Cigna Members should access care through their PCPs. If the PCP determines that specialty care, diagnostic testing, or other ancillary services are required, the PCP should refer the Member to an in-network provider. Certain services require prior authorization from Cigna.
Cigna’s timelines for determinations are 3 business days for standard reviews and 1 business day for expedited or urgent requests. Urgent requests must meet the definition of urgent/expedited when the decision is required quickly based on the Member's health status. The amount of time necessary to complete standard authorization could jeopardize the Member's life or health or ability to attain, maintain, or regain maximum function.
Examples of three-day turnaround authorizations are for outpatient services, planned inpatient admissions, skilled nursing facility admissions and inpatient rehabilitation admissions.
STAR+PLUS Members are notified in writing within two days of determination. STAR+PLUS, providers are notified by fax, mail and by phone the same day of decision or no later than the next business day.
The clinical information Cigna Utilization Management (UM) team needs for an inpatient Medical is the Complete ER record, Admitting orders, History and Physical, Physician’s treatment plan, and/or Operating Room Report if applicable and any other pertinent clinical information such as abnormal lab results, imaging and/or results, IV medications, consults, evaluations, etc.
For Behavioral Health reviews, the UM team needs Urine Drug Screen results if applicable, Psychiatric evaluation, and intake assessment.
The clinical information Cigna UM team needs for outpatient services is recent office visit notes, applicable labs and imaging, current orders, current treatment plan.
If our members or providers need assistance in obtaining clarification and/or assistance submitting a prior authorization, they are welcome to call Member Services at 1 (877) 653-0327 8:00 am – 5:00 pm Monday – Friday.
Services that Require Prior Authorization
The following services require prior authorization (view Pre-certification List):
- Non-emergency ambulance
- Audiology testing and hearing aids
- Behavioral health services after the 30th session
- DME - all rental as well as purchase, maintenance, or repair over $500
- Home health services
- Inpatient services
- Long term services and supports (Long Term Support Services)
- Outpatient surgeries/procedures in hospital as well as certain procedures in ASC (refer to complete list in Cigna's Provider Manual)
- Psychological and Neuropsychological Testing
- Radiological procedures such as MRI, MRA,CT Scan, Pet Scan, maternity ultrasound
- Rehabilitative Therapy - OT/PT/ST, cardiac, pulmonary rehab
- Sleep studies
- TMJ treatments
- Transplant services
Providers should refer to Appendix E and/or F in Cigna's Provider Manual for a complete overview of services requiring authorization.
How to Request Prior Authorization for Acute Care Services
There are three ways to request a prior authorization.
- Fax a Prior Authorization Form for Acute Care Services to Cigna at the applicable fax number listed below.
- Request a Prior Authorization for Acute Care Services online through Cigna's Provider Portal.
- Speak with a Cigna representative in the Prior Authorization Department at 1 (877) 725-2688.
List/Description of documentation needed for Prior Authorization
- For Inpatient
- Complete ER record
- Admitting orders
- History and Physical
- Physician’s treatment plan or report (if applicable)
- Urine Drug Screen
- Psychiatric evaluation
- Any other pertinent clinical information such as abnormal lab results, imaging results, IV medications, consults, evaluations, etc.
- For Outpatient
- Recent Office Visit Notes
- Applicable labs and imaging
- Current orders
- Current treatment plan
- InterQual: The Cigna STAR+PLUS UM team uses an evidence based criteria. Details of the review are available upon request.
- Discharge info:
- Discharge date: <xx/xx/xxxx>
- Discharge summary (please send)
- Date and results of each MCO’s review of coverage policy
Members may call Member Services at 1 (877) 653-0327 8:00 am – 5:00 pm or leave a message after hours.
Prior Authorization Process
Cigna prioritizes prior authorization requests according to medical necessity. If a prior authorization request is approved, Cigna issues an authorization number that should be used for billing. Cigna faxes the approved Prior Authorization Request Form and the authorization number to the requesting provider according to the following timeframes:
- Standard Request - If all required information is submitted at the time of the request, Cigna will respond to a Prior Authorization Request Form within three (3) business days of receipt of the request.
- Expedited Request - An expedited request can be requested if a Provider believes that waiting for a decision under the standard request timeframe could place the Member's life, health, or ability to regain maximum function in serious jeopardy. To request an expedited authorization, Providers should call 1 (877) 725-2688.
- Emergency Admissions & Services - Prior authorization is not required for Emergency Services. However, Providers must notify Cigna of Emergency Services within twenty-four (24) hours or by the next business day, whichever is later.
- Post-Stabilization Request - Post-stabilization requests can be made for covered services related to an Emergency Medical Condition provided after a Member has been stabilized. Cigna will respond to post-stabilization requests within one (1) hour.
Requests for authorization that are made after hours are reviewed the next business day.
To determine the status of an authorization request, call the Prior Authorization Department at 1 (877) 725-2688.
Limits of Authorization
Authorizations for Acute Care Services are usually issued for thirty (30) days. Authorizations for Long Term Support Services are issued for up to twelve (12) months, depending on the service requested.
Prior Authorization Forms - Acute Care Services
Cigna maintains the following Prior Authorization Forms for Acute Care Services:
Beginning September 1, 2015, the Texas Standard Prior Authorization Request Form for Health Care Services is mandatory for prior authorization of a health care service. Cigna-HealthSpring is currently accepting the Texas Standard Prior Authorization Request Form and the form may be used in lieu of our authorization form.
To review the Prior Authorization process for Long Term Support Services providers, please see link for Long Term Support Services Providers under Resources for Providers.