Certification Requirements
For all medical plans, all inpatient hospital admissions, outpatient diagnostic tests and outpatient procedures must be reviewed to certify the medical necessity of the admission, test or procedure.

For the CIGNA Point-of-Service Plans, if you are using an in-network physician for care, the in-network physician is responsible for contacting CIGNA to certify the admission, test or procedure. If you are using an out-of-network physician, you are responsible for requesting certification. If you are using an out-of-network physician and you do not obtain approval through certification, penalties will apply.

For the CIGNA Indemnity Plan, you are responsible for requesting certification. If you do not obtain approval through certification, penalties will apply.

For certification, call CIGNA Member Services at 1-800-244-6224.

Preadmission Certification/ Continued Stay Review for Hospital Confinement
Preadmission Certification (PAC) and Continued Stay Review (CSR) refer to the process used to certify the medical necessity and length of a hospital confinement when you or your Eligible Dependent requires treatment in a hospital:

• as a registered bed patient
• for a partial hospitalization for the treatment of mental health or substance abuse

or

• for substance abuse residential treatment services.

PAC should be requested prior to any nonemergency treatment in a hospital described above. In the case of an emergency admission, the Review Organization should be contacted within 48 hours after the admission. For an admission due to pregnancy, the Review Organization should be contacted by the end of the third month of pregnancy. CSR should be requested, prior to the end of the certified length of stay, for continued hospital confinement.

Covered expenses incurred will be reduced by 50% for hospital charges made for each separate admission to the hospital

• unless PAC is received:

(a) prior to the date of admission;

              or

(b) in the case of an emergency admission, within 48 hours after the date of admission.

Covered expenses incurred for which benefits would otherwise be payable under this plan for the charges  listed below will not include:

• hospital charges for bed and board, for treatment listed above for which PAC was performed, which are made for any day in excess of the number of days certified through PAC or CSR;

and

• any hospital charges for treatment listed above for which PAC was requested, but which was not certified as medically necessary.

PAC and CSR are performed through a utilization review program by a Review Organization with which CIGNA has contracted.

In any case, those expenses incurred for which payment is excluded by the terms set forth above will not be considered as expenses incurred for the purpose of any other part of this plan, except for the "Coordination of Benefits" section.

Outpatient Certification Requirements
Outpatient Certification refers to the process used to certify the medical necessity of outpatient diagnostic testing and outpatient procedures, including, but not limited to, those listed in this section when performed as an outpatient in a free-standing surgical facility, other health care facility or a physician's office. The toll-free number on the back of your ID card should be called to determine if Outpatient Certification is required prior to any outpatient diagnostic testing or procedures.

Outpatient Certification is performed through a utilization review program by a Review Organization with which CIGNA has contracted. Outpatient Certification should be only requested for nonemergency procedures or services, and should be requested at least four working days (Monday through Friday) prior to having the procedure performed or the service rendered.

Covered expenses incurred will be reduced by 50% for charges made for any outpatient diagnostic testing or procedure performed unless Outpatient Certification is received prior to the date the testing or procedure is performed.

Covered expenses incurred will not include expenses incurred for charges made for outpatient diagnostic testing or procedures for which Outpatient Certification was performed, but, which was not certified as medically necessary.

In any case, those expenses incurred for which payment is excluded by the terms set forth above will not be considered as expenses incurred for the purpose of any other part of this plan, except for the "Coordination of Benefits" section.

Diagnostic Testing and Outpatient Procedures
Diagnostic tests and outpatient procedures that require certification include, but are not limited to:

• advanced radiological imaging – CT scans, MRI, MRA or PET scans
• hysterectomy.

Prior Authorization/Pre-Authorized
For the CIGNA Point-of-Service Plans, the term Prior Authorization means the approval that a Participating Provider must receive from the Review Organization, prior to services being rendered, in order for certain services and benefits to be covered under this policy.
Services that require Prior Authorization include, but are not limited to:

• inpatient hospital services
• inpatient services at any participating other health care facility
• residential treatment
• outpatient facility services
• advanced radiological imaging
• nonemergency ambulance

and

• transplant services.

 

Emergency Hospitalization
If you have a medical emergency and are admitted to the hospital, someone must call for precertification within two days of your admission or on the first business day following your admission, if later.

For precertification call: 1-800-CIGNA24 (1-800-244-6224)

Expenses Not Covered
In addition to the coverage limitations shown on the plan’s Summary of Benefits, there are some expenses that are not covered. They include, but are not limited to:

• expenses for supplies, care, treatment, or surgery that are not medically necessary
• to the extent that you or any one of your Eligible Dependents is in any way paid or entitled to payment for those expenses by or through a public program, other than Medicaid
• to the extent that payment is unlawful where the person resides when the expenses are incurred
• charges made by a hospital owned or operated by, or which provides care or performs services for, the United States Government, if such charges are directly related to a military-service-connected injury or sickness
• for or in connection with an injury or sickness which is due to war, declared or undeclared
• charges which you are not obligated to pay or for which you are not billed or for which you would not have been billed except that they were covered under this plan
• assistance in the activities of daily living, including but not limited to eating, bathing, dressing or other custodial services or self-care activities, homemaker services and services primarily for rest, domiciliary or convalescent care
• for or in connection with experimental, investigational or unproven services (as defined and determined by CIGNA)
• cosmetic surgery and therapies. Cosmetic surgery or therapy is defined as surgery or therapy performed to improve or alter appearance or self-esteem or to treat psychological symptomatology or psychosocial complaints related to one’s appearance
• macromastia or gynecomastia surgeries
• surgical treatment of varicose veins
• abdominoplasty/panniculectomy
• rhinoplasty; blepharoplasty; orthognathic surgeries; redundant skin surgery; removal of skin tags; acupressure; craniosacral/cranial therapy; dance therapy, movement therapy; applied kinesiology; rolfing; prolotherapy; and extracorporeal shock wave lithotripsy (ESWL) for musculoskeletal and orthopedic conditions
• for or in connection with treatment of the teeth or periodontium unless such expenses are incurred for: (a) charges made for a continuous course of dental treatment started within six months of an injury to sound natural teeth; (b) charges made by a hospital for bed and board or necessary services and supplies; (c) charges made by a free-standing surgical facility or the outpatient department of a hospital in connection with surgery
• for medical and surgical services, initial and repeat, intended for the treatment or control of obesity including clinically severe (morbid) obesity, including: medical and surgical services to alter appearances or physical changes that are the result of any surgery performed for the management of obesity or clinically severe (morbid) obesity; and weight loss programs or treatments, whether prescribed or recommended by a physician or under medical supervision
• unless otherwise covered by the plan, for reports, evaluations, physical examinations, or hospitalization not required for health reasons including, but not limited to, employment, insurance or government licenses, and court-ordered, forensic or custodial evaluations.
• court-ordered treatment or hospitalization, unless such treatment is prescribed by a physician and listed as covered in this plan
• infertility services except as provided by the plan including infertility drugs, surgical or medical treatment programs for infertility, including in vitro fertilization, gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), variations of these procedures, and any costs associated with the collection, washing, preparation or storage of sperm for artificial insemination (including donor fees). Cryopreservation of donor sperm and eggs are also excluded from coverage
• reversal of male or female voluntary sterilization procedures
• transsexual surgery including medical or psychological counseling and hormonal therapy in preparation for, or subsequent to, any such surgery
• any medications, drugs, services or supplies for the treatment of male or female sexual dysfunction such as, but not limited to, treatment of erectile dysfunction (including penile implants), anorgasmy, and premature ejaculation – except as provided by the plan
• medical and hospital care and costs for the infant child of an Eligible Dependent, unless this infant child is otherwise eligible under this plan
• nonmedical counseling or ancillary services, including but not limited to custodial services, education, training, vocational rehabilitation, behavioral training, biofeedback, neurofeedback, hypnosis, sleep therapy, employment counseling, back school, return to work services, work hardening programs, driving safety, and services, training, educational therapy or other nonmedical ancillary services for learning disabilities, developmental delays, autism or mental retardation
• therapy or treatment intended primarily to improve or maintain general physical condition or for the purpose of enhancing job, school, athletic or recreational performance, including but not limited to routine, long term, or maintenance care which is provided after the resolution of the acute medical problem and when significant therapeutic improvement is not expected
• consumable medical supplies other than ostomy supplies and urinary catheters, except as provided by the plan
• private hospital rooms and/or private duty nursing unless determined by the utilization review physician to be medically necessary
• personal or comfort items such as personal care kits provided on admission to a hospital, television, telephone, newborn infant photographs, complimentary meals, birth announcements, and other articles which are not for the specific treatment of an injury or sickness
• artificial aids including, but not limited to, corrective orthopedic shoes, arch supports, elastic stockings, garter belts, corsets, dentures and wigs
• hearing aids, except as provided by the plan,  including but not limited to semi-implantable hearing devices, audiant bone conductors and bone anchored hearing aids (BAHAs). A hearing aid is any device that amplifies sound
• aids or devices that assist with nonverbal communications
• medical benefits for eyeglasses, contact lenses or examinations for prescription or fitting thereof, except that covered expenses will include the purchase of the first pair of eyeglasses, lenses, frames or contact lenses that follows keratoconus or cataract surgery
• charges made for or in connection with routine refractions, eye exercises and for surgical treatment for the correction of a refractive error, including radial keratotomy, when eyeglasses or contact lenses may be worn
• treatment by acupuncture
• all noninjectable prescription drugs, nonprescription drugs, and investigational and experimental drugs, except as provided in the plan
• routine foot care, including the paring and removing of corns and calluses or trimming of nails. However, services associated with foot care for diabetes and peripheral vascular disease are covered when medically necessary
• membership costs or fees associated with health clubs, weight loss programs and smoking cessation programs
• genetic screening or pre-implantation genetic screening. General population-based genetic screening is a testing method performed in the absence of any symptoms or any significant, proven risk factors for genetically linked inheritable disease
• dental implants for any condition
• fees associated with the collection or donation of blood or blood products, except for autologous donation in anticipation of scheduled services where in the utilization review physician’s opinion the likelihood of excess blood loss is such that transfusion is an expected adjunct to surgery
• blood administration for the purpose of general improvement in physical condition
• cost of biologicals that are immunizations or medications for the purpose of travel, or to protect against occupational hazards and risks
• cosmetics, dietary supplements and health and beauty aids
• nutritional supplements and formulae except for infant formula needed for the treatment of inborn errors of metabolism and professional medical services under the supervision of a physician and special dietary formulas medically necessary for therapeutic treatment of PKU
• medical treatment for a person age 65 or older, who is covered under this plan as a retiree, or their Dependent, when payment is denied by the Medicare plan because treatment was received from a nonparticipating provider
• medical treatment when payment is denied by a primary plan because treatment was received from a nonparticipating provider
• for or in connection with an injury or sickness arising out of, or in the course of, any employment for wage or profit (including workers compensation).
• telephone, e-mail, and Internet consultations, and telemedicine
• massage therapy
• for charges which would not have been made if the person had no insurance
• to the extent that charges are more than Reasonable and Customary Charges
• expenses incurred outside the United States, unless you or your Eligible Dependent is a U.S resident and the charges are incurred while traveling on business or for pleasure
• charges made by any covered provider who is a member of your family or your Eligible Dependent’s family
• to the extent of the exclusions imposed by any certification requirement shown in this plan.

Filing Claims
If you stay in-network under the Point-of-Service Plans, your network provider is responsible for filing your claims.

To file a claim for out-of-network treatment under the Point-of-Service Plans or for any treatment under the Indemnity Plan, you must complete a claim form and send it to CIGNA within 90 days after the plan year in which services have been rendered. Be sure to:

• include the account number listed on your ID card
• use a separate form for each covered dependent
• indicate whether you would like reimbursement of a payment you have made sent to you. Otherwise, it will be sent to the provider.

You can either attach itemized bills or have your physician complete the physician’s section of the form. Either way, the following information must be provided:

• patient’s full name, date of birth and relationship to you
• physician’s full name, address and tax identification number
• diagnosis code
• date and charge for each service.

Claims forms can be obtained from CIGNA Member Services or the Benefit Plans Office.

Coordination of Benefits
If you or any of your Eligible Dependents are covered under another medical plan, CIGNA determines how benefits from all such plans will be coordinated, as described in the plan document that governs the company plan under which you are covered (refer to the “Administrative Information” section in this book on how to obtain a plan document).

Medicare Eligible
Benefits will also be coordinated with benefits you or a covered dependent receives or is eligible to receive under Part A and Part B of Medicare in accordance with Medicare Secondary Payor rules. This means that your plan benefit will be reduced to account for Medicare benefits you are eligible to receive – whether you are enrolled or not.