Insurance Forms

Questionnaire sent by an insurer when a claim suggests the injury or illness may have been caused by a third party (auto accident, workplace injury, slip-and-fall, etc.). Determines whether another insurer or liable party should pay.

Aetna-specific precertification request for inpatient admissions, outpatient procedures, and specialty services. Requires clinical documentation supporting medical necessity.

Anthem/BCBS-specific referral authorization form for specialist visits and out-of-network services. Documents the referring provider, specialist, clinical reason, and number of authorized visits.

Claim for Personal Injury Protection (PIP) or Medical Payments (MedPay) coverage under an auto insurance policy to pay for medical expenses resulting from a car accident, regardless of fault.

Dispute form for when a provider bills a patient for the difference between the provider's charge and the insurer's allowed amount. May violate the No Surprises Act or state balance billing protections.

Certificate proving prior health insurance coverage, used when enrolling in a new plan to avoid pre-existing condition exclusions or late enrollment penalties (particularly for Medicare Part D).

Cigna-specific medical necessity review request for services requiring clinical review. Includes patient clinical information, treatment history, and justification for the requested service or medication.

Election to continue employer-sponsored health coverage after a qualifying event (job loss, reduction in hours, divorce, etc.). Must be elected within 60 days of qualifying event. Coverage retroactive to loss date.

Request to continue seeing a current out-of-network provider at in-network cost-sharing rates during a plan transition. Typically available for a limited period (60-90 days) when switching insurance plans or when a provider leaves the network mid-treatment.

Questionnaire sent by an insurer to determine primary and secondary payer responsibility when a member may have coverage under multiple health plans. Required to correctly coordinate benefits and avoid duplicate payments.

Request for coverage of wheelchairs, CPAP machines, hospital beds, prosthetics, orthotics, and other durable medical equipment.

Request for expedited external review when standard timeframe would jeopardize life or health. The IRO must render a decision within 72 hours.

Request for expedited (urgent) internal appeal when standard timeframe could jeopardize life, health, or ability to regain maximum function. Decision required within 72 hours.

Formal dispute of a processed claim as reflected on the Explanation of Benefits. Used when the patient believes the claim was processed incorrectly, wrong amount was applied to cost-sharing, or coding was inaccurate.

Request for independent external review after exhausting internal appeals. Must be filed within 4 months of final internal denial. Reviewed by an Independent Review Organization (IRO). Decision is binding on the insurer.

HHS-administered Federal External Review for states without compliant external review processes. Filed through the CMS online portal at no cost to the consumer.

Request for coverage of a drug that is not on the plan's formulary. Prescriber must document why formulary alternatives are not appropriate for the patient due to medical necessity.

Estimate of expected charges for scheduled health care items and services. Under the No Surprises Act, providers must give uninsured or self-pay patients a good faith estimate before or at the time of scheduling.

Formal complaint about quality of care, access to providers, customer service, or other non-claim-related issues with a health plan. Distinct from an appeal of a specific claim denial.

Annual health risk assessment required by Medicare Advantage plans and offered by many commercial insurers. Covers health history, current conditions, medications, lifestyle factors, fall risk, mental health screening, and preventive care status.

Request for authorization of home health services including skilled nursing, physical therapy, occupational therapy, speech therapy, and home health aide. Requires signed physician orders and supporting clinical documentation.

Humana-specific request for formulary exception to cover a non-formulary medication or to reduce cost-sharing tier. Requires clinical justification for why formulary alternatives are insufficient.

First-level appeal of claim denial or adverse benefit determination. Must be exhausted before external review. Insurer must respond within 30 days (pre-service) or 60 days (post-service).

Structured letter template for a physician to complete, documenting the medical necessity of a requested service, procedure, or medication. Used to support prior authorizations, appeals, and exception requests.

Request for approval of surgical procedures, imaging studies, specialist referrals, or other services requiring pre-authorization. Must demonstrate medical necessity.

Complaint filed when a member cannot find an in-network provider within a reasonable distance or wait time for a needed specialty. May trigger an out-of-network exception or regulatory action against the insurer.

Request for patient-provider dispute resolution when the actual charges substantially exceed the good faith estimate (by $400 or more). Initiates an independent resolution process.

Written notice and consent form allowing a provider to balance-bill a patient for certain non-emergency out-of-network services at an in-network facility. Patient must receive notice 72 hours before the service and consent in writing.

Request to receive out-of-network services at in-network cost-sharing levels. Typically requires demonstrating that no in-network provider can deliver the needed service within a reasonable distance or timeframe.

Pre-certification for outpatient surgical procedures, diagnostic procedures, and same-day surgeries. Documents medical necessity and planned approach.

Request for coverage of formulary drugs requiring PA, non-formulary drugs, or override of step therapy, quantity limits, or other utilization management edits.

Request for a coverage determination before an expensive or elective procedure. The insurer reviews the proposed service and provides a written estimate of coverage, cost-sharing, and any applicable limitations.

Request to correct inaccurate provider directory information, such as a doctor listed as in-network who is actually out-of-network, or incorrect contact information. May support a claim dispute or balance billing complaint.

Prior authorization request for high-cost specialty medications including biologics, gene therapies, and other complex drugs. Requires detailed clinical criteria documentation.

Formal complaint to state insurance regulator about insurer practices, claim handling, coverage disputes, or unfair treatment. Each state has its own form and process.

Request to bypass step therapy requirement and proceed directly to a preferred or non-preferred drug. Must document why first-step drugs are not appropriate for the patient.

Form used when an insurer seeks to recover medical costs paid on behalf of a member from a liable third party or their insurer. Member must provide details about the incident and any legal proceedings.

Complaint form for violations of the No Surprises Act, including balance billing by out-of-network providers in emergency or in-network facility settings, or failure to provide good faith estimates.

Request to obtain a non-preferred drug at the lower cost-sharing tier. Prescriber must provide a supporting statement documenting why the lower-tier alternatives are not appropriate.

Claim for reimbursement of medical expenses incurred while traveling domestically or internationally. Requires documentation of the medical event, itemized bills, and proof of payment.

UnitedHealthcare-specific prior authorization request form for medical services, procedures, or medications requiring advance approval. Includes clinical justification, diagnosis codes, and requested service details.