Registration

Welcome to the WINFertility Family

Please fill the following details to send a request to WINFertility to complete your registration process and join the WinFertility family.

Administrator Full Name *

Address 1

Organization/Practice Name *

Address 2

Contact Phone *

Extn

city, State and Zip
State *	City *	Zip Code *

Fax Number

Contact Email ID *

Have you had previous Interaction with WINFertility?
Yes No

Group Tax ID *

Anthem/Empire/Emblem Group Tax ID

Cigna Group Tax ID

BCBSRI Group Tax ID

Any Special Requests?

Approximate number of users that will be using the WIN Provider Portal

WIN Provider Portal Features

This portal provides services including :

• Search authorization history
• Request a prior authorization
• Submit medical/cycle history information
• Upload documents
• Enter Treatment Outcome
• Enter Prescription
• Search claims and remittance report

877.444.4946

Seeking a diagnosis of and/or confirmed ovarian hyperstimulation syndrome (OHSS)

Seeking a diagnosis of and/or confirmed ectopic pregnancy

Pregnant and bleeding

Seeking a diagnosis of and/or confirmed ovarian torsion

Fertility preservation related to a cancer diagnosis and/or iatrogenic cause of infertility. Requires impending plans for medical treatment, chemotherapy, radiation, and/or surgery that may lead to infertility

Any other medical condition deemed potentially harmful to the patient if not medically addressed.

None of the above apply.

Patient ID

First Name

Last Name

DOB

Contract

Patient Group ID

Patient Address

Authorization #

Authorized Service Date(From)

Authorized Service

Authorized Service Date(To)

Physician Full Name

Physician Group

Notification
Notification Date	Notifications	User Name

Document Types:

Choose Attachment:

First Name

Last Name

Member ID

Authorization #

From Date

To Date

Claim List Table
Member ID	First Name	Last Name	DOB	Authorization #	Click To Select

Patient ID

First Name

Last Name

DOB

Authorized #

Authorized Service

Auth Requested Date

Related Service Codes
Service Code	Service Code Description	Base Service

As a valued member of WINFertility’s Provider Network we’d like to share with you the link to WINFertility’s Quarterly Provider Newsletter, offering the latest fertility news, tools and resources for your practice. Click Here

With the increased focus on diversity, equity and inclusion, clients expect WIN to make provider demographic information available to members. We ask that you share the requested information about your doctors to help our members select a provider. Any categories without a response will be indicated with “Not Available” on our member search. WIN appreciates your willingness to help us create great experiences for our shared members and patients.

If you would like this sent to a specific person in your practice who can provide this information, please provide their email id

Please provide the following information for each provider in your practice (At this time, your practice has provided this information for of providers)

Gender

Languages Spoken

Ethnicity

Do you want to identify in our provider directory as a member of the LGBTQIA community

Yes No

Is your practice LGBTQIA friendly

Yes No

Please provide the following information for your practice to enable WIN to automate future interaction and data exchange Name of EMR/s used in your practice

Name of Billing system used in your practice

Current Password

New Password

Confirm New Password

WINFertility will be closed on Thursday, November 24 and November 25 in observance of the Thanksgiving holiday.

However, patients will have the support services of a Nurse Care Manager by calling the toll-free WINFertility number during this time.
Please try to get your authorization and prescription requests in early for any patients in cycle.

We are here to provide support to both you and your patients.

Have a safe Holiday.