In all cases where the proposed treatment plan includes services that are determined not to be medically necessary, according to Cigna Behavioral Health’s Level of Care Guidelines, the care manager will discuss treatment alternatives with the professional. When mutual agreement is reached regarding alternative level of care, an authorization will be issued.

When agreement is not reached, an opportunity will be offered for the professional to review the requested treatment with a clinical peer. The care manager will facilitate this peer-to-peer review process. In the event a mutually agreed upon decision is still not reached, a coverage denial will be issued.

All reviews are conducted in a timely manner consistent with the level of urgency in the participant’s clinical presentation and in compliance with state law and accreditation standards. Determinations are communicated in writing to the participant, professional and in instances of hospitalization, the facility.