Transcription of Infertility Services Precertification Information Request Form
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Infertility Services Precertification Information Request Form
Page 1 of 5 PCFXI nfertility ServicesPrecertification Information Request FormApplies to:Aetna plansInnovation Health plansHealth benefits and health insurance plans offered, underwritten and/oradministered by the following:Allina Health and Aetna Health Insurance Company (Allina Health | Aetna)Banner Health and Aetna Health Insurance Company and/or Banner Health and Aetna Health Plan Inc. (Banner | Aetna)Sutter Health and Aetna Administrative Services LLC (Sutter Health | Aetna)Texas Health + Aetna Health Plan Inc. and Texas Health + Aetna Health InsuranceCompany (Texas Health Aetna)Aetna 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. GR-69375-2 (12-18) V1 Page 2 of 5 GR-69375-2 (12-18) V1 PCFX Infertility Services Precertification Information Request Form About this form You can t use this form to initiate a Precertification Request .
Effective December 21, 2018, this form replaces all other Infertility Services precertification information request documents and forms. This form will help you supply the right information with your precertification request.
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