Cigna Prior Authorization and Referral Requirements for Medical Practices

Our A2Z Billings team has over 150 years of combined experience with payer rules like these, and this guide is the plain version for you on what needs approval, who approves it, how referrals work, and where practices are losing money.

Authorization and Referral Are Two Different Gates

Practices mix these up all the time, and it costs them.

You need a prior authorization (Cigna also calls this process a precertification) from Cigna or a vendor working for Cigna before you give a certain service. A referral is when a primary care doctor sends a patient to a specialist.

One is about the service. The other is about the path the patient took to reach you. A patient can arrive with a perfect referral and still need approval for the MRI you order. A patient can have an approved authorization and still get your claim denied because the plan wanted a PCP referral first. When both apply, you have to clear both.

Cigna is direct about the stakes. It states that skipping precertification may lead to a denial of payment.

Which Services Need Approval Before You Treat

First, check Cigna’s master list of precertified providers. It is a long list. It includes imaging, joint surgery, spine work, interventional pain management, cardiology testing, sleep studies, genetic and lab testing, radiation therapy, GI procedures, medical oncology, and specialty drugs.

Two habits save you here.

First, check the CPT or HCPCS code, not the service name. "Knee surgery" tells you nothing. The code on the order tells you everything.

Second, look at the patient's ID card. For programs like musculoskeletal and spine surgery and radiation therapy, every Cigna customer needs approval for inpatient care, but outpatient approval applies when the ID card says it is required. Two patients with Cigna cards can get two different answers for the same code. For programs including musculoskeletal and spine surgery and radiation therapy, inpatient care requires authorization for all Cigna customers, but if the ID card states that it is needed, outpatient authorization applies. For 2 patients with Cigna cards, you may get 2 different answers for the same code.

Think of this list as a living document. Services that used to go straight through now require a request because Cigna has moved outpatient surgery, unlisted procedures, and cosmetic and experimental or investigational codes to EviCore review. A list left in a folder and forgotten is a liability.

Who Reviews the Request: Cigna or eviCore

This area is where routing mistakes can occur.

Cigna conducts its own review for many procedures. Some of these procedures are handled by eviCore, a company by Evernorth, which performs precertification for plans that cover radiology, cardiology, musculoskeletal and spine surgery, radiation therapy, gastroenterology, and the outpatient surgery and unlisted procedure codes mentioned above. Medicare Advantage, prescription drugs, and behavioral health all have their own unique resources.

Send it to the wrong place; it sits. No one ever tells you that. You are getting closer to the date you have booked, and there is still no decision.

Build a simple map for your practice: service, reviewer, submission method. It takes an hour and saves weeks.

How to Submit a Request

Cigna prefers electronic submission. You can send requests through your EHR or EMR, or through a website that offers the service at no charge. eviCore programs: The preferred and most efficient route is to call eviCore’s own website. For those unable to submit requests electronically, Cigna accepts requests via phone at 800.88Cigna (882.4462). Each eviCore program page has its phone number.

Urgent requests are extraordinary. You must make requests for radiation therapy and musculoskeletal programs by telephone and state that the care is medically urgent. Do not upload a time-sensitive case to a portal and wait.

The biggest self-inflicted wound is lack of information. Cigna warns that failure to provide the required information can result in certification denial. The complete request includes the patient’s Cigna ID, CPT or HCPCS code, diagnosis codes, rendering provider and facility, planned date of service, and clinical notes justifying the service. Notes that say “patient has pain” are less helpful than those that describe how long the pain lasted, what was tried, and what the imaging showed.

How Long Decisions Take

For eviCore programs, non-urgent decisions are typically made within two business days after eviCore receives all the clinical information it needs.

Read that last part again: all the clinical information. If you send only part of the chart, the clock doesn't start. A clean first submission is the fastest route to a timely answer.

One more thing. EviCore states that a medical necessity approval does not guarantee Cigna will pay for the service. Eligibility, coding, and plan benefits still count at the claim stage.

Cigna Referral Requirements by Plan Type

Referral rules depend on the plan. Cigna's general breakdown looks like this:

• HMO and Network plans: The PCP must provide a referral for specialty care, and only in-network providers are covered. Cigna SureFit, plus Connect and Cigna Plus plans in Illinois, follow the same referral rule. Connect plans also require the PCP to submit the referral to Cigna.
• POS plans: The PCP must refer the patient for in-network specialty care, but the patient can see an out-of-network specialist without a referral. Cigna encourages these patients to stay in the network.
• Open Access, PPO, and Indemnity plans: Referrals are never needed.
• Women's health: Every Cigna plan has an open access policy, so patients can see a participating OB/GYN for covered services without a referral.

The PCP owns the documentation. The PCP must give the patient a written referral and record it in the medical record, as must the specialist. Unless a patient’s plan requires it, Cigna doesn’t require doctors who are in its network to inform the company of referrals to in-network specialists. If a plan does, use the Cigna Physician Referral Form or the portal and the phone and mail options Cigna provides.

If you are the specialist, do not accept "my doctor said it's fine" as a referral. Ask for it before the visit, and check the plan type first.

Why the Check Belongs at Scheduling

The least expensive time to fix an authorization issue is before the patient has a date on the calendar. You can still move the appointment, pick another specialist in the network, or ask the PCP for a missing referral when you schedule. When you check in, all you can do is say sorry. There is no recourse after the service except to appeal.

The reason why practices with checks at booking have fewer surprises is simple: every issue appears when it is still cheap to fix. A visit can be rescheduled by a simple phone call. Denied surgical claims cost a lot more, not to mention the hours your team spends fighting it.

Where Practices Lose Money

Most Cigna losses come from the same few mistakes. None of them are exotic. They are routine errors that repeat until someone owns the process.

• Service delivered with no approval. The remittance shows CARC 197, precertification or authorization absent. Appeals from this position are uphill.
• The approval on file does not match the claim. The discrepancy may be due to a wrong CPT code, a different rendering provider or facility, or extra units. The error reads as CARC 15, authorization missing, invalid, or not applicable to the billed service.
• Referral absent. CARC 288 appears when the plan needed a referral, and none was on record.
• Request sent to the wrong reviewer. Cigna and eviCore are not interchangeable.
• Approval is treated as a payment promise. It is not one.

Each one of these costs you twice: once in revenue you earned but did not collect, and again in staff hours spent on rework. Once in revenue you earned and did not collect, and again in staff hours spent on rework.

If you get denied anyway, read the denial notice before sending anything. It tells you where to file the appeal. Where to file depends on who made the decision.

The Successful Front-Desk Routine

You do not need a complicated system. You need the same seven steps every time.

1. Verify the plan type at booking, not at check-in.
2. Match the CPT or HCPCS code to the master precertification list.
3. Submit with full clinical notes and record the request number.
4. Confirm that the approval is for the same order, including the code, provider, facility, units, and dates.
5. For HMO, Network, and POS plans, get the PCP referral on file before the visit.
6. No decision, move the date. Do not treat, and just hope.

Print it, tape it to the scheduler's monitor, and walk every new hire through it in their first week. That is not difficult. The problem is that on busy days you skip steps, and those days cost you the most.

Frequently Asked Questions

Does Cigna require prior authorization for every service?

Nah. Only services that are on Cigna's master precertification list need approval, and some of the requirements vary by the patient's plan and ID card. Check the code; check the card.

What is precertification? How does precertification differ from prior authorization?

“Yeah.” Cigna also uses both terms for the same step: asking for approval before a service, treatment, or medication is delivered.

Who is responsible for getting the approval, the ordering provider or the rendering provider?

Cigna says referring, ordering, or admitting providers must request and obtain precertification for in-network services, and the rendering provider may also request it in some cases. For eviCore programs, the rendering facility and provider must confirm the approval is in place before the service. In practice, both offices should verify it.

Do all patients need a referral to see a specialist with Cigna?

Nah. HMO and network plans require a PCP referral for all services, POS plans require one for in-network specialty care, and open access, PPO, and indemnity plans never do. On any Cigna plan, OB/GYN visits for covered services do not need a referral to participate.

How long does a Cigna decision take?

For eviCore programs, non-urgent decisions are typically made within two business days after all necessary clinical information arrives. Urgent requests for programs like radiation therapy and musculoskeletal care must be phoned in.

Does an approved request guarantee Cigna will pay the claim?

Nah. Medical necessity approval does not guarantee payment. The claim still needs to pass approval and eligibility, coding, and benefit rules.

What if Cigna or eviCore says no to the request?

First, read the denial notice. It tells you where to send the appeal. If eviCore made the decision, its program pages say rendering providers may request a clinical discussion. If any records are missing, such as imaging results or treatment history, add them before re-submitting.

How do we know if a given piece of code requires approval?

Check the master precertification list in the Cigna provider portal, then confirm with the patient’s plan info. Its coverage guidelines and program pages identify the codes it accepts for eviCore-administered programs. If you don’t know the answer, call before you book.

Do Medicare Advantage and behavioral health follow the same rules?

Not really. Cigna said providers should consult separate resources for behavioral health authorization and Medicare Advantage requirements. Please check the rules for the correct line of business before you submit anything.