CIGNA network doctors responsible for precertification in 2010
Faculty and staff covered by any of Purdue's medical plans in 2010 have a new partner when it comes to precertifying inpatient care and other health care services requiring advance approval.
In the past, precertification has been solely the employee's responsibility. Under the CIGNA system, if a patient uses a CIGNA network provider, the provider will work with CIGNA to arrange precertification. If the patient is using the services of an out-of-network provider, the employee remains responsible for obtaining precertification.
"It's one less thing for our employees and their families to worry about," said John Beelke, director of the Staff Benefits and WorkLife Programs units, noting that the $250 penalty imposed in the past if the employee failed to precertify has been eliminated. "CIGNA will still need to approve the service before a benefit will be paid, but the penalty for failing to get advance approval is gone."
CIGNA requires precertification for hospital admissions and selected outpatient services. During the precertification process, a CIGNA nurse evaluates requests using nationally recognized guidelines that include input from actively practicing health care providers.
CIGNA nurses determine what services are covered based on the patient's medical plan benefits and the guidelines. When guidelines don't exist, the nurses use resource tools based on clinical evidence.
Anytime a CIGNA nurse is unable to approve coverage for clinical reasons, the nurse refers the case to a CIGNA doctor. The doctor may speak with the patient's doctor to obtain additional information. CIGNA will provide written notification to the covered employee and the patient's doctor if a precertification request cannot be approved.
Examples of common procedures, treatments, and services requiring precertification are:
* All inpatient admissions and non-obstetric observation stays.
* Potentially experimental or investigational procedures.
* Potentially cosmetic procedures.
* Maternity stays longer than 48 hours for vaginal delivery or 96 hours for cesarean delivery.
* Back surgery.
* MRIs, MRAs, CT/CAT scans, PET scans.
* Speech therapy.
* Injectable drugs.
This list does not include all services requiring precertification. For more information, visit www.myCIGNA.com.