Approval for Behavioral Health Care
Approval requirements for coverage of Behavioral Health treatment or other services are similar to those in the balance of the Medical Plan. Approval is always required for institutional care and for intensive therapy. The important issues in securing necessary approval are (1) who may request approval and (2) when must that approval be secured.
When a patient is referred to a Cigna Behavioral Health Manager by a MAP Counselor, approval for inpatient treatment will always be accomplished by that MAP Counselor at the time of the referral and the referral will be made to an In-Network provider. The MAP Counselor always will secure approval for behavioral health services on a completely confidential basis.
Alternatively, either you or your referring physician may call a Cigna Behavioral Health Manager directly. If a patient or the patient’s physician contacts a provider directly, no prior approval is required for the initial outpatient treatment. The charges will be covered depending upon whether the provider is In-Network or Out-of-Network. If the patient is covered in the Premier Plan or the MILA Medicare Wrap-Around Plan, both In-Network and Out-of-Network provider’s charges will be covered, subject to any applicable copays or deductibles and coinsurance. If the patient is covered in either the Basic Plan or the Core Plan, only In-Network provider’s charges will be covered, subject to any applicable copays or deductibles and coinsurance.
If you are to be admitted to an institution or to have institutional care or your procedure, treatment or service is extensive and requires advance approval for the extended procedure, treatment or service and you do not contact a Cigna Behavioral Health Manager before treatment begins, your benefits may be reduced.
The Plan will reduce your normal reimbursement by 20% of the amount of the eligible charge if:
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You do not call for approval at least four business days before being institutionalized (or for a valid emergency, within two (2) business days following admission) or for any extension of the originally approved length of stay before such extension begins; and
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You do not call for approval before receiving extended counseling treatment where approval is required.
If you call for approval, but the care you request is reviewed by the Cigna Behavioral Health Manager and found not to be medically necessary, the care will not be covered. Any additional expenses you have to pay because you did not get proper approval do not count toward your deductible, annual out-of-pocket maximum or the Plan’s coordination of benefits provision.
