Precertification can be complicated. Knowing the right place to start can make a big difference.
Below you will find when and where to submit precertification requests to Cigna and Cigna's national ancillary vendors for the following:
You'll also find answers to some of the most frequently asked questions related to precertification.
Contact participating home health, durable medical equipment, and home infusion therapy providers directly. CareCentrix no longer manages these services for Cigna. eviCore healthcare now administers these programs; however, approval or contact with eviCore is not needed.
To find a participating home health/DME provider:
View the complete list of services that require precertification of coverage:
Not registered yet? Go to CignaforHCP.com and click on "Register Now."
Please note: Precertification of coverage is not required for emergency services. However, emergency services that result in an inpatient hospital admission must be reported within one business day of the admission unless dictated otherwise by state mandate.
Please visit https://medicareproviders.cigna.com/ to view Cigna Medicare Advantage prior authorization requirements, including requirements for Arizona Medicare providers.
For precertification process and requests (Including Custodial Care):
There are three ways to request precertification for medical procedures. Upon submission of a precertification request, please provide all required information. Failure to provide all necessary information required for the review may result in the denial of certification for an admission, procedure or service. To submit additional information to supplement a previously submitted precertification request, please submit via the original form of transmission.
To request precertification, use the contact information below or visit the website for next steps.
Click the service type for more detailed information about each ancillary program and the services provided.
| Durable medical equipment (including Orthotics and Prosthetics), home health and infusion | Gastroenterology | Integrated oncology management |
| eviCore healthcare 800.298.4806 Website | eviCore healthcare 844.457.9810 Website | eviCore healthcare 866.668.9250 Website |
| Musculoskeletal and pain management | Radiation therapy | Radiology imaging |
| eviCore healthcare 888.693.3211 Website | eviCore healthcare 866.668.9250 Website | High- and low- technology and diagnostic cardiac imaging eviCore healthcare 888.693.3211 Website |
| Sleep |
| eviCore healthcare 800.298.4806 Website |
Click on the service type for more detailed information about each ancillary program and the services they provide.
When services do require precertification, please work with Cigna to obtain approval and then work directly with the vendor to perform/receive the services.
** Our network of participating laboratories consists of an extensive choice of regional and national providers of laboratory services, including Laboratory Corporation of America (LabCorp) and Quest Diagnostics, Inc. (Quest). For a complete list of participating laboratories, please visit Cigna.com or CignaforHCP.com.
To better serve our providers, business partners, and patients, the Cigna Coverage Review Department is transitioning from PromptPA™, fax, and phone coverage reviews (also called prior authorizations) to electronic prior authorizations, which save time and help patients receive their medications faster.
You can request prior authorization for your patients with Cigna-administered coverage through your electronic health record (EHR) or electronic medical record (EMR) system or via a website that offers this service at no charge.
| EHR/EMR | Online submission | Questions |
CoverMyMeds® |
If you have used PromptPA in the past for prior authorization requests, please know we will no longer accommodate this tool in 2020, and you may receive the following message if you continue to use it: "Eligibility not found." Thus, we encourage you to use CoverMyMeds or Surescripts.
If you are unable to use electronic prior authorization, you can call us at 800.88Cigna (882.4462) to submit a prior authorization request.
Precertification of coverage determinations are based upon the patient's eligibility, the specific terms of the applicable benefit plan, internal or external clinical coverage guidelines, and the patient's particular circumstances. Please note that failure to obtain precertification may result in an administrative denial of payment. Additionally, precertification is neither a guarantee of payment nor a guarantee that billed codes will not be considered incidental or mutually exclusive to other billed services. Coverage is subject to the terms of a participant's benefit plan and eligibility on the date of service.
We require that referring (ordering or admitting) physicians request and obtain precertification for in-network services. The rendering provider or facility is responsible for validating that precertification has been obtained for all elective (i.e., non-emergent or non-urgent) services prior to performing the service for patients whose benefit plans require precertification. In certain circumstances, the rendering provider can also request precertification.
For many benefit plans, we require precertification on targeted specialty medications across both pharmacy and medical benefits to help ensure medications are appropriately prescribed, utilized, and administered.
We apply prospective prior authorization reviews of certain specialty medications to ensure that medications are being prescribed according to FDA-approved indications and that they support evidence for appropriateness of use. Our policies are consistently applied to all outpatient services regardless of the provider type. We evaluate the specialty medications for potential use for off label indications, cost, likelihood for experimental use, waste management opportunities, site of care, and the opportunity to impact dosing or duration of therapy. All potential restrictions are evaluated based on current published literature and practice guidelines to help ensure that there is no interference with standards of practice.
In addition to the customer's insurance and diagnosis information, you will need the following information for prescription drug precertification:
Note: If you submit medication prior authorization requests using SureScripts or CoverMyMeds, you can also check the status of a prior authorization through the same ePA service.
Predeterminations are an option for providers to obtain a medical necessity review and estimation of patient liability prior to the rendering of the service.
Some customers' benefit plans do not require precertification for outpatient services. However, due to the nature of a small number of certain procedures and the possibility for them to be performed without medical necessity, our Claims department may ask, at the time of claim submission, for additional documentation demonstrating that the procedure was indeed medically necessary.
As a way to avoid delays in claim processing, we offer a predetermination option to providers. Predeterminations, while completely optional, serve the same purpose as a precertification in that they are a pre-service review of the requested procedure. If approval is given, an approved authorization is placed on file and your claim will pay appropriately.
Only a limited number of plans, containing a limited number of procedures, are eligible for predeterminations. Please note that a predetermination is not a requirement for payment.
A key part of monitoring and improving patient health is coordinating patient care between primary care physicians (PCPs), specialists, and other ancillary or hospital services for procedures and diagnostic testing through referrals.
Referrals are an "order" or request from a PCP for a patient to see another physician, typically a specialist. Using referrals help direct and coordinate patient care and allows a PCP to oversee, manage, and coordinate all care given to a patient, often resulting in overall appropriate care and reduced long term costs.
If you are a PCP and need to submit a referral, use one of the following options:
If you are a specialist and need to confirm a referral was submitted, you can:
Your patient may need a referral, depending on their plan type. Many HMO, individual & family plan (IFP), and exclusive provider organization (EPO) plans do require our customers to designate a PCP and would likely require a referral for a customer to see a specialist. Most of our Open Access Plus (OAP) or Preferred Provider Organization (PPO) plans do not require referrals at this time.
You can verify the patient's plan, product, and referral requirements by:
