Cigna Healthcare Prior Authorization

Cigna Healthcare prior authorization rules are often service-specific rather than universal, so the safest workflow is to confirm the requirement in the payer's provider resources before scheduling or submitting care. The notes below summarize the most actionable provider-side guidance captured in the research set for this payer.

At a glance

• Cigna Healthcare uses prior authorization/precertification workflows that vary by service type and line of business. Providers can submit through the Cigna for Health Care Professionals portal, EDI 278 via a practice management system/vendor, fax for some services, and phone for some categories. For medications/pharmacy services, Cigna indicates a shift toward electronic prior authorization (ePA) portals, with phone remaining an option if ePA cannot be used.
• Prior authorization requirements vary by service type, vendor, and plan.
• Cigna notes that oncology pharmacy drug and medical prior authorization may use Medical Oncology Pathways via eviCore/Evernorth.
• For medications/pharmacy services, Cigna indicates electronic prior authorizations are preferred and phone is a fallback if ePA cannot be used.
• This is provider operational guidance, not a guarantee of coverage or payment.

Where to verify prior authorization requirements

• Verification resource 1
• Verification resource 2

How to submit prior authorization requests

• Online portal / prior authorization portal

• EDI 278 transaction via practice management system or clearinghouse/vendor

• Fax for some precertification forms

• Phone for some service categories

• ePA portals for medications and pharmacy services

• Submission resource 1

• Submission resource 2

Information commonly required

• Service description
• Start date of service
• End date of service
• Service code if available (HCPCS/CPT)
• Appropriate precertification intake form for faxed requests
• Behavioral health service-specific forms or requirements from the Form Center / Evernorth Authorization and Billing Resource
• For EDI 278 requests, use the vendor/clearinghouse workflow

Turnaround notes and caveats

• Some behavioral health emergency admissions must be reported within one business day of admission unless state mandate says otherwise.
• The prior authorization pages do not provide a universal turnaround time for all requests; timeframes may vary by service, vendor, and plan.
• Prior authorization requirements vary by service type, vendor, and plan.
• Cigna notes that oncology pharmacy drug and medical prior authorization may use Medical Oncology Pathways via eviCore/Evernorth.
• For medications/pharmacy services, Cigna indicates electronic prior authorizations are preferred and phone is a fallback if ePA cannot be used.
• This is provider operational guidance, not a guarantee of coverage or payment.

Provider resources

• Cigna for Health Care Professionals portal (official)
• Precertification / Prior Authorization (official)
• Submit Claims (official)
• Appeals and Disputes (official)
• CHCP resources: Electronic Claims Submission (official)
• CHCP resources: How to Register (official)

Sources