Inside the Cigna Prior Authorization Process: What to Expect
- Jamie P
- Aug 12
- 7 min read
Learn how Cigna prior authorization works, what steps are involved, and how patients and providers can work together to avoid delays in care.
Introduction: Why Cigna Prior Authorization Matters
Prior authorization is a process used by insurance companies to ensure certain medical services, procedures, or prescriptions are necessary and appropriate before they’re covered. Cigna, a global health service company, uses prior authorization as a tool to promote safe, effective, and cost-efficient care.
For patients, it can sometimes feel like an extra hurdle to receiving treatment. For providers, it’s an administrative process that requires planning and coordination. But when approached strategically, prior authorization can be navigated efficiently — minimizing delays and ensuring coverage for necessary care.
This article explains how Cigna prior authorization works, why it exists, what the steps involve, and how both patients and providers can work together to make the process smoother.
What Is Cigna Prior Authorization?
Cigna prior authorization (PA) is a pre-approval process where Cigna reviews a proposed healthcare service, medication, or procedure before agreeing to cover it.
Why It’s Required
Medical Necessity: To ensure treatments are clinically appropriate for the patient’s condition.
Cost Control: To encourage the use of equally effective but less expensive alternatives.
Safety: To reduce the risk of side effects or unnecessary interventions.
Without prior authorization, patients may be responsible for the full cost of the service or medication — even if it’s something their provider recommends.
Services and Medications That May Require Cigna Prior Authorization
While requirements vary by plan, some common examples include:
High-cost specialty medications such as biologics for autoimmune diseases.
Advanced imaging like MRI, CT scans, or PET scans.
Elective surgeries and certain outpatient procedures.
Inpatient hospital admissions for non-emergency reasons.
Durable medical equipment (DME) above certain cost thresholds.
Cigna maintains a list of drugs and services that require prior authorization, updated regularly to reflect new treatments and cost trends.
The Cigna Prior Authorization Process
Determining the Need for PA
When a provider prescribes a medication or orders a service, the clinic checks whether prior authorization is required for the patient’s specific plan.
Submitting the Request
The provider sends a PA request to Cigna, including relevant medical history, diagnosis codes, test results, and treatment plans.
Review by Cigna
Cigna’s clinical team compares the request against established medical necessity guidelines.
Decision Issued
Approval: The service or medication is authorized for coverage.
Denial: Cigna explains the reason and provides an appeal option.
Request for More Information: Providers must send additional details to complete the review.
Typical Timelines for Cigna Prior Authorization
Standard Requests: Often processed within 3–5 business days.
Expedited Requests: May be completed within 24–48 hours for urgent needs.
Complex Cases: Some may take longer, especially if multiple specialists are involved or additional documentation is needed.
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Impact on Patients
Benefits
Helps ensure treatment is safe and backed by clinical evidence.
Can lower costs by steering toward covered, cost-effective options.
Drawbacks
Possible delays in starting treatment.
Additional communication between patient, provider, and insurer.
The Role of Patients in Speeding Up Cigna Prior Authorization
While much of the prior authorization process happens behind the scenes between providers and Cigna, patients can play an active role in reducing delays and keeping things on track.
Be Proactive Early
As soon as you know a prescription, procedure, or service might be needed, ask your provider whether Cigna requires prior authorization. This gives you and your healthcare team more time to gather documents before the request is urgent.
Provide Complete Information
Your provider will need details like past treatments, allergies, current medications, and any previous adverse reactions. Having this information ready can prevent back-and-forth requests that slow the process.
Stay Available for Follow-Up
Sometimes, Cigna or your provider may need additional information. Promptly answering calls, emails, or messages through the patient portal can shave days off the approval time.
Check In and Track Progress
A quick follow-up call to the provider’s office two or three days after submission can confirm whether the request is moving forward. You can also log into Cigna’s member portal for real-time status updates.
Keep Records
Save approval letters, reference numbers, and any appeal documentation. Having these on hand is especially helpful for future renewals.
When patients stay engaged in the process, approvals tend to happen faster, and there’s less chance of an unexpected delay disrupting care.
Impact on Providers
Advantages
Protects against providing services that won’t be covered.
Encourages evidence-based care.
Challenges
Additional administrative workload.
Potential patient frustration if requests take too long.
Comprehensive Patient and Provider Checklist for Cigna Prior Authorizations
For Patients:
Keep your insurance card and plan details on hand.
Share complete medical history with your provider.
Ask for the submission date and reference number for your PA request.
Follow up after 48 hours if you haven’t heard from your provider.
For Providers:
Verify PA requirements before prescribing or ordering.
Gather all needed documents upfront.
Use Cigna’s electronic submission tools for faster turnaround.
Assign a staff member or virtual assistant to track requests daily.
Special Considerations for High-Cost and Specialty Care
High-cost treatments and specialty care often face more rigorous review. Examples include:
Biologic injections for chronic conditions.
Advanced cancer therapies.
Surgeries involving multiple specialties.
These cases usually require extra documentation, such as specialist notes, genetic testing results, or proof that other treatments have been tried and failed.
Cigna Prior Authorization Renewal and Long-Term Management
For many patients, prior authorization with Cigna isn’t a one-time event. If you’re receiving long-term treatment — whether that’s a specialty medication, ongoing therapy, or recurring procedures — you may need to go through the prior authorization process again at regular intervals. These renewals ensure that the treatment is still medically necessary, appropriate, and aligned with your coverage plan.
Why Renewals Are Required
Clinical Reassessment: Health conditions can change over time. Cigna requires renewals to confirm that the treatment remains effective and necessary.
Guideline Updates: Medical guidelines and best practices evolve, and renewals help ensure treatment is still consistent with the latest standards.
Cost Review: Renewals allow Cigna to evaluate whether a lower-cost but equally effective alternative has become available.
Typical Renewal Timelines
Every 12 Months: Common for chronic medications or maintenance therapies.
Every 3–6 Months: Often applies to specialty drugs or high-cost treatments.
After Certain Milestones: Renewals may be triggered after a specified treatment phase or when diagnostic tests indicate a change in condition.
Best Practices for Providers
Track Renewal Dates: Use an internal PA calendar or EHR alerts to flag upcoming renewal deadlines.
Start Early: Begin the renewal process at least 30 days before the expiration date to avoid treatment gaps.
Submit Complete Documentation: Include updated medical records, lab results, and specialist notes demonstrating the ongoing need for treatment.
Coordinate with Specialists: If care involves multiple providers, ensure all required documentation is submitted together.
Patient Responsibilities
Stay Informed: Ask your provider when your current PA expires and note the date.
Schedule Follow-Ups Early: If lab tests, imaging, or progress evaluations are needed for renewal, book these appointments before the expiration deadline.
Confirm Submission: Request confirmation from your provider’s office when the renewal has been sent to Cigna, and keep the reference number.
Respond Promptly: If Cigna requests more information, reply as quickly as possible to prevent delays.
Avoiding Gaps in Care
A lapse in prior authorization can interrupt treatment, sometimes with serious consequences. To avoid this:
Monitor Renewal Status: Use Cigna’s member portal to check updates.
Ask About Bridge Prescriptions: In some cases, providers can request a short-term supply to cover you until renewal is approved.
Plan Around Travel: If a renewal date coincides with travel, complete the process early to ensure uninterrupted access to your treatment.
By approaching renewals proactively, both patients and providers can keep treatment plans on track and avoid last-minute complications.
Appealing a Denied Cigna Prior Authorization
If your request is denied:
Read the denial letter to understand the reason.
Gather additional evidence such as updated test results.
Submit an appeal within the stated deadline.
Consider peer-to-peer review between your provider and Cigna’s clinical team.
Technology’s Role in Streamlining Cigna Prior Authorization
EHR Integration: Auto-fills forms with patient data.
Real-Time Status Updates: Lets providers track requests instantly.
Automated Alerts: Reminds teams when renewals are approaching.
Common Challenges with Cigna Prior Authorization and How to Overcome Them
Even with the right tools and preparation, prior authorization requests can run into obstacles. Understanding these challenges and knowing how to address them can make the process significantly smoother.
Challenge 1: Incomplete or Missing Documentation
A missing lab report, incomplete form, or omitted diagnosis code can cause Cigna to delay or deny a request.
Solution:
For Providers: Use a standardized checklist for each type of request to ensure all necessary documents are included.
For Patients: Ask your provider if all documentation has been sent, and request copies for your records.
Challenge 2: Miscommunication Between Provider and Cigna
Sometimes, requests for more information aren’t relayed quickly, resulting in unnecessary delays.
Solution:
Centralized Communication: Providers should assign a single team member to handle all PA-related interactions with Cigna.
Patient Follow-Up: Patients should check in regularly with both their provider and Cigna to confirm status updates.
Challenge 3: Delays in Urgent Cases
Even expedited requests can stall if supporting evidence is insufficient or if the urgency isn’t clearly stated.
Solution:
Clearly Mark Requests as Urgent: Include documentation explaining the time-sensitive nature of the case.
Submit Electronically: Use Cigna’s ePA (electronic prior authorization) system to cut processing time.
Challenge 4: Plan-Specific Coverage Rules
What’s approved under one Cigna plan may be denied under another due to differences in coverage.
Solution:
Check Criteria Before Prescribing: Providers should verify the plan’s PA requirements before making a treatment decision.
Prepare for Appeals: If denied, review the reason carefully and submit additional documentation directly addressing the plan’s criteria.
Challenge 5: Missed Renewal Deadlines
Renewal delays are a common cause of treatment interruption, particularly for long-term medications.
Solution:
Start Early: Both patients and providers should begin renewal paperwork at least 30 days before expiration.
Set Reminders: Digital calendars and EHR alerts can prevent oversights.
Practical Tips for a Smoother Process
Document Everything: Keep records of all calls, emails, and letters exchanged with Cigna.
Stay Proactive: Don’t wait for Cigna to request more information — provide complete details upfront.
Leverage Technology: Use online tools to track status and avoid phone delays.
By anticipating common challenges and taking preventative action, both patients and providers can significantly improve approval rates and turnaround times, ensuring timely access to needed care.
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