Cigna Prior Authorization Fax Form (Medical Precert)

Cigna's general fax form for medical precertification pairs an authorization intake cover sheet with a one-page request naming the patient, the requesting and servicing providers, and the service with its diagnosis and procedure codes. Offices use it when a service on Cigna's precertification list needs approval and they are not submitting electronically or by phone. Cigna asks for clinical records to be attached and acknowledges a pending review within 24 to 48 hours.

Who completes it

The requesting provider's office completes both pages: the sender details on the cover sheet and every block of the prior authorization form, including the servicing provider who will perform the service. The patient does not sign it, and the form has no clinician signature line.

How to fill it in

Cigna authorization intake fax cover sheet

Page 1 is the cover sheet, preprinted with Cigna's intake fax number. Fill in the sender's name, phone number and fax number so Cigna knows who sent the request and where to reach them. It goes on top of the page 2 prior authorization form and the clinical records. The sheet marks the transmission as confidential Cigna property intended only for the addressee.

Patient information

Enter the patient's name, Cigna ID number, address, date of birth and phone number. The header above this block asks for the form to be completed in its entirety, so fill every line rather than relying on the attached records to supply demographics. Before faxing, the Cigna for HCP portal shows the precertification service list and the patient's benefits, which confirms the service needs review at all.

Requesting healthcare professional's information (HCP)

The requesting HCP is normally the ordering or admitting provider, who under Cigna's rules must request and obtain precertification for in-network services. Enter the name, address, city and state, Tax ID or NPI, an office contact name, and the contact's phone and fax. List a contact who can answer questions and supply more clinical records if the reviewer needs them.

Servicing healthcare professional information

Name the provider or facility that will perform the service, with its address, city and state, and Tax ID or NPI. Cigna's precertification page says the rendering provider or facility must confirm approval before an elective service, so the servicing provider named here should check that the request was approved before scheduling. Some services, such as dialysis or lab work, are then arranged with a Cigna vendor.

Service information

Mark the setting as Inpatient, Outpatient, DME or Other, and give the date of service. Add a diagnosis description and up to six diagnosis codes, then a procedure description. Cigna's precertification page says every request needs a description of the service, its start and end dates, and the HCPCS or CPT code if available, and that a request missing important details may be denied.

Procedure code, Modifier, Units and Visits

The grid holds up to five procedure codes, each with a modifier and a units count, and units must be specified per extremity. If the service is a series of visits, state the frequency and duration on the Visits line. Attach the clinical documentation supporting medical necessity, as the header instructs; reviewers also consider the care setting and whether lower-cost options exist.

Common mistakes

Faxing the form without clinical records, when the header says to attach clinical information supporting medical necessity.
Leaving out the service start and end dates or the HCPCS or CPT code, which Cigna lists as required details whose absence can lead to denial.
Entering units in the procedure grid without specifying them per extremity, as the column heading requires.
Using the fax form for a drug request, when Cigna handles medication prior authorization through ePA portals or by phone.
Faxing Cigna for services it routes through EviCore, such as radiology, sleep, musculoskeletal, oncology or home health, instead of submitting them to EviCore.
Performing an elective service before the rendering provider or facility has confirmed that precertification was approved.

Submitting and payment

How to submit it: Fax both pages with supporting clinical records to the Cigna intake number printed on the form, and allow 24 to 48 hours for acknowledgment of the pending review. Cigna also takes medical precertification requests electronically as EDI 278 transactions and by phone, and services it routes to EviCore, such as radiology, sleep and home health, go to EviCore instead.
Who pays: Cigna warns that not getting precertification may lead to denial of payment for the service, and that precertification does not guarantee payment or coverage of all billed services.

Good to know

Referring (ordering or admitting) providers must request and obtain precertification for in-network services, while rendering providers and facilities must confirm approval before performing elective services.
Emergency services do not need precertification, but an emergency that results in an inpatient admission must be reported within one business day of the admission unless a state mandate says otherwise.
Cigna posts separate fillable precertification forms for cervical fusion or cervical disc replacement and for lumbar fusion, plus state forms such as the Texas Standard Prior Authorization Request Form.
Drug prior authorization does not use this form: Cigna sends medication requests through ePA portals (EviCore, Surescripts or CoverMyMeds), and its pharmacy reviews run through Express Scripts.

Get the official form

Download the current version from the source each time; forms change without notice.

Prior Authorization Form (Cigna authorization intake fax cover sheet)

Official page PDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

Sources for this guide

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

How long does Cigna take to acknowledge a faxed prior authorization?

The form asks you to allow 24 to 48 hours for acknowledgment of the pending review. That acknowledgment confirms Cigna has the request; the decision follows a review of the attached clinical information, which Cigna says weighs medical necessity, the care setting and whether lower-cost options exist.

What information does Cigna require for a precertification request?

Cigna lists three items for every submission route: a description of the service, its start and end dates, and the HCPCS or CPT code if available, and warns that a request missing important details may be denied. The fax form also asks for diagnosis codes, modifiers, units per extremity, visit frequency and duration, and attached clinicals.

Who is responsible for getting Cigna precertification?

For in-network services, the referring provider, meaning the ordering or admitting provider, must request and obtain precertification. The rendering provider or facility must confirm approval before an elective service and may request precertification in some cases. That is why the form has separate blocks for the requesting and servicing healthcare professionals.

Can I use the Cigna prior authorization fax form for medications?

No. Cigna directs medication prior authorizations to electronic portals, naming EviCore, Surescripts and CoverMyMeds, with phone as the fallback. Cigna pharmacy reviews run through Express Scripts, which publishes its own General Request Form for faxed drug requests. This form is built around service dates, diagnosis codes and procedure codes for medical services.