SJRA Forms and Reference Information

Precertification Request Forms

South Jersey Radiology is pleased to introduce our Insurance Precertification Request service.

Most insurers permit SJRA to obtain the pre-cert on your behalf for patients referred to our practice. To initiate a precertification request, please fax the following to SJRA at (856) 772-0268.

  • Order/Referral/Prescription for the requested study;
  • Completed Precertification Request Form and
  • Any applicable clinical notes to support the Precertification Request.

We will contact the applicable Radiology Benefits Management Program (RBM) for the patient’s insurance carrier on your behalf using the above information. If the precertification is approved, we will contact the patient to schedule the study. If the precertification is pended or denied, we will notify you so you can provide any requested information or appeal the denial with the carrier directly.

SJRA is unable to obtain precertification for No-fault (MVA), Workers Compensation or non-participating insurance carriers.

If you have any questions about SJRA’s precertification services, please call our Precertification Coordinator at (856) 770-0504, x1155.

General Information

Patient Forms for Your Information

Body Specific CT Forms

Body Specific MRI Forms

Commonly-Used ICD-10 Codes

Click here for ICD-10 Codes. If you are a PC user, please press Ctrl F to search the ICD-10 commonly-used codes. If you are a Macintosh user, please press Option/Command F.

Disclaimer: Content on this page is subject to change without prior notice.

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