2022-2025 Form

What is the Evernorth Transcranial Magnetic Stimulation TMS Request Form 924445 Interactive PDF

The Evernorth Transcranial Magnetic Stimulation TMS Request Form 924445 Interactive PDF is a specialized document designed for healthcare providers to request authorization for TMS therapy. This form serves as a formal request to insurance companies, ensuring that patients receive necessary treatment for conditions such as depression and anxiety. The interactive PDF format allows for easy completion and submission, streamlining the process for both providers and patients.

How to use the Evernorth Transcranial Magnetic Stimulation TMS Request Form 924445 Interactive PDF

Using the Evernorth TMS Request Form is straightforward. Begin by downloading the interactive PDF from a reliable source. Open the form using a compatible PDF reader that supports form filling. Complete each section by entering the required information, including patient details, diagnosis, and treatment history. Once all fields are filled, review the information for accuracy before saving and submitting the form to the appropriate insurance provider.

Steps to complete the Evernorth Transcranial Magnetic Stimulation TMS Request Form 924445 Interactive PDF

To effectively complete the Evernorth TMS Request Form, follow these steps:

• Download the interactive PDF and open it in a PDF reader.
• Fill in the patient’s personal information, including name, date of birth, and insurance details.
• Provide the diagnosis and relevant medical history that justifies the need for TMS therapy.
• Include information about previous treatments and their outcomes.
• Sign the form electronically, if applicable, and ensure all required fields are completed.
• Save the completed form and submit it to the insurance provider as per their guidelines.

Key elements of the Evernorth Transcranial Magnetic Stimulation TMS Request Form 924445 Interactive PDF

The key elements of the Evernorth TMS Request Form include:

• Patient Information: Essential details such as the patient's name, contact information, and insurance policy number.
• Diagnosis: A clear statement of the patient's condition, including ICD-10 codes if applicable.
• Treatment History: Documentation of prior treatments and their effectiveness.
• Provider Information: Details about the healthcare provider submitting the request, including their credentials and contact information.
• Signature: An electronic signature or a space for a handwritten signature to validate the request.

Eligibility Criteria

Eligibility for TMS therapy as outlined in the Evernorth TMS Request Form typically includes criteria such as:

• Diagnosis of major depressive disorder or other specified conditions.
• Failure to respond to at least one prior antidepressant treatment.
• No contraindications for TMS therapy, such as certain medical implants or conditions.
• Age requirements, often limited to adults and adolescents.

Form Submission Methods

The Evernorth TMS Request Form can be submitted through various methods, depending on the insurance provider's requirements:

• Online Submission: Many providers allow for electronic submission through their online portals.
• Mail: The completed form can be printed and mailed to the insurance company’s claims department.
• In-Person: Some healthcare facilities may offer the option to submit the form directly at their office.