Preauthorization and Medical Necessity Requirements
Ensuring that you receive the right care in the right setting at the right time can make all the difference. To help guide your course of treatment, the Medical Plan administered by Cigna or UHC requires that you receive preauthorization before receiving certain services. The preauthorization process includes a review of the treatment or procedure under Cigna or UHC’s guidelines to ensure that it is considered medically necessary.
- If you are receiving services from an in-network provider, your doctor will submit the necessary clinical information.
- If you are receiving services from an out-of-network provider, you must follow up with your doctor to ensure the required clinical information is submitted to Cigna or UHC. If you do not obtain a preauthorization prior to receiving the service, you may not be reimbursed, even if the service is determined to be medically necessary at a later date.
Preauthorization is required for, but not limited to, hospital admission, surgical procedures, radiology services, chemotherapy (UHC), behavioral health services more than 45-50 minutes a session, cardiology services, chiropractic services, inpatient treatment of mental/nervous disorders and substance abuse, and physical, speech, and occupational therapy (Cigna). If you have any questions about whether preauthorization is required, please contact Cigna or UHC.
Preauthorization for all inpatient hospital admissions must be received at least five days before a scheduled procedure or within 48 hours following an emergency hospitalization to avoid services not being covered or a penalty being assessed for failure to obtain preauthorization from Cigna or UHC. Failure to receive preauthorization may result in services not being covered, even if the service is determined to be medically necessary by the Plan administrator. Preauthorization requirements and services subject to preauthorization may change throughout the year. Contact your Plan administrator for more details or confirmation if a service requires preauthorization.