Get Evernorth 924537 2020-2025

The Evernorth 924537 form is a crucial document for clinicians requesting an exception for outpatient behavioral services. This guide provides a clear, step-by-step approach to help users fill out the form accurately and effectively.

Follow the steps to complete the Evernorth 924537 form online.

1. Press the ‘Get Form’ button to access the Evernorth 924537 form online and open it in your preferred digital editor.
2. Begin by entering the date of the request in the designated field.
3. Input the customer’s full name and date of birth in the respective fields. Also, provide the Cigna member's identification number and the policyholder's social security number.
4. Fill in the customer’s current home address, ensuring it is accurate and complete.
5. Provide the outpatient provider's name along with their degrees and independent license information, including the license number and tax identification number (TIN). Indicate the state in which the provider is licensed.
6. Enter the provider's phone number, service address, and contact information at the provider's office.
7. Specify the requested start date for the NER if authorization is granted, and include any previous authorization numbers if applicable.
8. List the diagnosis codes (F codes) and the requested CPT codes for services.
9. Detail the clinical rationale for requesting the NER, including primary issues being treated and any clinical treatment specialties the provider will deliver.
10. Provide any additional relevant information in the designated section.
11. Date the form and include the provider's signature. Type or print the requesting provider's name in the final field.
12. Once all sections are completed, save the form to your computer and email it to NER@cigna.com or fax it to 860-687-7329.

Complete your Evernorth 924537 form online today to ensure a smooth submission process.