Medical and prescription drug plans may some time need approval from your health insurance carrier for certain treatments and medications before receiving care. Typically, Cigna prior authorization is required for complex treatments or prescriptions, and coverage will not be granted without it.
Starting the prior authorization process early is very important and crucial for providers and patients. To ensure a smooth process, inquire with your healthcare provider if a prescription or medical treatment requires prior authorization, enabling them to initiate the process promptly.
It’s important to note that this Cigna prior authorization process differs from seeking additional treatments or prescriptions after your initial visit, where a medical necessity review, or “authorization,” may be necessary. Cigna prior authorization is also called pre-authorization, pre-approval, and, pre-certification are often used interchangeably with Cigna prior authorization
The No Surprises Act, passed in 2020 and effective from January 1, 2022, offers federal consumer protections aimed at preventing unexpected out-of-network bills commonly known as “surprise bills.
Unexpected bills can occur during emergencies, where patients often lack control over their care location. They can also occur in non-emergency situations when patients in in-network hospitals or facilities receive care from providers, such as anesthesiologists, who are not part of the network and were not chosen by the patient.The law requires surprise bills must be covered without prior authorization and in-network cost sharing must apply.
If your healthcare provider is within the network, they will initiate the prior authorization process. However, if you choose a provider outside of your plan’s network, the responsibility falls on you to secure prior authorization.
Failing to obtain prior authorization may result in non-coverage of the treatment or medication, leading to potential increased out-of-pocket expenses. For detailed information about treatments, services, and supplies requiring prior authorization under your specific plan, refer to your plan documents or contact the number on your health plan ID card.
Usually, within 5-10 business days of receiving the prior authorization request, your insurance company will either:
These responses stem from evaluations by clinical pharmacists and medical doctors who assess the requests at the health insurance company.
If you are dissatisfied with the prior authorization response, you or your healthcare provider can request a review of the decision.
Will Cigna demand prior authorization in emergency situations?
No, prior authorization is not necessary in case of an emergency requiring medication. However, coverage for emergency medical costs is contingent upon the terms outlined in your health plan.
The prior authorization process provides your health insurance company with an opportunity to assess the necessity of a medical treatment or medication for your condition. For instance, certain brand-name medications can be expensive. In their evaluation, the health insurance company might determine that a generic or another more cost-effective alternative could be equally effective in treating your medical condition.
The prior authorization process can help you:
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