For Health Care Providers

January 2021

If you are a network-participating primary care provider (PCP) and need to submit a referral for your patients who have Cigna Connect or Cigna Plus plans in Illinois, Cigna SureFit®, HMO, or Network plans coverage, please use one of the channels listed below. ¹ If it’s an urgent referral, refer to the urgent referrals chart. Note: Prior authorization or precertification may also be needed.

¹ For Cigna Connect and Cigna Plus plans in Illinois, HMO, Network and SureFit plans, PCPs are required to make referrals to specialists participating in the network aligned to the appropriate plan.

Frequently asked questions

1. What services, by state, do not require referrals?
   Certain states mandate that referrals not be required for some specialists services. Please refer to the chart below.
   
   

   State	Specialist or specialty service	State	Specialist or specialty service
   Arizona	Behavioral health care provider3 Chiropractic Dentist (for pediatrics) Emergency or urgent care3 Laboratory2,3 OB/GYN Radiology2,3 Vision care (pediatrics)	Illinois North Carolina Tennessee Texas	Behavioral health care provider3 Dentist (for pediatrics) Emergency or urgent care3 Laboratory2,3 OB/GYN Radiology2,3 Vision care (pediatrics)
   Colorado	Behavioral health care provider3 Certified midwife Dentist (for pediatrics) Emergency or urgent care3 Laboratory2,3 OB/GYN Radiology2,3 Vision care (adults and pediatrics)	Missouri	Behavioral health care provider3 Emergency or urgent care3 Laboratory2,3 OB/GYN Radiology2,3
   Florida	Dermatologist (first five visits) Chiropractic Emergency or urgent care3 Laboratory2,3 OB/GYN Podiatrist Radiology2,3	Virginia	Behavioral health care provider3 Emergency or urgent care3 Laboratory2,3 OB/GYN Physical therapist Radiology2,3 Any specialty physicians that treat life-threatening, degenerative, disabling, or cancer diagnosis

   ² Prior authorization or precertification may be needed.
   ³ Referrals are not required in any market for emergency or urgent care, behavioral health care providers, laboratory, and radiology services.



2. How long is a referral valid for?
   Referrals are valid for up to six months based on the treatment plan determined by the PCP and the specialist. If the patient needs additional care, beyond a six month period, the specialist should contact the referring PCP to coordinate further care and the issuance of a new referral.


3. Is a referral only valid for one specific condition?
   Not always. A referral should indicate the medical reason the PCP is referring the customer to a specific specialist that may, in certain cases, include the customer’s diagnosis or condition. However, if the specialist confirms additional diagnoses at the time of service that he or she can treat, no additional referrals will be required.


4. If a customer changes their PCP after obtaining a referral, is the referral still valid?
   Yes. The referral is still valid. The new PCP does not need to submit another referral for the same visit to, or treatment by, the specialist. However, the new network-participating PCP must submit a referral for any different specialist visits or treatments.


5. What happens if the PCP submits a referral to a specialist who does not participate in the network aligned to the Cigna Connect, Cigna Plus, or SureFit plans?
   Since Cigna Connect and Cigna Plus plans in Illinois, and SureFit plans do not offer out-of-network benefits, we will advise them to select a network-participating specialist. The exception is if the PCP believes a network-participating specialist is not available for the needed care. The standard turnaround time for these requests is three to five business days, because we will need to research them. If we determine there is not an appropriate network-participating specialist, we will approve the request and issue an authorization number. If there are one or more appropriate network-participating specialists, we will deny the referral and give the PCP the specialist name(s). In both cases, we will notify the provider of our determination by fax and U.S. mail.


6. Are there services that will require both a referral and a preauthorization?
   Yes. Services such as chiropractic care or physical therapy require a PCP referral, and subsequent visits may require the specialist to obtain a prior authorization or predetermination request from one of our national ancillary vendors, such as American Specialty Health® (ASH) or OrthoNet™.


7. Where can a PCP look to find network-participating specialists?
   When making referrals, visit the online provider directory at Cigna.com > Find a doctor to find participating physicians, hospitals, and other providers. You can also call Cigna Customer Service at 1.866.494.2111 for this information.


8. Do customers need to provide a copy of the referral form at their initial specialist visit?
   No. Customers do not need to bring a paper referral form with them to specialist appointments. However, we highly recommend it. PCPs should submit a referral to Cigna electronically, or by phone, fax, or mail, and we encourage them to give a printed copy of the referral to their patient.


9. What additional information is available with the referral number?
   Cigna is able to provide the total visits approved for coverage and referral effective dates with the referral number.


10. Are network-participating specialists expected to confirm that a referral was received by Cigna before providing services?
    Yes. The specialist can call Cigna to confirm the referral was received. If it has not, Cigna will facilitate the issuance of the referral. The specialist should not turn a patient away or interrupt the patients care.


11. Are specialists expected to track visits and the expiration of the referral?
    Yes. Specialists should track visits and the expiration of the referral. If the patient needs additional care, beyond a six month period, the specialist should contact the referring PCP to coordinate further care and the issuance of a new referral.


12. Does a referral cover all physicians and physician types in the same specialist practice?
    No. Referrals are made to individual specialist. A separate referral is needed for different specialties.


13. Can specialists make referrals to other specialists?
    No. The customer will need to return to their PCP for a new referral.