Referral Process

The Primary Care Physician (PCP) is the customer's primary point of entry into the health care delivery system for all outpatient Specialist care. The PCP is required to obtain a referral for most outpatient specialist visits for Cigna-HealthSpring customers.

Requesting a Referral (excluding Delaware, Maryland, Pennsylvania, and Washington, DC)

Referrals can be requested through several methods, such as:

  • HSConnect
  • Fax
  • Phone


Requesting a Referral (for Delaware, Maryland, Pennsylvania, and Washington, DC)

Referrals can be requested through several methods, such as:

  • HSConnect
  • Phone

 

Your Network Operations representative can provide additional details regarding the preferred method of communication in your area. Likewise, the Specialist is required to ensure that a referral is in place prior to scheduling a visit (except urgent/emergent visits, which do not require referral). The Specialist is also required to communicate to the PCP via consultation reports any significant findings, recommendations for treatment and the need for any ongoing care.

Electronic submission/retrieval of referrals through HSConnect helps to ensure accurate and timely processing of referrals.

All referrals must be obtained prior to services being rendered. No retro-authorizations of referrals will be accepted. Please note that we value the PCP’s role in taking care of our Cigna-HealthSpring customers and that the PCP has a very important role in directing the customer to the appropriate Specialist based on your knowledge of the patient’s condition and health history. It is also absolutely essential that customers are directed to Participating Providers only. In order to ensure this, please refer to our online directory or contact Customer Service for assistance.

Remember: An authorization number does not guarantee payment – services must be a covered benefit. To verify benefits before providing services, call 1-800-230-6138.

  • PCPs should refer only to Cigna-HealthSpring participating specialists for outpatient visits
  • Non-participating Specialist’s visits require Prior Authorization by Cigna-HealthSpring
  • Referrals must be obtained PRIOR to Specialist services being rendered
  • PCPs should not issue retroactive referrals
  • Most referrals are valid for 120 days starting from the issue date
  • All requests for referrals must include the following information:
    • Customer name, date of birth, customer ID
    • PCP name
    • Specialist name
    • Date of referral
    • Number of visits requested

If a customer is in an active course of treatment with a Specialist at the time of enrollment, Cigna-HealthSpring will evaluate requests for continuity of care. A PCP referral is not required, but an authorization must be obtained from Cigna-HealthSpring’s Prior Authorization Department. For further details, please refer to the Continuity of Care section in Health Services. Please note: A Specialist may not refer the patient directly to another Specialist. If a patient needs care from another Specialist, he/she must obtain the referral from his/her PCP.

Self-Referrals (excluding Delaware, Maryland, Pennsylvania, and Washington, DC)
Customers have open access to certain Specialists, known as self-referred visits/ services; these include but are not limited to:

  • Emergency medicine (emergency care as defined in the provider contract)
  • Obstetric and Gynecological care (routine care, family planning).
  • Psychiatrist, Psychologist, Licensed Clinical Social Worker (Behavioral Health Participating Providers)

 

Please refer to Cigna-HealthSpring’s website, https://providersearch.hsconnectonline.com/OnlineDirectory, to view the current provider directory for Participating Specialists. If a customer has a preference, the PCP should accommodate this request if possible. Customers may only self-refer to:

To a Participating Gynecologist for annual gynecological exam except for infertility and to see a non-participating OB/GYN. The PCP may perform the annual exam if agreed upon by the customer

 

  • Behavioral health referrals to Cigna-HealthSpring’s Behavioral Health Care
  • Vision Exams – customers who have a Vision benefit may self-refer to a Participating Provider
  • Dental Coverage – customers who have a Dental benefit may self-refer to a Participating Dental provider

Georgia (All counties excluding Catoosa, Dade, and Walker), North Carolina, and South Carolina only: Customers may self-refer to a participating Dermatologist, Optometrist, or Ophthalmologist.

 

Self-Referrals (For Delaware, Maryland, Pennsylvania, and Washington, DC)
Customers have open access to certain specialists, known as self-referred visits/ services; these include but are not limited to:

  • Dentist - dental care (certain procedures require a prior authorization)
  • Nephrologist (referral not required for dialysis only)
  • Podiatrist (Pennsylvania plans only)
  • Emergency medicine (emergency care as defined in the provider contract)
  • Optometry routine eye care: annual eye exam (based on the customers benefit allowance for frames, lenses and contact lenses when using a Participating Provider)
  • Obstetric and Gynecological care (routine care, family planning)
  • Psychiatrist, Psychologist, Licensed Clinical Social Worker (mental health Participating Providers)
  • Nutritionist (diabetes and renal disease diagnosis only - 10 session annually by approved provider; additional visits require prior authorization)

Customers may be assessed a co-payment or coinsurance for some visits depending on coverage limits.

 

Referrals to Non-Participating Providers

Referrals to Non-Participating Providers may occasionally be made but only if prior authorization is obtained from the Prior Authorization Department (in special circumstances the Medical Director or his/her designee will approve out-of- network-care). A PCP must initiate requests for authorizations to Non-Participating Providers.

 

Obtaining and Verifying Referrals

Cigna-HealthSpring’s online provider portal HSConnect at http://hsconnect.bravohealth.com is available 24 hours a day, seven (7) days a week for referral requests. This flexibility allows data entry at any time and records the transaction for the referring specialist to verify that a referral is on file prior to the date of the visit. The PCP also has the ability to search for specialty requests for patients on his/her panel. The PCP has the responsibility of notifying the customer that the referral is approved and documenting the communication in the medical record.

 

For those PCPs who do not have web access, a request for a referral may be obtained by calling 1-888-454-0013. Our hours of operation are Monday through Friday 8:30 a.m. to 5:00 p.m. EST. PCPs that are having difficulty locating a Participating Provider for specialty care are encouraged to go to www.cignahealthspring.com to access our online Provider Directory. A referral is not a guarantee of payment. Payment is subject to eligibility on the date of service, plan benefits, limitations and exclusions under the benefit plan.

 

A PCP is responsible for ensuring a customer has a referral prior to the appointment with the specialist.

There are three ways a PCP can obtain referral to Specialists:

  1. Log in to HSConnect.
  2. Referral Form: Complete the referral form and fax it into our referral department.
  3. Call the Referral Department: If the referral is an emergency, or you simply would like to speak with a referral department representative, you may obtain a referral by phone by calling:

 

State: Contact:
Alabama 1-800-962-3016
Northwest Florida 1-800-962-3016
Southern Mississippi (Jackson) 1-866-949-7103
Georgia (All counties excluding Catoosa, Dade, and Walker) 1-866-949-7103
or fax to: 1-855-420-4717
North Carolina 1-866-949-7099
South Carolina 1-866-949-7101
Kansas City 1-888-454-0013
Tennessee, Northern Georgia, and Eastern Arkansas 1-800-453-4464
Illinois and Indiana 1-800-230-7298
Texas and Southern Arkansas Cigna-HealthSpring Precert:

Toll Free: 1-800-511-6932
Local: 1-832-553-3456
Toll Free Fax: 1-888-856-3969
Local Fax: 1-832-553-3426 Home Health/DME:
Toll Free: 1-800-511-6932
Local: 1-832-553-3313
Toll Free Fax: 1-888-205-8658

Delaware, Maryland, Pennsylvania, and Washington, DC 1-888-454-0013
Faxed requests not accepted

Specialists must have a referral from a PCP prior to seeing a customer if the customer’s plan requires a referral. Claims will be denied if a Specialist sees a customer without a referral when the health plan requires a referral. Cigna-HealthSpring is unable to make exceptions to this requirement. If a referral is not in place, Specialists must contact the customer’s PCP before the office visit. In order to verify that a referral has been made, the Specialist may log in to HSConnect or the Specialist may call Cigna-HealthSpring to verify.

Instructions for a Specialist to Obtain Referrals

The Specialist can obtain referrals directly for the customer to another Specialist with the following limits:

  1. The PCP referred the customer to the Specialist.
  2. The following five (5) conditions must be met:
  • o Diagnosis must be related to the specialty and/or service to be obtained;
  • o Diagnosis must be related to reason PCP referred to referring Specialist;
  • o Must be a covered benefit of the customer’s Benefit Plan;
  • o The customer must be currently under the care of the referring Specialist; and
  • o Referral must be made to a Participating Provider.
  1. The Specialist provides follow-up documentation to the PCP for all referrals obtained for further specialty care.
  2. Referrals for the following specialty care are excluded from this process and must be referred back to the 
    PCP to obtain referral: Non-Participating Providers, Chiropractor, Dermatology, Otolaryngology, Maxillofacial Surgeon, Podiatry, Optometry, Transplant Specialist, and Reconstructive (Plastic) Surgeon with the exception of breast reconstruction.
  3. The referral must be obtained prior to the services being rendered.

Note: If all elements within the limits above cannot be met, the Specialist must defer back to the PCP for further services.

The Specialist may obtain referrals via HSConnect or fax. Specialist should use the fax method if the referral is not needed within forty-eight (48) hours. If the referral is needed in less than forty- eight (48) hours, the Specialist must use either the telephone referral process or HSConnect. Requests are not accepted via fax for membership in the Delaware, Maryland, Pennsylvania, and Washington, DC service areas.