Approving your care
Care coordination is a “checks and balances” program for your medical care. To help make sure you get the right kind of treatment, at the right time, a care coordinator reviews your condition before, during and after you receive your medical care.
Hospital admissions always require approval for maximum benefits to be paid. If the admission is planned, approval is required in advance. Emergency admissions require approval within 48 hours after the admission. A maternity admission requires approval only if the stay exceeds 48 hours (96 hours for a cesarean section).
Hospital admissions will be approved for a specific number of days. If your stay must be extended for some reason beyond the approved number of days, you or your representative must call the CIGNA or ComPsych care coordinator to obtain approval for the additional days.
The care coordinator will certify those days that are approved under the Plan.
In addition, certain procedures, treatments and supplies — whether from an In-Network provider or another provider — must be approved before you receive them in order for the Plan to pay the maximum benefit.
The following surgeries and procedures require advance approval, regardless of whether they are performed on an inpatient or an outpatient basis:
- Adenoidectomy
- Carpal tunnel release
- Cataract extraction
- Cholecysectomy
- Colonoscopy
- Coronary angiography
- Hernia repair
- Hysterectomy
- Hysteroscopy
- Knee arthroscopy
- Lumbar myelography
- Magnetic resonance imaging (MRI) – brain, cervical, lumbar, musculoskeletal, thoracic regions
- Myringotomy with tube insertion
- Pelvic laparoscopy
- Positron-emission tomography (PET) scan
- Sinus surgery (all)
- Surgical procedures of the shoulder (including arthroscopy)
- Tonsillectomy
- Upper gastrointestinal (UGI)
Advance approval is also required if your doctor orders any of the following special care or services:
- Care in a skilled nursing facility
- Home health care
- Hospice care
- Transplant surgery
If you use an In-Network provider, that provider
will call the CIGNA or ComPsych care coordinator
directly for approval. However, it is your
responsibility to verify that your provider has
taken care of this for you.
If you use an Out-of-Network provider, it is your
responsibility to call for approval. Either you or
someone who can speak for you must call the care
coordinator. See the Resources chart at the back
of this SPD, in the Administration Information
Section, for how to find a CIGNA or ComPsych
care coordinator.
Approval must be requested at least four business
days (Monday through Friday) before you have
a procedure performed. Different rules apply
to medical emergencies;
see here
for more information.
