• Confirms the patient's eligibility and available benefits based upon the current enrollment information.
• Confirms the medical necessity of the proposed services.
• Evaluates the proposed setting and level of care to determine if it is clinically sound, safe and cost-effective.
• Educates providers and customers regarding the availability of more cost-effective participating providers.
• Facilitates timely referrals to disease management and similar programs.
• Engages timely case management resources to assist with continuity of care and service coordination.
• Directs the customer to a participating provider when appropriate.
• Facilitates timely payment of claims.

A note about coverage

Precertification of coverage determinations are based upon the patient's eligibility, the specific terms of the applicable benefit plan, internal or external clinical coverage guidelines, and the patient's particular circumstances. Please note that failure to obtain precertification may result in an administrative denial of payment. Additionally, precertification is neither a guarantee of payment nor a guarantee that billed codes will not be considered incidental or mutually exclusive to other billed services. Coverage is subject to the terms of a participant's benefit plan and eligibility on the date of service.

We require that referring (ordering or admitting) physicians request and obtain precertification for in-network services. The rendering provider or facility is responsible for validating that precertification has been obtained for all elective (i.e., non-emergent or non-urgent) services prior to performing the service for patients whose benefit plans require precertification. In certain circumstances, the rendering provider can also request precertification.

For many benefit plans, we require precertification on targeted specialty medications across both pharmacy and medical benefits to help ensure medications are appropriately prescribed, utilized, and administered.

We apply prospective prior authorization reviews of certain specialty medications to ensure that medications are being prescribed according to FDA-approved indications and that they support evidence for appropriateness of use. Our policies are consistently applied to all outpatient services regardless of the provider type. We evaluate the specialty medications for potential use for off label indications, cost, likelihood for experimental use, waste management opportunities, site of care, and the opportunity to impact dosing or duration of therapy. All potential restrictions are evaluated based on current published literature and practice guidelines to help ensure that there is no interference with standards of practice.

In addition to the customer's insurance and diagnosis information, you will need the following information for prescription drug precertification:

• Name of drug/medication
• Strength of the drug (example 5 mg)
• Quantity being prescribed
• Days supply

Note: If you submit medication prior authorization requests using SureScripts or CoverMyMeds, you can also check the status of a prior authorization through the same ePA service.

Predeterminations are an option for providers to obtain a medical necessity review and estimation of patient liability prior to the rendering of the service.

Some customers' benefit plans do not require precertification for outpatient services. However, due to the nature of a small number of certain procedures and the possibility for them to be performed without medical necessity, our Claims department may ask, at the time of claim submission, for additional documentation demonstrating that the procedure was indeed medically necessary.

As a way to avoid delays in claim processing, we offer a predetermination option to providers. Predeterminations, while completely optional, serve the same purpose as a precertification in that they are a pre-service review of the requested procedure. If approval is given, an approved authorization is placed on file and your claim will pay appropriately.

Only a limited number of plans, containing a limited number of procedures, are eligible for predeterminations. Please note that a predetermination is not a requirement for payment.

A key part of monitoring and improving patient health is coordinating patient care between primary care physicians (PCPs), specialists, and other ancillary or hospital services for procedures and diagnostic testing through referrals.

Referrals are an "order" or request from a PCP for a patient to see another physician, typically a specialist. Using referrals help direct and coordinate patient care and allows a PCP to oversee, manage, and coordinate all care given to a patient, often resulting in overall appropriate care and reduced long term costs.

If you are a PCP and need to submit a referral, use one of the following options:

• Health Care Request and Response (ANSI 278): Contact your Electronic Data Interchange (EDI) or Practice Management System vendor.
• Phone: Call 866.494.2111, and choose the prompt for "Specialist Referral."
• Fax: Send to 866.873.8279. You can obtain a referral form on the Cigna for Health Care Professionals website.
• Mail: Send to Cigna Attn. Precertification and Referral Department, 2nd Floor, 1640 Dallas Parkway, Plano, TX 75093.

If you are a specialist and need to confirm a referral was submitted, you can:

• Use the PCP's written referral presented by the patient.
• Call Cigna Customer Service at 866.494.2111, and choose the prompt for specialist referral.

Your patient may need a referral, depending on their plan type. Many HMO, individual & family plan (IFP), and exclusive provider organization (EPO) plans do require our customers to designate a PCP and would likely require a referral for a customer to see a specialist. Most of our Open Access Plus (OAP) or Preferred Provider Organization (PPO) plans do not require referrals at this time.

You can verify the patient's plan, product, and referral requirements by:

• Logging into CignaforHCP.com > Patients
• Calling the customer service at the number on the back of the patient's ID card