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Pre-certification

Changes in NIA Contrast Level Pre-certification Guidelines

Use the links below to learn about our Pre-certification policy, requirements and affected procedures.

Looking for a particular Pre-certification code? Use this link to access a detailed listing of procedures and corresponding codes.


Notification of Changes to Pre-certification List

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Dialysis Pre-notification Policy

Beginning 5/15/09, pre-notification is required for all new hemodialysis services for patients with CIGNA plans that require pre-certification of inpatient admissions and outpatient procedures (PHS+). Pre-notification is requested no less than two (2) business days prior to the patient’s initial assessment or hemodialysis treatment.

Effective 8/1/2011, pre-notification is required for all hemodialysis, peritoneal dialysis and home dialysis services for all CIGNA HealthCare plans regardless of medical management type. Pre-notification is requested no less than two (2) business days prior to the patient’s initial assessment or dialysis treatment.

Please click on the link to view the list of codes that require notification. Dialysis Codes

Pre-certification Policy


Purpose


Pre-certification prior to services being provided allows CIGNA the opportunity to:

  • Confirm the patient's eligibility and available benefits based upon the current enrollment information;
  • Confirm the medical necessity of the proposed services;
  • Evaluate the proposed setting and level of care to determine if it is clinically sound, safe and cost-effective;
  • Educate health care professionals and/or customers regarding the availability of more cost effective participating providers;
  • Facilitate timely referrals to disease management and similar programs;
  • Engage timely case management resources to assist with continuity of care and service coordination;
  • Direct the customer to a participating provider when appropriate, and
  • Facilitate timely payment of claims, and

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Medicare Primary        

Pre-certification of coverage when Medicare is primary is not required except in the following situations:

  • Transplant services (inpatient or outpatient)
  • Services not covered by Medicare
  • Medicare coverage exhausted; when CIGNA becomes primary; and
  • Medicare Risk products administered by CIGNA

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Obtaining Pre-certification

For all CIGNA HealthCare products, participating doctors are responsible for obtaining precertification of coverage for all in-network procedures requiring Precertification. The plan participant is responsible for obtaining Pre-certification for non-emergent services provided by a non-participating provider and/or facility.

Pre-certification requests may be submitted using the View and Submit Pre-certification Requests feature. Using this feature, you can submit Pre-certification requests, or check the status of pre-certification requests, for coverage of inpatient services, certain outpatient services (when required by a CIGNA HealthCare plan) and injectable medications (when covered under the medical plan). This service is not available for users who enter CIGNAforHCP.com from an external website or for behavioral health and substance abuse Precertification requests at this time.

Requests for pre-certification should be directed to CIGNA HealthCare at least 72 hours before the scheduled service.

IMPORTANT: Even if a service is pre-authorized, its associated code(s) may not be separately reimbursed if it is considered incidental or mutually exclusive when billed with other codes.

If the request is denied, the status will be updated and you will receive written notification, including the reason for the denial and information about how to appeal the decision.

Inquire about pre-certification requests by pre-certification tracking number, member ID number or individual's name. (If individual's ID number or name is used, you also will need to enter provider name and date range.) Through this quick and easy online process, you can receive an immediate response to your Pre-certification request, or your request may be temporarily pended for medical necessity review. For more complex services, you also can submit additional notes online or clinical information, by mail or via fax. In addition, through the inquiry feature, you may view the status of your requests. This online service can save you time and help you get the information you need faster.

Please note: If pre-certification for certain services is delegated to a third party, you will be directed as appropriate.

Get answers fast
Once information is entered, you will receive one of the following responses.

  • Approved – including a Pre-certification tracking number to use for future inquiries.
  • Pended – including a Pre-certification tracking number to use for future inquiries. The reason the request is pended will also display. Additional information will be requested, if needed, and medical review will be conducted (usually within 24 to 48 hours). You can use the inquiry function to find out the current status of any Pre-certification request. This will show you if it is approved, pended or denied.

If the request is denied, the status will be updated and you will receive written notification as you do today, including the reason for the denial and information about how to appeal the decision.

Inquire about Pre-certification requests by Pre-certification tracking number, member ID number or member name. (If member ID number or name is used, you also will need to enter provider name and date range.)

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How to determine Pre-certification requirement

To determine whether your patient's plan requires only inpatient Pre-certification, or both inpatient and outpatient Pre-certification:

  • use the View and Submit Precertification Requests feature
  • checking the back of the individual's CIGNA HealthCare ID card. Most cards will say, "Inpatient admission," or "inpatient admission and outpatient procedures."
  • checking the patient's coverage plan to determine Pre-certification requirements.

To access plan information not found on the individual's ID card, or for individuals who do not yet have an ID card:

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Services Requiring Pre-certification Process

Dental Services

  • Dental services are typically not covered under medical plans. However, if dental procedures are performed in a facility, the medical plan may cover the anesthesia and facility charges in which case pre-certification is required for all anesthesia and/or facility charges.
  • Please consult CIGNA Coverage Policy #0415 Anesthesia and Facility Services for Dental Treatment for further details and medical necessity criteria.

Home Health Care and Home Infusion

Home health care and home infusion services require pre-certification for any CIGNA administered plan with Personal Health Solutions Plus (PHS+) medical management.

Inpatient Admissions


  • Pre-certification is typically required two business days prior to the admission date for all elective, inpatient admissions. If coverage is approved, a pre-certification number will be given to the customer, health care professional and/or facility.
  • Notification of all emergent admissions, including observation stays, is typically required within one business day of the admission.
  • Pre-certification of maternity admissions with an anticipated stay of up to 48 hours after vaginal delivery, or 96 hours after a Cesarean section, is not required. However, if CIGNA is notified, a case manager can be assigned to help coordinate care needs and to monitor discharge needs.
  • Pre-certification is required for elective admissions to other inpatient facilities such as skilled nursing facilities, inpatient hospice and rehabilitation centers. When notified, CIGNA will assign a new pre-certification number if coverage is available and medically necessary under the individual’s benefit plan.

NOTE: Assuming no change in eligibility or coverage, the pre-certification number assigned to an inpatient admission applies to all anticipated covered services associated with that inpatient stay. Charges resulting from delays in service, undisclosed care that could have been provided in a less intensive setting, or any other non-covered service, are not included within the scope of an inpatient pre-certification. Transfer to another inpatient facility requires a separate approval and pre-certification number.

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Outpatient – Personal Health Solutions Plus (PHS+)


Outpatient

Pre-certification is required for specified outpatient services for any CIGNA administered plan with Personal Health Solutions Plus (PHS+) medical management.

Please click on the link Outpatient Pre-certification List to view the current complete list of outpatient procedures requiring pre-certification.

To determine if pre-certification is required, refer to the back of the customer’s CIGNA ID card. Most cards will say “Inpatient admission,” or “inpatient admission and outpatient procedures.” For CIGNA administered plans:

  • The referring professional is generally responsible for obtaining pre-certification for all in-network procedures requiring pre-certification, and
  • The rendering provider is responsible for verifying pre-certification in advance.
  • Hold harmless provisions in participating provider agreements preclude customers from being billed for services rendered by a participating provider when reimbursement is administratively denied due to failure to obtain required pre-certification.
  • The customer (plan participant) is responsible for obtaining pre-certification for non-emergent services provided by non-participating health care professionals and/or facilities./li>

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Failure to Obtain Pre-certification

Failure

  • Failure of customer to obtain pre-certification when required for out-of-network benefits may result in a reduction of benefits per plan terms.
  • Failure of participating provider to obtain pre-certification when required under participating provider agreement will result in a denial of reimbursement for the service. Customers are not financially responsible for the cost of such services due to member hold harmless provisions in provider agreements.

  • NOTE: Even if a service is pre-certified, all associated charges and code(s) may not be separately reimbursable. For example, associated code(s) may be considered incidental or mutually exclusive when billed with other codes.

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