Cigna routes most prior authorization requests through EviCore for medical services and through the Cigna provider portal for behavioral health. Standard auth decisions take 15 calendar days. Urgent requests are decided within 72 hours per CMS mandate.
Day 1: Submit auth request with complete clinical documentation. Days 2-3: EviCore or Cigna confirms receipt and completeness. Days 4-15: Clinical review and determination. If approved: auth number issued, typically valid 60 days. If denied: written notification with appeal instructions within 2 business days.
| CARC Code | Reason | Primary Cause | Fix |
|---|---|---|---|
| CO-197 | Precertification not obtained | Service performed without auth | Submit PA at least 10 days before service |
| CO-50 | Non-covered service | Service excluded from plan | Verify plan coverage before PA request |
| CO-21 | Required authorization absent | Auth expired or not on file | Confirm auth validity date before service |
Appeal denied authorizations within 180 days. Submit a peer-to-peer review request for clinical denials through EviCore within 5 business days of the denial. For formal appeals, submit clinical documentation to the address on the denial letter. Response time: 30 days standard, 72 hours expedited.
For medical auth: check EviCore's portal at evicore.com using the case reference number. For behavioral health: check the Cigna provider portal under Authorizations. Status updates are available within 24 hours of any change.
Yes. Request a peer-to-peer through EviCore within 5 business days of the denial. A Cigna medical director will review the case with the requesting provider. This is separate from the formal appeal process.
Respond within 5 business days. The review clock pauses until Cigna receives the requested documentation. Failure to respond results in a denial for insufficient information.
Altair checks Cigna auth requirements for every procedure before you submit the request.