CIGNA Preferred Provider Organization (PPO)

Visit a doctor – without a referral

CIGNA Preferred Provider Organization (PPO) plans offers the freedom to visit any licensed provider. A member does not need to choose a primary care physician (PCP) or need a referral to see a specialist. Even emergency services and urgent care are covered at the in-network benefit level.

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Where to Find the Care You Need

Here is a summary of your plan's services and how to arrange for care.

Routine Medical Care (such as physical exams, mild fever and pains, chronic pain and, headaches, colds and flu).

• Call your personal physician's office during office hours and he or she will provide you with medical advice and/or schedule an office visit for you.

Specialty Care (such as orthopedic or heart disease).

• Make an appointment with a specialist for an initial assessment and if needed, he or she will provide medical advice and treatment.

Hospital Care (such as inpatient care and surgery, or outpatient surgery)

• For non-emergency care, call CIGNA HealthCare for approval and someone will work with you to coordinate all your hospital care.

Urgent Medical Care (such as fever, sprains or strains, eye or ear infections, or severe sore throat)

• Call your personal physician. He or she will assess your situation and if necessary, give you advice on where to seek immediate care.

Emergency Care (such as poisoning, chest pains, broken bones, uncontrolled bleeding, loss of consciousness or sudden paralysis)

• Go to the nearest emergency facility or call 911. Call CIGNA HealthCare as soon as reasonably possible and your personal physician will coordinate all follow-up care.

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How a PPO might work for you

Staying Well

You choose a CIGNA physician and set up an appointment for a wellness exam. Your physician orders some lab tests and suggests you see a specialist about some problems you have with your stomach. You make an appointment with a specialist in the CIGNA PPO network

If you choose to see a physician who is not in the PPO network, you will have to pay the full amount until you meet your deductible, then pay a predetermined coinsurance amount.

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Special Programs

Members of CIGNA HealthCare plans may also have access to valuable Health and Wellness Programs:

• Well Informed — a personalized health improvement program designed to let CIGNA HealthCare members and their doctors know about opportunities to maintain or improve the member's health.
• 24-hour health information — call the CIGNA HealthCare 24-Hour Health Information Line^SM any time to speak with a registered nurse or listen to our audio library for health-related information.
• Support for chronic conditions — manage your asthma, diabetes, heart condition, low back pain, or chronic obstructive pulmonary disease with help from CIGNA Well Aware for Better Health^®.
• Member discounts — save up to 60% on products and services-from acupuncture to weight management-with our Healthy Rewards^® discount program. Note: not all programs are available in all states.
• Quality transplant care — access care from nationally recognized facilities in the CIGNA LIFESOURCE Transplant Network^®.
• CIGNA HealthCare Healthy Babies^® — give your child a healthy beginning with information and support from the CIGNA HealthCare Healthy Babies^® program.
• CIGNA Healthy Pregnancies, Healthy Babies^SM — the CIGNA Healthy Pregnancies, Healthy Babies^® program offers a full scope of educational and care management services to members who are pregnant or considering pregnancy.
• Cancer prevention and education — the Comprehensive Oncology Program^® addresses cancer prevention and education, as well as active management of members diagnosed with cancer.
• High Touch Personal Assistance — with CIGNA Health Advisor^SM, CIGNA Health Advisors proactively identify and reach out to members who are at risk for significant health issues but are not appropriate candidates for chronic or acute disease or case management programs.
• Lose weight and improve your health — when you enroll in the CIGNA Healthy Steps to Weight Loss^SM, you won't be starting a diet. Instead, this program helps you change your behaviors permanently. You'll learn healthier eating habits and how to incorporate exercise into your schedule – helping you to feel better, look better and improve your overall health.

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Employer Advantages

FAQ

• What is the difference between in-network and out-of-network coverage?
• Do I have to choose between in-network and out-of-network now?
• How do I find in-network doctors?
• What if I go to an out-of-network doctor, and he or she sends me to a participating hospital? Will I pay in-network or out-of-network charges for the hospitalization?
• Do I need a referral to see a specialist?
• What is utilization review?
• What if my doctor keeps me hospitalized longer than my pre-admission certification allows?
• Do I need pre-admission certification if my doctor recommends outpatient surgery instead of a hospital stay?
• Who is responsible for obtaining pre-admission certification?
• How do I file a claim? How long does it take to be reimbursed?
• Am I covered for emergency care?
• What if my doctor isn't a preferred provider?
• Can my current doctor be added to your network?

What is the difference between in-network and out-of-network coverage?
HealthCare preferred provider, and your out-of-pocket costs are lowest.
With out-of-network benefits, you can see any doctor you wish and still be covered for treatment of illness or injury, but your out-of-pocket expenses will be higher.

Do I have to choose between in-network and out-of-network now?
No. Each time you seek medical care, you choose your doctor, whether he or she is a preferred provider or an out-of-network provider.

How do I find in-network doctors?
Start with the CIGNA HealthCare Provider Directory or visit myCIGNA.

What if I go to an out-of-network doctor, and he or she sends me to a participating hospital? Will I pay in-network or out-of-network charges for the hospitalization?
You may be admitted to a participating hospital by either an in-network or out-of-network doctor. CIGNA HealthCare will cover authorized medical services provided by the participating hospital at your in-network level.

Do I need a referral to see a specialist?
Though you may want your doctor's advice and assistance in arranging care with a specialist in the network, you do not need a referral to see a participating specialist. If you choose to see an out-of-network specialist, services will be covered at the out-of-network benefits level.

What is utilization review?
Utilization review is a process that helps determine if the services you receive are a covered benefit. CIGNA HealthCare performs utilization review, including hospital pre-admission certification, continued stay review and case management.

Requests for non-emergency hospital stays other than maternity stays must be approved before you are admitted. Pre-admission certification is not required for a maternity stay of 48 hours for vaginal deliveries or 96 hours for cesarean sections. Depending on your benefit plan, you may be eligible for additional benefits. Any hospital stay beyond the initial 48 or 96 hours must be approved. For details, please contact your benefit plan administrator or call the toll-free number on your CIGNA HealthCare ID card.

What if my doctor keeps me hospitalized longer than my pre-admission certification allows?
CIGNA HealthCare will contact your hospital the day before your scheduled discharge. If you remain in the hospital beyond your original discharge date, CIGNA HealthCare will continue to review your hospital stay for coverage until you are discharged.

Do I need pre-admission certification if my doctor recommends outpatient surgery instead of a hospital stay?
Some medical procedures are handled best in an outpatient setting. In most cases, you'll be home the same day, returning to your normal lifestyle as soon as possible. Certain outpatient surgical and diagnostic testing procedures must be precertified. Your benefits materials will provide you with the information if this applies to you.

Who is responsible for obtaining pre-admission certification?
Your doctor will help you decide which procedures require hospital care and which can be handled on an outpatient basis. If your doctor participates in the CIGNA HealthCare network, he or she will arrange for precertification. If you use an out-of-network doctor, you are responsible for making the arrangements.

How do I file a claim? How long does it take to be reimbursed?
Every time you use out-of-network services, you may need to submit a claim form. To get a claim form, see your benefits manager or visit myCIGNA. Submit your completed claim form to the address on your CIGNA HealthCare ID card. Once you file your completed claim form, claims are generally paid within 10 to 15 working days. However, if questions about your claim arise, payment may be delayed.

Am I covered for emergency care?
Whenever there is an emergency, seek medical help immediately. An emergency is an accident or sudden illness that a person with average knowledge of medical science believes needs to be treated right away or it could result in serious medical complications or permanent disability. Emergencies are covered 24 hours a day, seven days a week, no matter where you are.

What if my doctor isn't a preferred provider?
You can continue seeing your doctor. However, your health care services will be covered at the out-of-network benefits level. To receive your maximum benefit, you should select a doctor from the CIGNA HealthCare list of preferred providers. Participating providers must meet credentialling standards to become part of our network.

Can my current doctor be added to your network?
If your current doctor meets our credentialling standards and is interested in becoming a CIGNA HealthCare preferred provider, he or she can call our Provider Relations Department to get more information.

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