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Cigna Pre-Certification Program

Cost of health care


Pre-certification of inpatient — and some outpatient — services helps you know in advance how care will be covered by the Health Plan. Your best defense against surprise health care costs is choosing Cigna network providers – as they have agreed to accept Cigna’s reimbursements as payment in full and will automatically request pre-certification for all services that require it. However, if you choose to seek care from non-network providers, we are pleased to inform you of a new Cigna program that will provide you with information that will allow you to make smart health care decisions.

How Cigna’s care management program works

Under this program, all inpatient care, and certain outpatient services, are pre-certified. Pre-certification allows you to know what care will be covered in advance, and at what level. To pre-certify care from non-network providers, you or your doctor calls Cigna at (800) 244-6224 (the number on the back of your Cigna ID card), and you will be notified promptly of the decision. Even if the same treatment was approved for you previously (or approved at a certain level), you should take the time to contact Cigna for each instance of treatment — because Cigna makes ongoing updates to its cost data and care guidelines.

If Cigna determines the care you are seeking is not medically necessary, or if some element of the treatment or charges is otherwise denied, you may appeal this decision. To do so, call Cigna at (800) 244-6224 to initiate a level-one appeal of the pre-certification denial (which may also be referred to as denial of a pre-service claim).

There is still a $250 fee if you don’t pre-certify non-network inpatient hospital care. There is no fee if you don’t pre-certify outpatient services, but it is to your advantage to do so — to be sure you’ll know in advance if they will be covered.

Care that requires pre-certification

Refer to the table below to learn what types of care and procedures should be pre-certified under Cigna’s care management pro¬gram.

Inpatient pre-certification

Pre-certification is required for all non-emergency, non-obstetric inpatient admissions.

Cigna also considers some care to be “inpatient” even if it doesn’t require admission to an acute care hospital. Cigna considers the following services to be inpatient, and so they should be pre-certified:

  • Hospital stays
  • Skilled nursing care, or care from rehab and long-term care facilities
  • Hospice care
  • Transfers between inpatient facilities
  • Any procedures considered to be experimental or investigational Cosmetic procedures
  •  Maternity stays of longer than 48 hours (longer than 96 hours when there has been a C-section)
Outpatient pre-certification

The following outpatient services should be pre-certified, so that you’ll know what will be covered — and at what level — in advance:

  • Outpatient surgery
  • High-tech radiology (MRI, CAT Scans, PET Scans, nuclear cardiology)
  • Injectable drugs (other than self-injectables)
  • Home health care/home infusion therapy
  • Dialysis (to direct to participating facilities)
  • Durable medical equipment
  • External prosthetic appliances
  • Biofeedback
  • Speech therapy
  • Cosmetic or reconstructive procedures
  • Infertility treatment
  • Radiation therapy
  • Sleep management
  • Musculoskeletal services (major joint surgery and pain management)
  • Transplants
  • Requests for services provided by a non-participating doctor to be

Choosing network providers provides additional protection

Choosing Cigna network providers has always been the surest way to avoid unexpected charges, and that is still the case. Network providers are prohibited from balance billing you for amounts over the Plan’s maximum reimbursable charges (MRCs). Also, Cigna network doctors are responsible for contacting Cigna for pre-certification of all services. In fact, they are financially liable — not you — if they fail to do so.

Protect yourself when choosing non-network providers

If you choose to use a non-network provider, while you are not automatically protected from balance billing, there are steps you can take to guard against unexpected charges.

1. First, always pre-certify the inpatient and outpatient services listed above that fall under the scope of the new program, including care Cigna considers to be inpatient.

2. Second, ask your non-network provider what he or she will charge for a given procedure. Once you have the pro¬vider’s charge, call Cigna at (800) 244-6224 to learn if the provider’s charge exceeds the Health Plan’s maximum reimbursable charge for that procedure.

If you have any questions about Cigna’s care management program or the pre-certification process, please call Participant Services at (212) 869-9380 (New York City) or toll-free nationwide at (800) 344-5220.