What is an organization determination?
An “organization determination,” or medical prior authorization, is a decision we make about your medical benefits and coverage or about the amount we will pay for your medical services. This means we ask our plan to authorize, provide, or pay for medical services. We want to make sure you’re getting the type or level of services you think you should get.
A Medical Prior Authorization allows Cigna to:
- Check that you can get the service you asked for through your benefit package
- Review services to decide if care is medically necessary for you
- Review services to make sure they are given by the appropriate provider in an appropriate setting
- Make sure that ongoing and recurring services are actually helping you
Some examples of services that may need Medical Prior Authorization are:
- Home Health Care (HHC)
- Specialist or Specialty Care Visits (other than your PCP)
- Outpatient surgical procedures
- Durable Medical Equipment (DME)
- Non-emergent ambulance transport
- Outpatient diagnostic testing
- Outpatient therapy
You can review services that need Medical Prior Authorization within your Evidence of Coverage (EOC).
Emergency services are not included from prior authorization requirements. An emergency is a medical condition that may cause harm to your health.
You can ask us for an organization determination or medical prior authorization for yourself, or your doctor or someone you name may do it for you. The person you name would be your appointed representative. You can name a relative, friend, advocate, doctor, or anyone else to act for you.
If you want someone to act for you, then you and that person must sign and date the Appointment of Representative form that legally allows that person to act as your appointed representative. This statement must be faxed or mailed to us at the same number or address where you send your organization determination information.
This form does not have to be filled out if your doctor is sending a request.
The Prior Authorization Department is made up of licensed nurses, clinical pharmacists, and doctors. They review requests for authorization using nationally recognized industry standards to decide if the Prior Authorization is medically necessary. Once a decision is made, they will let you and your provider know.
A Medical Prior Authorization or Organization Determination is not a guarantee that the services are covered. A Prior Authorization is a determination of medical necessity and is not a guarantee of claims payment. Claim reimbursement may be changed by factors such as eligibility, participating status, and benefits at the time the service is rendered.
To start an organization determination, you must file a Preservice Organization Determination, also known as a Prior Authorization Request, by phone, mail, or fax. The prior authorization request will be reviewed to determine if services are covered before they are provided. While your doctor will often help you arrange care and get Prior Authorization, you can send a Prior Authorization request yourself before getting services.
For Cigna Medicare Advantage customers (except Arizona)
Contact us by mail:
PO Box 20002
Nashville, TN 37202
Call us: 1 (800) 668-3813
8:00 am - 8:00 pm, 7 days a week
From April 1 - September 30: Monday - Friday 8:00 am - 8:00 pm. Messaging service used weekends, after hours, and federal holidays.
By fax: 1 (888) 766-6403
For Cigna Medicare Advantage customers in Arizona
Contact us by mail:
Cigna Medicare Services
Attn: Prior Authorization Dept.
PO Box 29030
25500 N. Norterra Drive
Phoenix, AZ 85085
Call us: 1 (800) 558-4314
8:00 am - 5:00 pm (Mountain time), Monday - Friday
By fax: 1 (866) 730-1896
A standard decision will be made as fast as your health condition requires, but no later than 14 calendar days after receipt of the request.
If you need a quicker response because of your health, you should ask our plan to make a Fast Decision. A fast decision will be made as quickly as your health condition requires, but no later than 72 hours after receipt of the request.