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Forms and Practice Support
FORMS AND PRACTICE SUPPORT
Policy Summary – July 2022
Prior Authorizations
- Cigna provides up-to-date prior authorization requirements at your fingertips, 24/7, to support your treatment plan, cost effective care and your patients’ health outcomes.
- If prior authorization cannot be obtained timely, be sure to notify Cigna or the delegated UM agent and the appropriate participating provider as soon as possible (but no later than 24 hours after ordering or providing the covered service, or on the next business day). Check prior authorization requirements regularly and prior to delivering planned services at MedicareProviders.Cigna.com > Prior Authorization Requirements.
- Home health agencies have 7 calendar days from the initial visit to establish the care plan and must include all visits needed to establish the plan of care specific to the customer’s needs when requesting authorization.
Admission Notifications
- Admission notification for emergent or urgent admission is required within 24 hours of admission or next business day, whichever was later, even when the admission was prescheduled.
You can avoid adverse determinations and disruptions in your treatment plans by revisiting prior authorization requirements regularly and ensuring timely notification for admissions.
Complete policy details are available at MedicareProviders.Cigna.com > Provider Manual
Appeals and Dispute Forms
Contracted Providers
- Contracted Post Service Appeal and Claim Dispute Form [PDF]
- Contracted Post Service Appeal and Claim Dispute Form [PDF] (AZ Only)
Non Contracted Providers
Network Interest Forms - Facility/Ancillary
- Alabama, North Florida, and Southern Mississippi [PDF]
- Arkansas [PDF]
- Colorado, New Mexico, Oregon, Utah, and Washington [PDF]
- Connecticut [PDF]
- Delaware, Maryland, New Jersey, Pennsylvania, Virginia, and Washington DC [PDF]
- Florida - Central [PDF]
- Florida - South [PDF]
- Georgia [PDF]
- Illinois [PDF]
- Kansas City [PDF]
- North Carolina and South Carolina [PDF]
- Ohio [PDF]
- Oklahoma and Texas [PDF]
- St. Louis [PDF]
- Tennessee [PDF]
- Vermont [PDF]
Network Interest Forms - Practitioner
- Alabama, North Florida, and Southern Mississippi [PDF]
Note: This dynamic PDF form will not open and display properly in your browser.
To use this form as intended, right click on the link, chose “Save link as,” and download the PDF to your computer. Open the file in your PDF viewer application to fill out the form and submit your request. - Arkansas [PDF]
- Colorado, New Mexico, Oregon, Utah, and Washington [PDF]
- Connecticut [PDF]
- Delaware, Maryland, New Jersey, Pennsylvania, Virginia, and Washington DC [PDF]
- Florida - Central [PDF]
- Florida - South [PDF]
- Georgia [PDF]
- Illinois [PDF]
- Kansas City [PDF]
- North Carolina and South Carolina [PDF]
- Ohio [PDF]
- Oklahoma and Texas [PDF]
- St. Louis [PDF]
- Tennessee [PDF]
- Vermont [PDF]
Part B Drugs/Biologics
2023
Drugs/Biologics Part B Step Therapy Quick Reference Guides
- Part B Step Therapy Quick Reference Guide [PDF] Effective 1/1/2023
Drugs/Biologics Part B Precertification Forms
- Drugs/Biologics Part B Precertification Form [PDF]
- Durable Medical Equipment (DME) Diabetic Testing Supplies Request [PDF]
Drugs/Biologics Part B Step Therapy Precertification Forms
- Avastin [PDF]
- Eylea, Lucentis, Beovu, Vabysmo, Byooviz, and Cimerli [PDF]
- Herceptin [PDF]
- Monoferric, Feraheme, and Injectafer [PDF]
- Neupogen, Granix, and Releuko [PDF]
- Remicade [PDF]
- Rituxan [PDF]
- Udenyca Fulphila [PDF]
- Viscosupplement [PDF]
2022
Drugs/Biologics Part B Step Therapy Quick Reference Guides
- Part B Step Therapy Quick Reference Guide [PDF] Effective 10/1/2022
Drugs/Biologics Part B Precertification Forms
- Drugs/Biologics Part B Precertification Form [PDF]
- Durable Medical Equipment (DME) Diabetic Testing Supplies Request [PDF]
Drugs/Biologics Part B Step Therapy Precertification Forms
Practice Support
- 360 Annual Wellness Exam [PDF] UPDATED 1/2022
- Access and Availability Survey Standards – Medical Providers [PDF]
- Behavioral Health
- Cigna Medicare ID Cards [PDF]
- Clinical Practice Guidelines – 2022 [PDF]
- Medicare Seasonal Vaccine Coverage, Reimbursement, and Patient Education Information [PDF]
- Patient Support Programs
- Physician Notice to Discharge Customer from Panel Form [PDF]
- PPO In and Out-of-Network Guide [PDF]
- Provider Directory
- Provider Online Portal – Claimstat MCIS (Arizona only)
- Provider Online Portal – HSConnect
- Quick Reference Guide
- Quick Reference Guide – Oncology [PDF]
- Special Needs Plans Model of Care Training
- Stay Informed – Provider Updates
Prior Authorization Request Forms
- Drug Prior Authorization Request Forms Coverage Determinations
- Inpatient Admission Request Form [PDF]
- Prior Authorization Request Form [PDF]
- Prior Authorization Request Form – Durable Medical Equipment (DME) [PDF] Updated 5/27/2022
- Prior Authorization Request Form – Durable Medical Equipment (DME) [PDF] (AZ Only)
- Prior Authorization Request Form – Home Health Care (HHC) [PDF] Updated 5/27/2022
- Prior Authorization Request Form – Home Health Care (HHC) [PDF] (AZ Only)
- Prior Authorization Request Form – Orthopedic Spine Procedures
- Note: This dynamic PDF form will not open and display properly in your browser.
To use this form as intended, right click on the link, chose “Save link as,” and download the PDF to your computer. Open the file in your PDF viewer application to fill out the form and submit your request. Download Orthopedic Spine Procedure Prior Authorization Request Form [PDF]
- Note: This dynamic PDF form will not open and display properly in your browser.
- Prior Authorization Request Form – Post-Acute Care Initial Request [PDF] Updated 5/27/2022
- Prior Authorization Request Form – Post-Acute Care Concurrent Review [PDF] Updated 5/27/2022
- Prior Authorization Request Form – Transplant [PDF]
Prior Authorization Requirements
2022
- Prior Authorization Requirements – October 2022 [PDF] NEW
- Prior Authorization Requirements – July 2022 [PDF]
- Prior Authorization Requirements – April 2022 [PDF] - Updated June 1, 2022
- Prior Authorization Requirements – January 2022 [PDF]
2021
- Prior Authorization Requirements – October 2021 [PDF]
- Prior Authorization Requirements – July 2021 [PDF]
- Prior Authorization Requirements – April 2021 [PDF]
- Prior Authorization Requirements – January 2021 [PDF]
2020
- Prior Authorization Requirements – October 2020 [PDF]
- Prior Authorization Requirements (Arizona only) [PDF]
- Prior Authorization Requirements – July 2020 [PDF]
- Prior Authorization Requirements – April 2020 [PDF]
- Prior Authorization Requirements – January 2020 [PDF]
- Prior Authorization Requirements – October 2019 [PDF]
Provider Information Change Forms
- Alabama, Georgia, North Carolina, North Florida, South Carolina,and South Mississippi [PDF]
- Arizona [PDF]
- Colorado, New Mexico, and Utah [PDF]
- Delaware, Maryland, New Jersey, Pennsylvania, and Washington DC [PDF]
- Illinois [PDF]
- Kansas City and Missouri [PDF]
- Tennessee [PDF]
- Texas [PDF]
- Texas MMP/Texas StarPlus [PDF]