Network Operations and Provider Relations 1-847-318-8844
Provider Services 1-800-230-6138
• Eligibility Status
• Claim Status
• Authorization Status
Health Services 1-800-230-7298
• Eligibility and Enrollment
• Pre Certification DME/Home Health Care
• Inpatient Certification
• Skill Nursing/Rehab
• Solution Dept/Appeals Unit
• Case Management
Cigna-HealthSpring Pharmacy Department 1-800-331-6293
Cigna-HealthSpring Behavioral Healthcare 1-866-780-8546
Informed Rxc 1-800-792-7487
Cigna-HealthSpring Connect 1-866-952-7596
Marketing and Sales 1-888-886-1993
Customer Service 1-888-588-4827
First Continental Life (Dental) 1-800-259-3081
Vision Care Block Vision 1-800-428-8789
Organ Transplant Services 1-800-230-7292
Revised 06/01/2014
1 REVISED
CENTRAL GEORGIA/ILLINOIS/INDIANA/ NORTH CAROLINA/SOUTH CAROLINA PRIOR AUTHORIZATION LIST
FOR DATES OF SERVICE ON OR AFTER JUNE 1, 2014 Prior Authorization (PA) Requirements
This Cigna-HealthSpring Prior Authorization list supersedes any lists that have been previously distributed or published–older lists are to be replaced with the latest version.
Cigna-HealthSpring Prior Authorization (PA) Policy
PCP’s or referring providers should OBTAIN Prior Authorization BEFORE services requiring Prior Authorizations are rendered.
Prior Authorizations may be obtained via HealthSpring Connect (HSC) or as otherwise indicated in the Health Services section of the 2014 Provider Manual. Please see the HealthSpring Connect section of the Provider Manual for an overview of the HSC portal capabilities and instructions for obtaining access.
Rendering Providers should VERIFY that a Prior Authorization has been granted BEFORE any service requiring a Prior
Authorization is rendered. Prior Authorizations may be verified via HealthSpring Connect (HSC) or as otherwise indicated in the Health Services section of the Provider Manual.
IMPORTANT – Prior Authorization and/or Referral Number(s) is/are not a guarantee of benefits or payment at the time of service. Remember, benefits will vary between plans, so always verify benefits.
Cigna-HealthSpring Referral Policy
Cigna-HealthSpring values the PCP’s role in directing the care of Members to the appropriate, participating Providers.
Participating Specialists are contracted to work closely with our referring PCPs to enhance the quality and continuity of care provided to Cigna-HealthSpring Members.
Although a Prior Authorization may not be required for certain services, a REFERRAL from a PCP to a Specialist MUST BE in place. The Referral should indicate PCP approved for a consultation only or for consultation and treatment, including the number of PCP approved visits.
Refer to the online directory at www.cignahealthspring.com or contact Provider Services, toll-free phone: (800) 230-6138 to locate an in-network provider.
Procedures/Services PA
Required PA Not
Required Comments
Admissions
Inpatient Admission Yes, Prior Auth required Inpatient Observation Yes, Prior Auth required Inpatient Rehabilitation Yes, Prior Auth required Skilled Nursing Facility Yes, Prior Auth required LTAC Yes, Prior Auth required
Intermediate Care Yes, Prior Auth required Facility/Assisted
Living Allergy Injections without a MD visit
Allergy Serum and Testing No auth required with a Specialist referral
Ambulance (Air or Ground) See Comments
Non-Emergent
Transports Yes, Prior Auth required Emergent Transports No, Prior Auth not required
Prior authorization list
48
Revised 06/01/2014
2
Procedures/Services PA
Required PA Not
Required Comments
Ambulance (Air or Ground) cont. See Comments Facility to Facility Transfer Yes, Prior Auth required
Amniocentesis
Angioplasty/Cardiac Catheterization/
Stents (cardiac and renal) Arteriogram/Angiogram Audiogram
Biopsy
Blood Services (Outpatient) Bone Density Study Bronchoscopy Cardiac Monitoring
Cardiac Rehab Only covered for specific conditions under Medicare
guidelines Cardiac Testing
Cardioversion
Chemotherapy Initial treatment only
Chiropractic Only covered for specific conditions under Medicare
guidelines CT Scans
Fast (EBCT)
64 Slice
CTA Scans – all modalities
Diabetic Supplies and Monitors Prior Auth required if provided under Part B benefits Doppler/Duplex Studies
Durable Medical Equipment (DME)
Prior Authorization is Required For:
• All rental DME
• Purchased DME with billed charges, per line item, greater than $500; certain items require Prior Auth regardless of price 2
• All supplies with billed charges, per line item, greater than $500
• All repairs to DME Echocardiogram (ECG)
Electrocardiogram (EKG) Electroencephalogram (EEG) Electromyography (EMG) Electrophysiology (EP)
Education Includes diabetic education, nutritional counseling,
and smoking cessation Endoscopy
Facility to Facility Transfers See ambulance
Genetic Testing Only covered under certain conditions under Medicare
guidelines Hemodialysis
Home Health Services Home Infusion
Interventional Radiology
Lab work Must use contracted provider
Revised 06/01/2014
3
1 DME requiring prior auth regardless of price – chest wall oscillation vest, conductive garment for TENS or NMES, cough stimulating device, cuirass chest shell, external defibrillator, gel pressure pad or non-powered pressure overlay for mattress, hydrocollator portable unit, implantable infusion pump, incontinent treatment system, pelvic floor stimulator, jaw motion rehab system, manual and power wheelchair cushions and accessories, osteogenesis stimulator, pneumatic compression device and/or any appliance to use with it, powered wheelchair or scooter, seat lift mechanism, shoulder flexion rotation device, speech generating device, TENS device, traction equipment
Procedures/Services PA
Required PA Not
Required Comments
MRA (all modalities) MRI (all modalities) Myelogram
Nuclear Cardiac Studies Nuclear Radiology Studies Occupational Therapy
Orthotics See Comments
Prior Authorization is Required For:
• Purchased Orthotics with billed charges, per line item, greater than $500
• All repairs to Orthotics Outpatient Observation
Outpatient Surgical Procedures Outpatient hospital and ambulatory surgical centers require prior authorization
Oxygen Equipment Part B Drugs
Peritoneal/Home Dialysis Physical Therapy
Podiatry Only covered for specific conditions under Medicare
guidelines Positron Emission Tomography (PET)
Preventive Screenings Include mammogram, pap test, colonoscopy, flu and
pneumonia vaccines, bone density, glaucoma screening
Prosthetics See Comments
Prior Authorization is Required For:
• Purchased Prosthetics with billed charges, per line item, greater than $500
• All repairs to Prosthetics
Pulmonary Rehab Only covered for specific conditions under Medicare
guidelines
Radiation Therapy Prior Auth only required for IMRT, Gamma knife, and
Cyber knife
Respiratory Therapy
See Comments
In home setting Yes, Prior Auth required
In hospital or
outpatient setting No, Prior Auth not required Sleep Study
See Comments
In home setting Yes, Prior Auth required
In hospital or
outpatient setting No, Prior Auth not required
Specialty Services PCP Referral to Specialty Physician is required
Speech Therapy Ultrasound
Wound Care (Physician Office or Outpatient Wound Center) X-ray