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Click ‘Get Form’ to open the Evernorth Outpatient Behavioral Network Exception Request Form in our editor.
Begin by filling in the 'Requested Start Date of Network Exception' section. Indicate whether treatment has started and provide the start date if applicable.
Complete the customer information fields, including name, date of birth, and member ID. Ensure all details are accurate for processing.
In the 'Outpatient Provider' section, enter your name, degree(s), license information, and contact details. Confirm if voicemail is confidential.
List the diagnosis codes (F codes) and requested CPT codes relevant to the treatment. Specify the location of services as either home or office.
Provide a detailed clinical rationale for requesting the network exception, explaining why your treatment specialties are uniquely suited for this customer.
Finally, sign and date the form, then save it to your computer. Email it to NER@Evernorth.com or fax it to 860-687-7329.
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On February 13, 2023, Cigna renamed its holding company The Cigna Group, its health benefits provider business unit Cigna Healthcare, and its Evernorth business unit Evernorth Health Services.
What is the fax number for Evernorth behavioral health?
Please complete this form, save it to your computer, then email it to: NER@Evernorth.com (preferred) or fax 860-687-7329.
What insurance is Evernorth behavioral health?
Evernorth Behavioral Care Group offers end-to-end services to all those covered under our partnering insurers. We provide in-network services to all members covered under Evernorth Health Services and Cigna Healthcare commercial plans.
What is the fax number for eviCore clinical?
Please complete this request with your contact details and some information about your needs. If you are a member and need help with your benefits, call (888) 736-7499.
What is the fax number for Cigna Evernorth?
Please provide any additional relevant information (do not attach extra pages): 6. Please complete this form, save it to your computer, then email it to: NER@Evernorth.com (preferred) or fax 860-687-7329.
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