Blank Cigna Prior Auth Template

The Cigna Prior Authorization Form is a critical document used by healthcare providers to request approval for specific medications before the insurance company will cover the costs. Completing this form accurately is essential to ensure timely processing of medication requests. For a smooth experience, fill out the form by clicking the button below.

Article Guide

When navigating the complexities of prescription medication approvals, the Cigna Prior Authorization form plays a crucial role for both healthcare providers and patients. This essential document is designed to streamline the process of obtaining necessary medications while ensuring that the treatment is medically appropriate and aligned with Cigna's coverage policies. The form captures critical information, such as the physician's and patient's details, the requested medication's specifics, and the urgency of the request. For urgent cases, there is a designated phone number to expedite the process, highlighting the importance of timely access to healthcare. Additionally, significant sections inquire about alternative medications and any previous treatments, which help create a comprehensive profile of the patient's medical history. By including these details, healthcare providers can present a compelling case for the necessity of the requested drug. A quick submission option is available online, further enhancing efficiency in an era where time is often of the essence. Overall, understanding the major aspects of the Cigna Prior Authorization form can be a powerful tool for healthcare providers in securing timely and effective treatments for their patients.

Form Sample

Fax completed form to: (855) 840-1678

If this is an URGENT request, please call (800) 882-4462 (800.88.CIGNA)

Medication Prior

Authorization Form

PHYSICIAN INFORMATION

PATIENT INFORMATION

* Physician Name:

*Due to privacy regulations we will not be able to respond via fax

with the outcome of our review unless all asterisked (*) items on

Specialty:

* DEA or TIN:

this form are completed.*

Office Contact Person:

* Patient Name:

Office Phone:

* Cigna ID:

* Date of Birth:

Office Fax:

* Patient Street Address:

Office Street Address:

City:

State:

Zip:

City:

State:

Zip:

Patient Phone:

Urgency:

Standard

Urgent (In checking this box, I attest to the fact that applying the standard review time frame may

seriously jeopardize the customer’s life, health, or ability to regain maximum function)

Medication requested: (please specify name, strength, and dosing schedule)

Duration of therapy:

Quantity:

Diagnosis related to use:

[For pain medications only]: Does the patient have a terminal illness?

Yes

Alternative Medications:

Has your patient ever received the generic alternative of the requested medication?

Yes

No generic available

(if yes) Did your patient try more than one manufacturer of this generic?

Yes

Unavailable

Please provide the following details for each trial: manufacturer name, date(s) taken and for how long, and what the documented results were of taking the drug, including any intolerances or adverse reactions your patient experienced.

(please note that the manufacturer's information can be obtained through the dispensing pharmacy):

Drug Name	Dates taken & how long	Documented results, including intolerances/adverse
Drug Name	Dates taken & how long	reactions the patient experienced
		reactions the patient experienced




Has your patient ever received any other alternative treatments for this diagnosis?			Yes	No
(if yes) Please provide the following details: date(s) taken and for how long, and what the documented results were of taking
this drug, including any intolerances or adverse reactions your patient experienced:
Drug Name	Dates taken & how long	Documented results, including intolerances/adverse
Drug Name	Dates taken & how long	reactions the patient experienced
		reactions the patient experienced




(if no to any question above) Is your patient able to use any other alternatives for this diagnosis?			Yes	No

(if no) Please provide the reason(s) why your patient is unable to use the available alternative(s):

Additional pertinent information: (please include other clinical reasons for drug, relevant lab values, etc.)

Save Time! Submit Online at: www.covermymeds.com/main/prior-authorization-forms/cigna/ or via SureScripts in your EHR.

Our standard response time for prescription drug coverage requests is 5 business days. If your request is urgent, it is important that

you call us to expedite the request. View our Prescription Drug List and Coverage Policies online at cigna.com.

v091619

“Cigna" is a registered service mark, and the “Tree of Life” logo is a service mark, of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include, for example, Cigna Health and Life Insurance Company and Cigna Health Management, Inc. Address: Cigna Pharmacy Services, PO Box 42005,

Phoenix AZ 85080-2005

⇩ PDF

Document Specifications

Fact Name	Details
Submission Method	The completed Cigna Prior Authorization form can be submitted via fax to (855) 840-1678. Additionally, there is an option to submit online at www.covermymeds.com.
Urgent Requests	For urgent requests, it is advised to call (800) 882-4462. The urgency classification is crucial, as it directly affects the review time frame.
Patient Privacy	Due to regulations protecting patient privacy, the outcome of the review cannot be communicated via fax unless all required information marked with an asterisk is provided.
Standard Response Time	The standard response time for prescription drug coverage requests is typically 5 business days. Urgent requests are prioritized and handled more swiftly.
Coverage Policies	Details regarding medication coverage and policies can be found online at cigna.com. Understanding these policies can streamline the authorization process.
Governing Laws	Each state may have specific laws related to prior authorizations, so it is essential to check for state-specific regulations that govern these processes.

Steps to Filling Out Cigna Prior Auth

Once the Cigna Prior Authorization form is filled out, it must be submitted for review. An accurate and complete form facilitates quicker processing. Be sure to follow the steps below carefully to ensure your submission is successful.

Gather necessary information. Before starting, ensure you have all the required details about the physician and patient at hand.
Fill in physician information. Include the physician's name, specialty, DEA or TIN, office contact person, phone number, fax number, and office address.
Complete patient information. Input the patient's name, Cigna ID, date of birth, street address, city, state, zip code, and phone number.
Select urgency level. Indicate whether the request is standard or urgent by checking the corresponding box. If marking urgent, be mindful of the implications.
Detail medication requested. Clearly specify the name, strength, and dosing schedule of the medication in need of authorization.
Provide therapy duration. Indicate how long the therapy will be needed along with the quantity of medication requested.
State the diagnosis. Clearly explain the diagnosis related to the medication's use, particularly for pain medications.
Address terminal illness. Answer whether the patient has a terminal illness by selecting “Yes” or “No.”
List alternative medications. Indicate if the patient has tried the generic alternative. Provide details on any trials with the generic, including manufacturer names and documented results.
Detail alternative treatments. If applicable, explain any alternative treatments the patient has undergone, making sure to list relevant details and outcomes.
Describe patient alternatives. If the patient cannot use alternatives, clearly state the reasons.
Add additional information. Include any pertinent clinical information, lab values, or other relevant details that support the request.
Submit the form. Fax the completed form to (855) 840-1678. For urgent requests, call (800) 882-4462. Alternatively, consider submitting online for efficiency.

More About Cigna Prior Auth

What is the purpose of the Cigna Prior Authorization form?

The Cigna Prior Authorization form is used to request prior approval for certain medications that Cigna may require before covering the cost. This process helps ensure that the medication is medically necessary for the patient’s condition.

How do I submit the Cigna Prior Authorization form?

You can submit the completed form by faxing it to (855) 840-1678. For urgent requests, it is recommended to call (800) 882-4462. Additionally, forms can be submitted online through CoverMyMeds or via SureScripts in your EHR, which may save time.

What information is required on the form?

Important details needed include the physician's name, patient’s Cigna ID, date of birth, and contact information. The form must also specify the requested medication, duration of therapy, and diagnosis related to the use of the medication. Ensure all required fields are filled out, as incomplete forms may delay processing.

What happens after I submit the form?

Once the form is submitted, Cigna will review the information provided. The standard response time for requests is typically 5 business days. If you submitted an urgent request, the review process may be expedited. However, outcomes will only be communicated via phone call if privacy regulations are met.

What should I do if the patient’s medication is not approved?

If a medication is not approved, you may receive a notice explaining the reason. In such cases, you might consider discussing alternative medications with the physician or reviewing other treatment options that could be more suitable for the patient’s needs.

Can I appeal the decision if the prior authorization is denied?

Yes. If the prior authorization request is denied, you can initiate an appeal. It is important to gather relevant documentation and communicate effectively with Cigna regarding the necessity of the medication for the patient’s health condition.

Is there a way to ensure faster processing of the prior authorization request?

For quicker processing, ensure that all mandatory fields on the form are completed accurately. Also, if the request is urgent due to serious health concerns, calling Cigna directly can expedite the review process. Utilizing online submission options may also enhance response times.

Common mistakes

Incomplete Information: One of the most common mistakes is failing to fill in all required fields, particularly those marked with an asterisk (*). This includes essential details about the physician and patient that are crucial for processing the request.
Lack of Documentation: Not providing adequate documentation of previous treatments or alternative medications can lead to delays. Be sure to list specifics about any past medications, including manufacturer details and patient responses.
Urgency Misclassification: Choosing 'Standard' instead of 'Urgent' incorrectly can slow down the process. It's essential to accurately assess the patient's condition and mark the appropriate urgency level if the situation is critical.
Ignoring Additional Information Space: Some may overlook the section for additional pertinent information, which can be an opportunity to include clinical reasons or relevant lab values that support the medication request.
Not Using Online Submission: Submitting paper forms instead of utilizing the online option may prolong processing times. Online submissions can be faster and more efficient.
Contact Information Errors: Providing incorrect contact details may result in communication issues. Ensure that the office phone and fax numbers are accurate so that Cigna can follow up if needed.

Documents used along the form

When seeking prior authorization from Cigna, various forms and documents may accompany the Cigna Prior Authorization Form. Each of these documents serves a specific purpose and helps facilitate the review process.

Medication Therapy Management Form: This document assesses the patient's medications to ensure they are effective and safe. It includes a summary of all current medications and evaluates potential interactions.
Clinical Summary: A concise overview of the patient's medical history, treatment progression, and relevant clinical findings. It provides context for the requested medication and justifies its necessity.
Lab Results: Relevant laboratory tests may need to be submitted to support the prior authorization request. These results help establish the diagnosis and the need for the prescribed medication.
Patient Consent Form: This form grants permission to share the patient's health information among healthcare providers and insurers. It is crucial for complying with privacy regulations.
Alternative Treatment Documentation: This document outlines any previous treatments and medications attempted for the diagnosis. It provides evidence that the requested medication is necessary after other options have failed.
Medical Necessity Letter: A letter from the prescribing physician that explains why the specific medication is medically necessary for the patient, including potential risks of not providing it.
Insurance Information: Proof of coverage details, such as a copy of the patient's insurance card or relevant identification numbers, ensuring the request is properly processed.

Completing and submitting these documents accurately ensures a smoother prior authorization process. Each piece of information contributes to establishing a compelling case for the requested treatment. Patience and thoroughness during this process can greatly affect patient care outcomes.

Similar forms

The Cigna Medication Prior Authorization Form is similar to the Blue Cross Blue Shield Prior Authorization Form. Both documents serve the purpose of ensuring that specific medications are medically necessary before they are covered by insurance. Each form requires detailed patient and physician information, including the reason for the medication request and the patient’s history with alternative treatments. This process promotes a thorough review to confirm that the prescribed medication is the most suitable option for the patient's needs.

Another document resembling the Cigna form is the Aetna Prior Authorization Request Form. Like Cigna's, Aetna's form is designed to assess whether a medication meets the criteria set forth by the insurance provider. Similar sections in both forms ask for patient demographics, prescribed medications, dosage, and previous medication trials. The goal is to provide the insurance provider with all necessary information to make an informed decision about coverage, ensuring patient safety while managing costs.

The UnitedHealthcare Prior Authorization Form also shares similarities with the Cigna form. The structure of both documents includes sections for physician details, patient information, and specific medication inquiries. Each requires an explanation of the urgency of the request and any alternative medications the patient may have tried. This redundant collection of information helps streamline the approval process for medications by making sure that all relevant data is provided upfront.

Finally, the Humana Prior Authorization Form mirrors the aspects of the Cigna Medication Prior Authorization Form. Each document includes common elements such as detailed inquiries into previous treatment failures and clinical justification for the requested medication. By doing so, both forms aim to establish medical necessity, allowing insurers to make informed and timely decisions about patient care. This encourages appropriate medication use, aligning with the best practices in healthcare management.

Dos and Don'ts

When filling out the Cigna Prior Authorization form, it is important to approach the process carefully. Here are nine helpful dos and don’ts to guide you.

Do ensure all required fields with asterisks (*) are completed. This is vital for processing your request.
Don’t skip the urgency question. Indicate if your request is standard or urgent, as this can affect response times.
Do provide precise medication details. Include the name, strength, and dosing schedule to avoid confusion.
Don’t forget to check if alternatives have been tried. Providing this information can expedite your request.
Do include any relevant clinical information. Additional details may support your case for approval.
Don’t submit without reviewing the form. Double-check for any errors or incomplete sections before sending it.
Do save time by submitting online if possible. Use the provided online link for a quicker response.
Don’t rely solely on fax submission. While it is an option, exploring online submission can lead to faster processing.
Do keep a copy of the completed form for your records. This can be helpful for follow-up inquiries.

Following these guidelines can help ensure a smoother experience when submitting the Cigna Prior Authorization form. Being thorough and attentive to detail will benefit both you and your patient.

Misconceptions

Understanding the Cigna Prior Authorization form can be challenging. Here are 10 common misconceptions about the form, along with clarifications:

Only doctors can submit the Prior Auth form.
While the form must be filled out by a physician, office staff can assist with submission on behalf of the physician.
The fax number is the only way to submit the form.
You can also submit the form online through Cigna's website, which may save time.
All fields on the form must be completed.
Only the fields marked with an asterisk (*) are mandatory. Missing information in non-required fields will not hinder the submission.
Cigna will always provide an immediate response.
The standard response time is 5 business days, unless the request is classified as urgent.
Urgent requests must always be faxed.
For urgent requests, it is advised to call Cigna directly to expedite the process.
Only brand-name medications require Prior Authorization.
Generic medications may also require authorization, depending on Cigna's policies.
The form guarantees approval of requested medication.
Submission of the form does not guarantee approval; it initiates the review process.
Cigna will communicate results via fax.
Due to privacy regulations, Cigna cannot respond via fax unless all required fields are completed.
Patients need to follow up on every submission.
Generally, Cigna will notify the healthcare provider once a decision has been made but follow-up may be necessary in some cases.
Patients cannot provide additional information.
Patients can share pertinent information with their healthcare provider to assist in completing the form.

Key takeaways

Here are some key takeaways for filling out and using the Cigna Prior Authorization form:

Complete all required fields: All items marked with an asterisk (*) must be filled out to ensure a timely response.
Fax number: Send the completed form to (855) 840-1678. Use this line for standard requests.
Urgent requests: For urgent situations, it’s crucial to call (800) 882-4462 to expedite processing.
Online submission: Save time by submitting the form online at www.covermymeds.com or via SureScripts in your electronic health record (EHR).
Response time: Expect a response within 5 business days for standard requests; following up on urgent requests is highly recommended.