pre-certification of benefits?\",\"answer\":\"No. The document states it is a courtesy review and not a pre-certification of benefits.\"},{\"question\":\"What information is required to prevent delays in the predetermination process?\",\"answer\":\"All applicable fields are required; submissions without the member/patient’s group number, ID number, and date of birth cannot be completed and may be returned.\"},{\"question\":\"How should fax submissions and supporting documentation be handled?\",\"answer\":\"Fax each patient separately using the fax number indicated on the form, do not send duplicate requests, place the Predetermination Request Form on top of supporting documentation, and mail any required photos instead of faxing them.\"}]","REQUEST FOR INFUSION DRUG AUTHORIZATION - Instructions for Submitting Predeterminations | PDF"]