Cigna Preauthorization Requirements and Guidelines

To get a Cigna preauthorization, you'll need to submit a request at least 5 business days in advance.

Cigna requires preauthorization for certain services, including hospital stays, surgeries, and some medical procedures.

You can submit a preauthorization request online, by phone, or by mail.

Cigna will review your request and respond within 2 business days.

Precertification can be a complicated process, but knowing the right place to start can make a big difference. Precertification is required for medical procedures, medications, and behavioral services.

To submit a precertification request, you can use one of three methods: online submission, via your electronic health record (EHR) or electronic medical record (EMR) system, or by faxing or calling Cigna. For online submission, you can use CoverMyMeds or Surescripts, which can be accessed through CoverMyMeds.com/epa/Cigna or your EHR/EMR system.

If you're unable to use electronic prior authorization, you can call Cigna at 800.88Cigna (882.4462) to submit a prior authorization request.

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Here are the precertification guidelines for medical procedures:

You'll need to provide all required information when submitting a precertification request to avoid denial of certification. You can also submit additional information to supplement a previously submitted request via the original form of transmission.

Precertification benefits include confirming patient eligibility and available benefits, confirming medical necessity, and evaluating the proposed setting and level of care. Predeterminations are an option for providers to obtain a medical necessity review and estimation of patient liability prior to rendering the service.

Precertification is required for some services, including medical procedures, medications, and behavioral services. However, emergency services do not require precertification, but inpatient hospital admissions resulting from emergency services must be reported within one business day of admission.

To request precertification for Wegovy, your healthcare provider will need to inform Cigna that you have performed behavioral modifications and a reduced-calorie diet for at least three months and meet certain BMI or comorbidity criteria.

Cigna Medicare Advantage medical services require prior authorization for certain procedures. This includes durable medical equipment, home health, and infusion services.

If you're a provider in Arizona, you can view the complete list of services that require prior authorization on the Cigna website. To review previous versions of the list, click on the link provided.

For precertification requests, including those for custodial care, contact EviCore at 800.298.4806 or visit their website.

To request precertification for medical procedures, you'll need to follow Cigna's specific process, which can be done in three ways.

You'll need to provide all required information with your precertification request, or it may be denied. If you need to add more information to a previously submitted request, you can do so via the original form of transmission.

Cigna has specific vendors for certain services, such as dialysis and laboratory tests, and you'll need to work with them directly after obtaining approval.

Here are some specific vendors for certain services:

If you're used to submitting prior authorizations through PromptPA, you'll need to switch to electronic prior authorizations, which can be done through your EHR or EMR system or via CoverMyMeds or Surescripts.

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EviCore by Evernorth is a convenient way to manage medical and pharmacy drug prior authorization. You can use it to streamline the process for Cigna Healthcare patients.

For oncology pharmacy drug and medical prior authorization, choose the Medical Oncology Pathways option. This will help you navigate the specific requirements for these types of requests.

To access pharmacy drug prior authorization for Cigna Healthcare patients, select the Pharmacy Drugs (Express Scripts Coverage) option. This will guide you through the process for non-oncology related pharmacy drug requests.

Learn more about EviCore by Evernorth to make the most of its features and simplify your precertification process.

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The service specific precertification process can seem overwhelming, but it's actually quite straightforward. You can request precertification for medical procedures in three ways.

To submit a precertification request, you'll need to provide all required information. Failure to do so may result in the denial of certification for an admission, procedure, or service.

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You can find more detailed information about each ancillary program and the services provided by clicking on the service type. This will help you understand what's required for each specific service.

There are several vendors that require precertification, including Davita for dialysis, LabCorp and Quest Diagnostics for laboratory services, and Fresenius for dialysis.

To work with these vendors, you'll need to obtain approval from Cigna first, and then work directly with the vendor to perform or receive the services.

Here are some specific vendors and their contact information for precertification:

By following these steps and working with the appropriate vendors, you can ensure a smooth precertification process for your patients.

If you're looking to get Cigna to cover a GLP-1 drug for weight loss, you're in for a bit of a challenge. Cigna generally only covers GLP-1 drugs for their FDA-approved indications, not for weight loss.

These medications, like Ozempic and Mounjaro, are typically approved for treating Type 2 diabetes, not weight loss. But, there are some exceptions. Wegovy and Zepbound, for example, are approved for weight loss, but not for treating Type 2 diabetes.

To get Cigna to cover a GLP-1 drug, you'll need to meet specific criteria, which vary depending on the medication. For example, to get Ozempic covered, you'll need a diagnosis of Type 2 diabetes and be at least 18 years old.

Here's a breakdown of the Cigna prior authorization requirements for some popular GLP-1 drugs:

Cigna typically requires prior authorization for all types of weight loss drugs, including GLP-1 agonists, but the prior authorization criteria for drugs on its national formulary are somewhat flexible. Patients often receive prior authorization approval but typically need to have tried other strategies, like behavioral and dietary changes for at least three months before coverage is approved.

Cigna has been working to simplify the healthcare experience for both consumers and clinicians by removing prior authorization requirements for certain medical services. Since 2020, they've removed prior authorization on over 1,100 medical services, with the latest update removing close to 25% of medical services from prior authorization requirements.

This move aims to reduce administrative burdens on the healthcare system and make care more affordable. With the update, prior authorization now applies to less than 4% of medical services for most Cigna Healthcare customers.

Cigna will continue to engage with clinicians to align on care delivery goals and outcomes, and evaluate whether there are other changes they can make without compromising patient safety.

Staying on top of your healthcare can be overwhelming, but being informed and proactive can make a big difference.

To make prior authorization less intimidating, stay informed about your insurance plan's formulary and coverage policies. This will help you anticipate prior authorization requirements.

Maintaining open communication with your healthcare provider is crucial. Make sure to provide them with updated insurance information.

Having all the necessary medical documentation is key to a successful prior authorization request. Ensure your healthcare provider has everything they need to submit a request to your insurance provider.

Prior authorization requests can take time, so be patient and don't be afraid to follow up. If needed, advocate for yourself, but also be understanding of the provider's busy schedule.

If your request isn't approved, don't worry – explore alternative medication options with your provider.

Cigna Healthcare has removed prior authorization for over 1,100 medical services since 2020, with the goal of simplifying the healthcare experience for consumers and clinicians.

Removing prior authorization for 600-plus additional codes has reduced the number of medical services subject to prior authorization to less than 4% for most Cigna Healthcare customers.

This change will enable Cigna to focus on making care more affordable and improving health outcomes, while reducing administrative burdens on the healthcare system.

Cigna aims to remove prior authorization for nearly 500 additional codes for Medicare Advantage plans later this year.

Prior authorization now applies to less than 4% of medical services for most Cigna Healthcare customers.