For certain Cigna plans, PCPs are required to make patient referrals to specialists in order for:
- Any part of that care to be covered (the customer may otherwise be responsible for full payment), or
- Covered care to be reimbursed at the highest coverage level
PCP and specialist responsibilities
When referrals are required, PCPs are responsible for:
- Providing the patient with a written referral to the specialist
- Noting the referral in the patient's medical record
- Submitting the referral to Cigna for certain plans
Specialists are also responsible for noting the referral in the patient's medical record.
Cigna Connect, HMO, and Network plans. PCPs are required to refer customers with Connect, HMO, or Network plan coverage to specialists who participate in the network aligned to that plan. Note that Connect plans also require that PCPs submit these referrals to Cigna.
Cigna Point of service plans. PCPs are encouraged to refer customers with point of service (POS) plan coverage to specialists who participate in the network aligned to the plan. This will help their patients receive the highest levels of coverage, and prevent them from incurring unexpected, out-of-pocket costs. However, customers may receive care from participating or non-participating specialists without a referral from their PCP.
Cigna Open Access, PPO, and Indemnity plans. Referrals are never needed for these plans. Customers may visit any doctor for primary or specialty care services.
How to submit referrals to Cigna (Connect plans)
There are multiple options for PCPs to submit referrals to Cigna:
- Online: Health Care Request and Response (ANSI* 278): Contact your electronic data interchange (EDI) or practice management system vendor
- Phone: 1.866.494.2111. choose the prompt for specialist referral.
- Fax: 1.866.873.8279. Obtain a referral form.
- Mail: Cigna
Attn. Precertification and Referral Department, 2nd Floor
1640 Dallas Parkway
Plano, TX 75093
*American National Standards Institute
Exceptions for submitting referrals
Lab and radiology services
Referrals are not required. However, prior authorization or precertification may be needed.
Certain states mandate that referrals not be required for some specialists or services:
- Arizona – OB/GYNs, dentists (pediatric), vision care (pediatric), chiropractors, emergency or urgent care
- Tennessee and Texas – OB/GYNs, dentists (pediatric), vision care (pediatric), emergency or urgent care
- Colorado – OB/GYNs, dentists (pediatric), vision care (adult and pediatric), emergency or urgent care, certified nurse midwives
Referrals are not required when referring patients to behavioral health care professionals in any market
Special note about women’s health care
All Cigna health plans have adopted an "open access" policy for women's health care. Referrals are not needed for visits for covered services to obstetricians/gynecologists who participate in Cigna's network.