Prior Authorization Services
Select medical services may require Prior Authorization to determine if they are medically necessary and appropriate for you before services are received. Medicare refers to a Prior Authorization as a preservice Organization Determination. Your doctor will help you coordinate care and obtain Prior Authorization.
Prior Authorization is required for several reasons. A Prior Authorization allows Cigna-HealthSpring to:
- Verify that the service requested is available in your benefit package
- Review services to determine if care is medically necessary and appropriate for you
- Review services to ensure services are being provided by the appropriate provider in a setting that is appropriate for you
- Confirm that ongoing and recurring services are effective and are actually helping you
Some examples of services that may require Prior Authorization include:
- Home Health Care
- Specialist or Specialty Care Visits (other than your PCP)
- Outpatient surgical procedures
- Durable Medical Equipment
- Non-emergent ambulance transport
- Outpatient diagnostic testing
- Outpatient therapy
You can review services that require Prior Authorization within your Evidence of Coverage (EOC).
Emergency services are excluded from prior authorization requirements. An emergency is a medical condition that may cause serious jeopardy to the health of the individual.
Prior Authorization Decision
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 determine if the Prior Authorization is medically necessary. Once a decision is made, you and your provider will be notified.
A Prior Authorization 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 impacted by various factors including eligibility, participating status, and benefits at the time the service is rendered.
If you have questions regarding referral requirements or want to follow-up on an existing authorization, please contact our Customer Service Department at 1-800-668-3813 (TTY: 711) 8am to 8pm Central time M-F. Messaging service used weekends, after hours, and Federal holidays.
While your doctor will help you coordinate care and obtain Prior Authorization, you can submit a Prior Authorization yourself before getting services. Learn more about submitting your own Prior Authorization Request.