URAC Accreditaion Confirmation URAC Accreditaion Confirmation URAC Accreditaion Confirmation

<-  iNetico Precertification Request -> 

For immediate questions or concerns regarding iNeticare PreCert and Care Management please call our 24 hr toll free line at 1-877-608-2200.

Contact Info 

Facility Info 

Member Info 

Contact Type *
Contact Name *
Contact Phone *

Employer/Payor Info 

Payor Name * (On Member Id Card)
Plan Name or Group Number
Precert Request  Date and Time
9/22/2017 2:2:53
    * Required fields
Federal Tax Id Provider Phone
 
Facility Name *
 
Service Street Address
 
Service City, State *, Zip
   

Physician Info 

Federal Tax Id Provider Phone
 
Physician Name *
 
Service Street Address
 
Service City, State *, Zip
   
Member Id Member Phone
 
Insured Full Name
 
Patient Full Name *
 
Patient Birth * Gender *
   
Patient Street Address
 
Patient City, State *, Zip
 
Patient Relation to Insured
Medical Procedure Details
Diagnosis Code
Diagnosis Description *
 
Procedure Code
Procedure Description *
 
Admission Type *
Intended Service Date
Admission Date
Discharge Date
Type of Units Requested
Num of Units Requested
I understand that precertification does not guarantee payment or coverage
I understand that precertification only identifies medical necessity and does not identify benefits
I have or will call the benefit and eligibility department to verify coverage
Please note: Final claim determination is made following receipt and review of the actual claim. For eligibility or plan benefits, call the Benefit and Eligibility phone number located on the members ID card
 

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