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Online Precertification

Please call (317) 655-4500 for Emergency Medical Evacuation requests. Do not use this form for Evacuation requests. You will be notified upon receipt of this precertification. Precertification is not a guarantee of payment nor is it a denial. It remains the insured person's responsibility to verify benefits. All conditions and provisions of the insured person's certificate of insurance apply.
 
Is this Precertification Initiation Form being submitted by the Provider?
 
* Denotes a required field
 
Patient Information
 
Name of Insured*
Certificate / Group Number*
Date of Birth*
RadDatePicker
RadDatePicker
Open the calendar popup.
Country*
Address*
Address 2
City*
State or Province*  
(US & Canada only)
Postal Code*  
(US & Canada only)
Region
Phone Number*
Fax Number
Insured E-mail Address*
Confirm E-mail Address*
 
Policy Information Requested
Please select additional policy information that you would like to receive.
 


Other
 
How would you prefer to receive the Precertification letter?
 
If additional information is needed to complete the Precertification,
is it okay to contact you by e-mail?
 
Would you like a Verification of Benefits to be forwarded to you
within two business days via e-mail?
 
Type of Service




 
Date of Service
Date of Service*
RadDatePicker
RadDatePicker
Open the calendar popup.
Discharge Date (if known)
RadDatePicker
RadDatePicker
Open the calendar popup.
Requested Number of Inpatient Days*
 
 Proposed Treatment / Service / Supply*
 
CPT
 
 Diagnosis*
 
ICD-9
 
 History of Diagnosis*
 
According to your Certificate wording, medical necessity must be established for all hospitalizations or procedures. To make this determination, our medical department will need clinical information pertaining to this procedure prior to the date of service (within 48 hours of emergency admission or treatment). Please arrange to have the medical records faxed to the attention of the Precertification Department at: (317) 655-4505. The Medical Records should include: diagnoses, symptoms, history of present condition, progress or office notes, lab results, medication administered, surgery planned (if applicable) and treatment plan.
Physician Information
Name of Physician*
Physician Country*
Physician Address*
Physician Address 2
Physician City*
State or Province* (US & Canada only)
Physician Postal Code*
Physician Region
Physician Phone*
Physician Fax
E-mail Address*
 
Facility Information
 
Name of Facility*
Facility Country*
Facility Address*
Facility Address 2
Facility City*
Facility State or Province*
Facility Postal Code*
Facility Region
Facility Phone*
Facility Fax
E-mail Address*
 
Additional Notes
ACM® will notify you upon receipt of this e-mail. Once we have received this request, our medical team will review the information you have provided and respond to you within 2 business days. We will either approve or deny the precertification request based on Medical Necessity, or we will pend the request while we gather further information. You may choose to withdraw your request at any time. Precertification is not a guarantee of payment nor is it a denial. It remains the insured person's responsibility to verify benefits. All conditions and provisions of the insured person's certificate of insurance apply.
 
Online Precertification Agreement
All users of IMG®'s online Precertification feature understand and agree that the online Precertification Form is made available and is to be used solely in an effort to expedite and assist the Precertification process.
Online use and submission of the Precertification Form will not automatically provide a Precertification number or certifiy a request. Upon submission the user will be notified by email of IMG's receipt of the Form, and the user will subsequently be contacted by IMG’s subsidiary (and URAC accredited) medical management company, Akeso® Care Management®, Inc. (ACM®), to complete the Precertification process.
The user understands and agrees that Precertification is only a determination of Medical Necessity, and that such determination is made in reliance and based upon the completeness and accuracy of the information provided by the user, the insured, and/or the insured's relatives, guardians and/or healthcare providers at the time of Precertification.
Precertification is neither an assurance, authorization or verification of coverage, a verification of eligible benefits, or a guarantee of payment, nor is it a denial of such matters. The fact that Treatment, services or supplies are certified does not guarantee either the payment or reimbursement of benefits or the amount or eligibility of benefits.
Any consideration and/or determination of a Precertification request, as well as any subsequent review or adjudication of all medical claims and invoices submitted in connection therewith, will remain subject to all terms and conditions of the Insured's insurance Certificate, including exclusions and/or limitations for Pre-existing Conditions (as applicable) and other designated exclusions, benefit limitations, and the requirement that claims be Usual, Reasonable and Customary. No consideration or determination of a Precertification request will be deemed or considered as an approval, authorization, or ratification of, recommendation for, or consent to any diagnosis or proposed course of Treatment. Neither the Company (as insurance carrier), IMG (as Plan Administrator, nor ACM (as the medical management company), nor anyone acting on their respective behalfs, has any authority or obligation to select Physicians, Hospitals or other healthcare providers for the lnsured Person, or to make any diagnosis or medical Treatment decisions on behalf of the lnsured Person, and all such decisions must be made solely and exclusively by the lnsured Person and his/her family members, guardians, and treating Physicians and other healthcare providers.
If the lnsured Person and/or his/her provider(s) comply with the Precertification requirements of the insurance Certificate, and the Treatment, services or supplies are certified by ACM as Medically Necessary, the Company will reimburse the lnsured Person for Eligible Medical Expenses incurred in relation thereto, subject to all Terms of the Master Policy and Certificate, including any applicable Deductible and Coinsurance.
Every attempt will be made to help the lnsured Person and his/her healthcare providers understand the status, scope and extent of available benefits and coverages under the Master Policy as outlined in the Certificate; provided, however, that no statement made by any agent, employee or representative of the Company, the Plan Administrator or ACM will be deemed or construed as an estoppel or to create any liability against the Company, the Plan Administrator or ACM, or be deemed or construed to bind the Company, the Plan Administrator or ACM or to modify, replace, waive, extend or amend any of the Terms of the Master Policy or the Certificate, unless expressly set forth in writing.
Actual eligibility determinations, final coverage decisions, and benefit or claim payments and/or reimbursements can only be determined and adjudicated at the time a proper and complete Proof of Claim is submitted, an opportunity for reasonable investigation and/or review is provided, required cooperation received, and all facts and supporting information, including relevant medical records, are presented in writing. The Terms of the Master Policy govern all available coverages, eligibility and payments made or to be made.
If a definite answer to a specific benefits or coverage question is required for any reason, the lnsured Person or his/her provider may submit a written request to IMG in that regard, including all pertinent medical information and a statement from the attending Physician (if applicable), and a written reply will be sent by IMG on behalf of the Company and kept on file. If IMG on behalf of the Company elects to verify generally and/or preliminarily to a provider or the lnsured Person that an Injury, Illness, diagnosis or proposed course of Treatment is or may be covered under the Master Policy, or that benefits for same are or may be available as outlined in the insurance Certificate, any such verification of benefits does not guaranty either payment or reimbursement of benefits or the amount or eligibility of benefits. Final eligibility determinations, coverage decisions, and actual reimbursement or payment of claims or benefits are subject to all Terms of the Master Policy and Certificate, including without limitation filing a proper and complete Proof of Claim in accordance with the requirements outlined in the Certificate.
As used herein, the terms "Certificate," "Coinsurance," "Company," "Deductible," "Eligible Medical Expenses," "Hospital," "Illness," "Injury," "lnsured Person," "Master Policy," "Medical Necessity (Medically Necessary)," "Physician," "Plan Administrator," "Precertification (Precertify)," "Pre-existing Condition," "Proof of Claim," "Terms," "Treatment," and "Usual, Reasonable and Customary," shall have the respective meanings and definitions ascribed to them in the applicable certificate wording (available to any insured or provider upon request).
 
Agreement Signature

   Signature:    

Summary
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