ORGANIZATION DETERMINATION

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An “Organization Determination” is a decision we make about your medical benefits and coverage or about the amount we will pay for your medical services. This includes asking our plan to authorize, provide, or pay for medical services, including the type or level of services, you believe you should receive.

You can ask us for an organization determination 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 gives the person legal permission to act as your appointed representative. This statement must be faxed or mailed to us at the designated number or address. This form does not have to be completed if your doctor is submitting a request.

To initiate an Organization Determination, start by calling, writing, or faxing our plan to make your request.

Contact Information for Organization Determination for a Preservice Organization Determination or Prior Authorization Request

A Preservice Organization Determination – also known as a Prior Authorization request is a review to determine if services are covered before services have been provided. While your doctor will help you coordinate care and obtain Prior Authorization, you can submit a Prior Authorization request yourself before getting services.

For Cigna-HealthSpring Medicare Advantage

To Contact us by mail:
Cigna-HealthSpring
Attn: Precertification
PO Box 20002
Nashville, TN 37202

Call us:
Phone Number: 1-800-668-3813
TTY/TDD: 711
Fax Number: 1-888-766-6403
8am – 8 pm, 7 days a week (your local time)

 

For Cigna-HealthSpring Medicare Advantage (Arizona)

For authorization of medical items/services you have not yet received:

To Contact us by mail:
Cigna Medicare Services
Attn: Prior Authorization Dept. – PO Box 29030
25500 N. Norterra Drive
Phoenix, AZ 85085

Call us:
Phone Number: 1-800-558-4314
TTY/TDD: 711
Fax Number: 1-866-730-1896
8 am – 5 pm (MST), Monday – Friday

If your health requires a quick response, you should ask our plan to make a Fast Decision. To get a Fast Decision, you must meet two requirements:

  1. You are asking for coverage for medical care or a drug you have not yet received; and Using the standard decision timeline could cause serious harm to your health or hurt your ability to function.

Fast and Standard Decisions

  1. A standard decision will be made as expeditiously as your health condition requires, but no later than 14 calendar days after receipt of the request
  2. A fast decision will be made as expeditiously as your health condition requires, but no later than 72 hours after receipt of the request

Learn more about a Prior Authorization Requests

If you disagree with an Organization Determination, you have the right to appeal our decision.
Learn more about Appeals

You have the right to file a complaint:

If you have a complaint, you can submit feedback directly to Medicare: