Coverage and ClaimsCoverage and Claims Overview
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Coverage and Claims
Coverage and Claims
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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 HealthcareSM plan’s network. Not only is it helpful to them, but it’s also good for your relationship with Cigna Healthcare, as it’s required in most Cigna Healthcare medical provider contracts.
There are exceptions to using the network – some are required by law, while others are pre-approved by Cigna Healthcare 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 Healthcare plans have adopted an "open access" policy for women's health care. Referrals are not needed for visits to Cigna Healthcare 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.
The Value of In-Network Labs
Did you know that lab fees could be one of the biggest drivers of your patients' health care costs?
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The Cigna Group Information
Individual and family medical and dental insurance plans are insured by Cigna Health and Life Insurance Company (CHLIC), Cigna HealthCare of Arizona, Inc., Cigna HealthCare of Illinois, Inc., Cigna HealthCare of Georgia, Inc., Cigna HealthCare of North Carolina, Inc., Cigna HealthCare of South Carolina, Inc., and Cigna HealthCare of Texas, Inc. Group health insurance and health benefit plans are insured or administered by CHLIC, Connecticut General Life Insurance Company (CGLIC), or their affiliates (see a listing of the legal entities that insure or administer group HMO, dental HMO, and other products or services in your state). Accidental Injury, Critical Illness, and Hospital Care plans or insurance policies are distributed exclusively by or through operating subsidiaries of The Cigna Group Corporation, are administered by Cigna Health and Life Insurance Company, and are insured by either (i) Cigna Health and Life Insurance Company (Bloomfield, CT); (ii) Life Insurance Company of North America (“LINA”) (Philadelphia, PA); or (iii) New York Life Group Insurance Company of NY (“NYLGICNY”) (New York, NY), formerly known as Cigna Life Insurance Company of New York. The Cigna Healthcare name, logo, and other Cigna Healthcare marks are owned by The Cigna Group Intellectual Property, Inc. LINA and NYLGICNY are not affiliates of Cigna Healthcare.
All insurance policies and group benefit plans contain exclusions and limitations. For availability, costs and complete details of coverage, contact a licensed agent or Cigna Healthcare sales representative. This website is not intended for residents of New Mexico.