Precertifications

When is precertification needed?

Precertification helps us make sure the service is needed and covered by the patient’s insurance. Not getting a precertification may lead to a denial of payment. Precertification does not guarantee payment or coverage of all billed services. You may need to request precertification for:

• Medical procedures
• Medications
• Behavioral health services
• Home health care
• Durable medical equipment
• Imaging

Precertification is not required for emergency services. However, emergency services that result in an inpatient hospital admission must be reported within one business day of the admission unless dictated otherwise by state mandate.

What We Look For

Precertification decisions are based on the patient’s eligibility, their benefit plan, clinical guidelines, and their specific situation. We check for things like:

• Patient's current coverage and benefits
• Whether treatment is medically necessary
• If the care setting and level are safe, appropriate, and cost-effective
• If lower-cost providers available
• Whether the patient could benefit from disease management or similar programs
• If case management is needed to help with care coordination
• Whether the patient should be directed to a participating provider
• That claims can be paid on time

When we review medication requests, we also look at:

• If the medicine is being used for something not listed on the label (off-label use)
• How much it costs
• If it might be used in an experimental way
• Ways to reduce waste
• Where the care will happen
• If we can help adjust the dose or how long the medicine is used

We base all decisions on trusted medical research and guidelines. This helps us make sure we don’t interfere with good medical practice.

Provider Responsibilities

As a health care provider, you play a key role in making sure patients get the care they need while following our coverage rules:

• Referring (Ordering or Admitting) Providers - Must request and obtain precertification for in-network services
• Rendering Providers or Facilities - Must confirm that precertification has been approved before performing any elective (non-emergency) services prior to performing the service for patients whose benefit plans require precertification. In some cases, the rendering provider may also request precertification.

Do I need a precertification or a predetermination?

Predeterminations can help you check if a service is needed and how much the patient might have to pay before the service is done. This can help avoid delays when the claim is sent in.

Some patients don’t need precertification for outpatient care. But for a few special procedures, Cigna Healthcare^® might ask for proof that the service was needed after the care is given. To help things go smoothly, you can ask for a predetermination before doing the service. This is optional, but it works like a precertification. If it’s approved, the claim is more likely to be paid correctly.

Only certain plans and procedures allow predeterminations. You don’t have to get one to be paid, but it can help.

Dental Predeterminations

For dental providers, a predetermination of benefits is a voluntary review of a dentist’s treatment plan before care begins. It’s not a preauthorization and isn’t required.

To request a review, the dentist should send the treatment plan along with x-rays or other materials if asked by a Cigna Healthcare dental consultant. If the treatment plan changes, a revised plan should be sent for review.

Cigna Healthcare will review the plan and let you know which dental costs are covered. If no predetermination review is done ahead of time, coverage will be decided when the claim is received. We recommend asking for a review if the dental work is extensive or costs more than $200.

Please note that a review does not guarantee payment. Final payment depends on the actual services provided and the coverage in place when treatment is finished.