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Referrals have a direct effect on your patients’ cost, experience, and quality of care. You can help your patients keep their medical costs down by referring them to providers in their Cigna plan’s network. Not only is it helpful to them, but it’s also good for your relationship with Cigna, as it’s required in most Cigna medical provider contracts.
There are exceptions to using the network – some are required by law, while others are pre-approved by Cigna before you refer or treat the patient.
We've introduced an Out-of-Network Referral Disclosure Form [PDF], which must be completed by the referring physician (and not delegated) each time a referral is made to a non-participating provider (excluding emergency and pre-approved situations).
Depending on the patient's benefit plan, referrals from the patient’s primary care provider (PCP) may be required for specialty-care services to be covered at the highest benefit level. Please check the CignaforHCP provider portal for patient-specific information. Generally the referral requirements are:
- HMO and Network Plans – The PCP must provide a referral for specialty care. Only in-network providers are covered.
- POS Plans – The PCP must provide a referral for specialty-care services from in-network providers. Patients may receive services from out-of-network providers without a referral from their PCP. However, there is a strong incentive for patients who obtain a referral and remain within the provider network – they'll enjoy the highest benefit levels for covered services and lowest out-of-pocket expenses.
- Open Access, PPO and Indemnity Plans – Referrals are never needed. Patients may visit any doctor for primary or specialty care.
One exception is 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 to Cigna participating OB/GYNs for covered obstetrical or gynecological services.
We do not require participating physicians to notify us of referrals to in-network specialty-care providers, unless a specific requirement exists in a patient’s plan. In that case, please use the Physician Referral Form [PDF]
PCPs are responsible for providing a written referral to the specialty-care physician, and for noting the referral in the patient's medical record.
Specialty care providers also must note the referral in the patient's record.