PCP Referrals for Specialty Care

For Health Care Providers

May 2018

If you are a network-participating primary care provider (PCP) and need to submit a referral for your patient who has Cigna Connect or Cigna SureFit® plan coverage, please use one of the channels listed below. 1 If it’s an urgent referral, refer to the urgent referrals chart. Note: Prior authorization or precertification may also be needed.

Standard referrals
Submission channel How PCP receives referral number Standard turnaround time Specialist confirmation options Additional Information
Fax
1.866.873.8279
Fax Two business days Obtain the PCP’s written referral from the patient

OR

Call Cigna Customer Service at 1.866.494.2111; choose the prompt for specialist referral (option 4).
To obtain a referral form, go to the Cigna for Health Care Professionals website (CignaforHCP.com) > Find a Form > Medical Forms.
Health Care Request and Response
(ANSI 278)
Fax or U.S. mail Two business days Contact your electronic data interchange (EDI) or practice management system vendor.
Phone
1.866.494.2111

Choose the prompt for specialist referral (option 4).
Fax 24 hours
Mail
Cigna, Attn. Precertification and Referral Dept., 2nd Floor, 1640 Dallas Parkway, Plano, TX 75093
U.S. mail Within two business days of receipt To obtain a referral form, go to CignaforHCP.com > Find a Form > Medical Forms.

1 For most Cigna Connect and SureFit plans, PCPs are required to make referrals to specialists participating in the network aligned to the appropriate plan. For the Cigna Connect plan, referrals are not required in St. Louis, MO and Memphis, TN. For the Cigna SureFit plan, referrals are required in all markets.

Urgent referrals
Urgent situation Submission channel How PCP receives referral number Approximate turnaround time Specialist confirmation options
Patient is not seeing the specialist today, but needs expedited service. Phone
1.866.494.2111

Choose the prompt for specialist referral (option 4).
Fax One hour Obtain the PCP’s written referral from the patient

OR

Call Cigna Customer Service at 1.866.494.2111; choose the prompt for specialist referral (option 4).
Patient is in the PCP office and seeing the specialist today. Over the phone 15 minutes (during the same phone call)

Frequently asked questions

  1. What services, by state, do not require referrals?
    Certain states mandate that referrals not be required for some specialists services. Please refer to the chart below.

    State Specialist or specialty service State Specialist or specialty service
    Arizona
    • Behavioral health care provider3
    • Chiropractic
    • Dentist (for pediatrics)
    • Emergency or urgent care3
    • Laboratory2,3
    • OB/GYN
    • Radiology2,3
    • Vision care (pediatrics)
    Illinois
    North Carolina
    Tennessee
    Texas
    • Behavioral health care provider3
    • Dentist (for pediatrics)
    • Emergency or urgent care3
    • Laboratory2,3
    • OB/GYN
    • Radiology2,3
    • Vision care (pediatrics)
    Colorado
    • Behavioral health care provider3
    • Certified midwife
    • Dentist (for pediatrics)
    • Emergency or urgent care3
    • Laboratory2,3
    • OB/GYN
    • Radiology2,3
    • Vision care (adults and pediatrics)
    Missouri
    • Behavioral health care provider3
    • Emergency or urgent care3
    • Laboratory2,3
    • OB/GYN
    • Radiology2,3
    Florida
    • Dermatologist (first five visits)
    • Chiropractic
    • Emergency or urgent care3
    • Laboratory2,3
    • OB/GYN
    • Podiatrist
    • Radiology2,3
    Virginia
    • Behavioral health care provider3
    • Emergency or urgent care3
    • Laboratory2,3
    • OB/GYN
    • Physical therapist
    • Radiology2,3
    • Any specialty physicians that treat life-threatening,
      degenerative, disabling, or cancer diagnosis

    2 Prior authorization or precertification may be needed.
    3 Referrals are not required in any market for emergency or urgent care, behavioral health care providers, laboratory, and radiology services.


  2. How long is a referral valid for?
    Referrals are valid for up to six months based on the treatment plan determined by the PCP and the specialist. If the patient needs additional care, beyond a six month period, the specialist should contact the referring PCP to coordinate further care and the issuance of a new referral.

  3. Is a referral only valid for one specific condition?
    Not always. A referral should indicate the medical reason the PCP is referring the customer to a specific specialist that may, in certain cases, include the customer’s diagnosis or condition. However, if the specialist confirms additional diagnoses at the time of service that he or she can treat, no additional referrals will be required.

  4. If a customer changes their PCP after obtaining a referral, is the referral still valid?
    Yes. The referral is still valid. The new PCP does not need to submit another referral for the same visit to, or treatment by, the specialist. However, the new network-participating PCP must submit a referral for any different specialist visits or treatments.

  5. What happens if the PCP submits a referral to a specialist who does not participate in the network aligned to the Cigna Connect or SureFit plan?
    Since Cigna Connect and SureFit plans do not offer out-of-network benefits, we will advise them to select a network-participating specialist. The exception is if the PCP believes a network-participating specialist is not available for the needed care. The standard turnaround time for these requests is three to five business days, because we will need to research them. If we determine there is not an appropriate network-participating specialist, we will approve the request and issue an authorization number. If there are one or more appropriate network-participating specialists, we will deny the referral and give the PCP the specialist name(s). In both cases, we will notify the provider of our determination by fax and U.S. mail.

  6. Are there services that will require both a referral and a preauthorization?
    Yes. Services such as chiropractic care or physical therapy require a PCP referral, and subsequent visits may require the specialist to obtain a prior authorization or predetermination request from one of our national ancillary vendors, such as American Specialty Health® (ASH) or OrthoNet™.

  7. Where can a PCP look to find network-participating specialists?
    When making referrals, visit the online provider directory at Cigna.com > Find a doctor to find participating physicians, hospitals, and other providers. You can also call Cigna Customer Service at 1.866.494.2111 for this information.

  8. Do customers need to provide a copy of the referral form at their initial specialist visit?
    No. Customers do not need to bring a paper referral form with them to specialist appointments. However, we highly recommend it. PCPs should submit a referral to Cigna electronically, or by phone, fax, or mail, and we encourage them to give a printed copy of the referral to their patient.

  9. What additional information is available with the referral number?
    Cigna is able to provide the total visits approved for coverage and referral effective dates with the referral number.

  10. Are network-participating specialists expected to confirm that a referral was received by Cigna before providing services?
    Yes. The specialist can call Cigna to confirm the referral was received. If it has not, Cigna will facilitate the issuance of the referral. The specialist should not turn a patient away or interrupt the patients care.

  11. Are specialists expected to track visits and the expiration of the referral?
    Yes. Specialists should track visits and the expiration of the referral. If the patient needs additional care, beyond a six month period, the specialist should contact the referring PCP to coordinate further care and the issuance of a new referral.

  12. Does a referral cover all physicians and physician types in the same specialist practice?
    No. Referrals are made to individual specialist. A separate referral is needed for different specialties.

  13. Can specialists make referrals to other specialists?
    No. The customer will need to return to their PCP for a new referral.