Precertification Request
**No retro-precerts after 90 days from the date of service.**
Required Information: Member Demographics
(Please verify eligibility prior to rendering service).
Name:
Date of Birth:
Employer:
Insurance ID #:
Member Email:
Core is:
Primary
Secondary
Required Information: Provider Information
Provider Name:
Provider Tax ID#:
Enter exactly 9 digits!
Facility:
Facility Tax ID#:
Enter exactly 9 digits!
Contact Person:
Contact Phone:
Email:
Provider NPI:
Enter exactly 10 digits!
Required Information: Procedural Information
Date of Service:
Diagnosis Codes (ICD-10):
Use commas to separate codes. No line breaks.
Procedure Codes (CPT):
Use commas to separate codes. No line breaks.
Inpatient?
Yes
No
File Attachments:
Upload File:
Upload File:
Upload File:
(
The maximum file size is 50MB. Submitting large files may cause a delay — please do not close your browser while the upload is in progress.
)
Please be sure to complete the entire form and attach any office notes, pathologies, and diagnostics in the File Attachments box above. Once finished, click the Submit Precertification Request button below.