Cigna Out of Network Therapy Provider Fax Request Form - OrthoNet 2026

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The document is a fax request form for Cigna members seeking pre-certification for out-of-network therapy visits, including physical and occupational therapy. It provides instructions for completing and submitting the form to OrthoNet, along with necessary patient and provider information.

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Click ‘Get Form’ to open the Cigna Out of Network Therapy Provider Fax Request Form in our platform.
Begin by filling out the 'Therapy Provider Information' section. Enter the facility name, street address, city, state, zip code, return fax number, telephone number, National Provider Identifier (NPI), and provider tax ID number. Ensure all fields are completed accurately.
Next, move to the 'Patient Information' section. Input the patient's first name, last name, member ID number, and date of birth. Use the provided format for clarity.
In the 'Request Information' section, specify the service type (Physical Therapy or Occupational Therapy) and provide the initial evaluation date along with the diagnosis code in ICD-9 or ICD-10 format.
Review all entered information for accuracy. Once confirmed, save your changes and prepare to fax this request form along with any supporting documentation to OrthoNet at 1-888-779-8365.

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How do I get a prior authorization form from Cigna?

Moving forward, please visit CoverMyMeds at .covermymeds.com/main/prior-authorization-forms/cigna/ or via SureScripts in your EHR to learn more and submit all new PA requests electronically. If you are unable to use electronic prior authorization, please call us at 1.800. 882.4462 (1.800. 88.

What is the phone number for OrthoNet provider portal?

If you have any questions regarding this process, please contact our Credentialing department at 1-800-873-4575. Please note: You have the right to review submitted information supporting your application for participation in OrthoNets network.

Are OrthoNet and Optum the same?

OrthoNet LLC, which is part of Optum Health, reviews preauthorization requests for EmblemHealths Spine Surgery and Pain Management Therapies Program for select spine surgery and interventional pain management therapy.

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