Cigna Prior Authorization Process
Cigna Prior Authorization Process: Overview
Cigna requires prior authorization for high-cost procedures, advanced imaging, specialty referrals, and behavioral health services before delivery. Processing window: 60 days. Requests without authorization result in CO-45 denials. Commercial claims file within 90 days from date of service. Use cigna.com for real-time submission and status tracking.
Key Requirements
- Pre-Service Submission: Submit authorization before service date. Post-service authorizations are not accepted. Include member ID, procedure code, CPT codes, and clinical justification.
- Clinical Documentation: Provide diagnosis, treatment plan, medical history, and clinical evidence supporting necessity. Cigna reviews against evidence-based guidelines and plan coverage criteria.
- Correct Procedure Codes: Use accurate CPT and ICD-10 codes matching the planned service. Incorrect coding delays review and extends processing time.
- Portal Access: Register for Cigna provider portal at cigna.com. Submit authorizations electronically for faster processing and real-time status updates.
- Member Eligibility Verification: Confirm coverage active on service date, plan type, and authorization requirements. Verify via portal or phone before submission.
- Expedited Review Requests: For urgent cases, request expedited review (24-48 hours) via telephone with clinical justification.
Timeline & Process
Standard Review: Submit 10+ days before service. Cigna processes within 60 days via portal and mail with authorization number.
Expedited Review: Call with urgent clinical details. Response within 24-48 hours; verbal approval must follow with written confirmation.
Claim Filing: File within 90 days from service date with authorization number for faster payment.
Common Denials
| CARC Code | Reason | Prevention |
|---|---|---|
| CO-45 | Not covered (no authorization) | Submit prior authorization before service. Include clinical evidence and procedure codes. |
| CO-16 | Not medically necessary | Include clinical justification, diagnosis codes, prior treatment history, and physician notes. |
| CO-50 | Services not rendered as billed | Ensure billed codes match authorized procedure. Use same CPT codes in claim as in authorization. |
Appeal Process
File appeal within 180 days (365 in California) of denial. Include authorization documentation and clinical records. Submit via portal or mail. Cigna responds within 60 days. Request independent external review if denied.
Common Questions
Which procedures require prior authorization at Cigna?
High-cost surgeries, advanced imaging (MRI, CT, PET), orthopedic procedures, mental health inpatient, physical therapy, and some specialist referrals require prior authorization. Check Cigna's plan documents for specific procedure lists.
How long does Cigna take to process authorization requests?
Cigna allows 60 days for processing. Emergency requests may receive expedited review within 24-48 hours. Submit before the service date to avoid claim denials.
What happens if I submit a claim without prior authorization?
Claims submitted without required authorization are typically denied as CO-45 (not covered). File an appeal with retroactive authorization request, but approval is not guaranteed.
Altair checks Cigna requirements before submission . flagging missing authorizations and coding mismatches in real time. See how Altair works.
This reference is for informational purposes. Payer policies change frequently. Always verify against Cigna's current provider documentation. Last updated: 2026-03-16.
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