Skip to main navigation Skip to main content Skip to footer
  • For Individuals & Families
  • For Providers
  • For Brokers
  • For Employers
  • Search
    Search
    Español
  • For Medicare:
  • For Medicare:
  • Shop for Plans

    Shop for Plans

    Medicare Overview
  • Member Resources

    Member Resources and Services

    Overview
    • Online Access to Your Plan
    • myCigna gives you one-stop access to your coverage, claims, ID cards, providers, and more.
    • Log in to myCigna
  • Eligibility & Enrollment

    Eligibility & Enrollment

    Overview
  • Log in to myCigna
  • Log in to myCigna
  • Shop for Plans

    Shop for Plans

  • Member Resources

    Member Resources

  • Eligibility & Enrollment

    Eligibility & Enrollment

  • Find a Doctor
  • Home Medicare Member Resources and Services Organization Determination

    Organization Determination (Medical Prior Authorization)

    Learn how to get an organization determination, also known as a medical prior authorization, for your Medicare Part C plan.

    What is an organization determination?

    An “organization determination,” or medical prior authorization, is a decision we make about your medical benefits and coverage or about the amount we will pay for your medical services. This means we ask our plan to authorize, provide, or pay for medical services. We want to make sure you’re getting the type or level of services you think you should get.

    A Medical Prior Authorization allows Cigna HealthcareSM to:

    • Check that you can get the service you asked for through your benefit package
    • Review services to decide if care is medically necessary for you
    • Review services to make sure they are given by the appropriate provider in an appropriate setting
    • Make sure that ongoing and recurring services are actually helping you

    Some examples of services that may need Medical Prior Authorization are:

    • Home Health Care (HHC)
    • Specialist or Specialty Care Visits (other than your PCP)
    • Infusions
    • Outpatient surgical procedures
    • Durable Medical Equipment (DME)
    • Non-emergent ambulance transport
    • Outpatient diagnostic testing
    • Outpatient therapy

    You can review services that need Medical Prior Authorization within your Evidence of Coverage (EOC).

    Emergency services are not included from prior authorization requirements. An emergency is a medical condition that may cause harm to your health.

    Who can ask for an organization determination or medical prior authorization?

    You can ask us for an organization determination or medical prior authorization for yourself, or your doctor or someone you name may do it for you. The person you name would be your appointed representative. You can name a relative, friend, advocate, doctor, or anyone else to act for you.

    If you want someone to act for you, then you and that person must sign and date the Appointment of Representative form that legally allows that person to act as your appointed representative. This statement must be faxed or mailed to us at the same number or address where you send your organization determination information.

    This form does not have to be filled out if your doctor is sending a request.

    Download an Appointment of Representative form [PDF]

    Who determines my request?

    The Prior Authorization Department is made up of licensed nurses, clinical pharmacists, and doctors. They review requests for authorization using nationally recognized industry standards to decide if the Prior Authorization is medically necessary. Once a decision is made, they will let you and your provider know.

    A Medical Prior Authorization or Organization Determination is not a guarantee that the services are covered. A Prior Authorization is a determination of medical necessity and is not a guarantee of claims payment. Claim reimbursement may be changed by factors such as eligibility, participating status, and benefits at the time the service is rendered.

    How do I get an organization determination or medical prior authorization?

    To start an organization determination, you must file a Preservice Organization Determination, also known as a Prior Authorization Request, by phone, mail, or fax. The prior authorization request will be reviewed to determine if services are covered before they are provided. While your doctor will often help you arrange care and get Prior Authorization, you can send a Prior Authorization request yourself before getting services.

    For Cigna Healthcare Medicare Advantage customers (except Arizona)

    Contact us by mail:
    Cigna Healthcare Medicare
    Attn: Precertification
    PO Box 20002
    Nashville, TN 37202

    Call us: 
    TTY/TDD: 711
    8:00 am - 8:00 pm, 7 days a week

    From April 1 - September 30: Monday - Friday 8:00 am - 8:00 pm. Messaging service used weekends, after hours, and federal holidays.

    By fax:

    For Cigna Healthcare Medicare Advantage customers in Arizona

    Contact us by mail:
    Cigna Healthcare Medicare Services
    Attn: Prior Authorization Dept.
    PO Box 29030
    25500 N. Norterra Drive
    Phoenix, AZ 85085

    Call us:
    TTY/TDD: 711
    8:00 am - 5:00 pm (Mountain time), Monday - Friday

    By fax:

    How long does it take to get?

    A standard decision will be made as fast as your health condition requires, but no later than 14 calendar days after receipt of the request.

    If you need a quicker response because of your health, you should ask our plan to make a Fast Decision. A fast decision will be made as quickly as your health condition requires, but no later than 72 hours after receipt of the request.

    Appeals and Complaints

    If you don’t agree with an organization determination, you have the right to appeal our decision.

    Learn more about appeals

    If you have a complaint, you can send feedback straight to Medicare:

    Questions?

    If you have questions about requirements or want to check on an existing authorization, please reach out to our Customer Service Department at (TTY 711), Oct. 1–March 31: 8 am–8 pm, 7 days a week; April 1–Sept. 30: Mon.–Fri. 8 am–8 pm. A messaging service is used weekends, after hours, and federal holidays.

    Customer Plan Links
  • Choosing a Medicare Plan
  • Contact Cigna Healthcare
  • Disaster Policy
  • Enrollment and Eligibility
  • Filing a Grievance
  • Medicare Appeals Process
  • Medicare Coverage Decisions and Exceptions
  • Medicare Disenrollment
  • Organization Determination
  • Pre-Enrollment Disclaimers
  • Audiences
  • Individuals and Families
  • Medicare
  • Employers
  • Brokers
  • Providers
  • About Cigna Healthcare
  • Other Cigna Healthcare Websites
  • Health Care Providers
  • Pharmacists
  • Pharmacy Residents
  • Group Plans
  • Medicare Links
  • Medicare.gov
  • Medicare Ombudsman
  • Medicare Complaint Form
  • Cigna Healthcare. All rights reserved.
  • Privacy
  • Legal
  • Medicare Supplement State Disclosures
  • Customer Rights
  • Accessibility
  • Notice of Nondiscrimination
  • Language Assistance [PDF]
  • Report Fraud
  • Sitemap
  • Cookie Settings
  • Medicare Advantage and Medicare Part D Policy Disclaimers

    Cigna Healthcare products and services are provided exclusively by or through operating subsidiaries of The Cigna Group. The Cigna Healthcare names, logos, and marks, including THE CIGNA GROUP and CIGNA HEALTHCARE are owned by The Cigna Group Intellectual Property, Inc. Subsidiaries of The Cigna Group contract with Medicare to offer Medicare Advantage HMO and PPO plans and Part D Prescription Drug Plans (PDP) in select states, and with select State Medicaid programs. Enrollment in a Cigna Healthcare product depends on contract renewal.

    To file a marketing complaint, contact Cigna Healthcare or call 1-800-MEDICARE (), 24 hours a day, 365 days a year, TTY . Please include the agent/broker name if possible.

    Medicare Supplement Policy Disclaimers

    Medicare Supplement website content not approved for use in: Oregon.

    AN OUTLINE OF COVERAGE IS AVAILABLE UPON REQUEST. We'll provide an outline of coverage to all persons at the time the application is presented.

    Our company and agents are not connected with or endorsed by the U.S. Government or the federal Medicare program. This is a solicitation for insurance. An insurance agent may contact you. Premium and benefits vary by plan selected. Plan availability varies by state. Medicare Supplement policies are underwritten by Cigna National Health Insurance Company, Cigna Health and Life Insurance Company, American Retirement Life Insurance Company or Loyal American Life Insurance Company. Each insurer has sole responsibility for its own products.

    The following Medicare Supplement Plans are available to persons eligible for Medicare due to disability: Plan A in Arkansas, Connecticut, Indiana, Maryland, Oklahoma, Texas, and Virginia; Plans A, F, and G in North Carolina; and Plans C and D in New Jersey for individuals aged 50-64. Medicare Supplement policies contain exclusions, limitations, and terms under which the policies may be continued in force or discontinued. For costs and complete details of coverage, contact the company.

    This website is designed as a marketing aid and is not to be construed as a contract for insurance. It provides a brief description of the important features of the policy. Please refer to the policy for the full terms and conditions of coverage.

    In Kentucky, Plans A, F, G, HDG, N are available under Cigna National Health Insurance Company, Plans A, F, G, HDF, N are available under Cigna Health and Life Insurance Company and Plans A, B, C, D, F, G, N are available under Loyal American Life Insurance Company.

    Kansas Disclosures, Exclusions and Limitations

    Medicare Supplement Policy Forms: Plan A: CNHIC-MS-AA-A-KS, CNHIC-MS-AO-A-KS; Plan F: CNHIC-MS-AA-F-KS, CNHIC-MS-AO-F-KS; Plan G: CNHIC-MS-AA-G-KS, CNHIC-MS-AO-G-KS; Plan N: CNHIC-MS-AA-N-KS, CNHIC-MS-AO-N-KS

    Exclusions and Limitations:

    The benefits of this policy will not duplicate any benefits paid by Medicare. The combined benefits of this policy and the benefits paid by Medicare may not exceed one-hundred percent (100%) of the Medicare Eligible Expenses incurred. This policy will not pay benefits for the following:

    (1) the Medicare Part B Deductible;

    (2) any expense which You are not legally obligated to pay; or services for which no charge is normally made in the absence of insurance;

    (3) any services that are not medically necessary as determined by Medicare;

    (4) any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid); or for which payment would have been made by Medicare if You were enrolled in Parts A and B of Medicare;

    (5) any type of expense not a Medicare Eligible Expense except as provided previously in this policy;

    (6) any deductible, Coinsurance or Co-payment not covered by Medicare, unless such coverage is listed as a benefit in this policy; or

    (7) Preexisting Conditions: We will not pay for any expenses incurred for care or treatment of a Preexisting Condition for the first six (6) months from the effective date of coverage. This exclusion does not apply if You applied for and were issued this policy under guaranteed issue status; if on the date of application for this policy You had at least six (6) months of prior Creditable Coverage; or, if this policy is replacing another Medicare Supplement policy and a six (6) month waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for this policy. If You had less than six (6) months prior Creditable Coverage, the Preexisting Conditions limitation will be reduced by the aggregate amount of Creditable Coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied.

    Selecting these links will take you away from Cigna.com to another website, which may be a non-Cigna Healthcare website.

    Y0036_24_1037312_M | Page last updated 01/01/2024

    MS-SITE-AllHome2022