As a result, Cigna Commercial and Cigna Medicare Advantage plan to make the following changes on May 12, 2023:
Tag: Referral
Five (5) Tips for Tightening Referrals
When a patient leaves your office with a referral slip, it should represent the start of seamless specialty care. Too often, though, the process falls apart. Patients forget to schedule, specialists never send notes back, or documentation gaps raise liability concerns. The result? Fragmented care, frustrated patients, and potential revenue leakage for your practice. By rethinking how referrals are handled, physicians and administrators can strengthen continuity of care, reduce risks, and make the process smoother for everyone involved. Here are five strategies to tighten up your referral process.
Standardize your referral protocols.
Without a consistent system, referrals can become a patchwork of individual physician habits. Establishing clear protocols, such as using a referral checklist or template, helps reduce variation and improves reliability. Standardization also supports quality initiatives and payer requirements. One practice leader told Physicians Practice that creating uniform workflows was key to making sure payers actually paid for the care provided, underscoring the financial upside of consistency
Lean into data-driven decision support
Referrals don’t have to be based on gut instinct or habit alone. Practices can use analytics to weigh outcomes data, proximity, and even HEDIS scores when deciding which specialist to send patients to. This kind of data-driven approach has been shown to reduce unnecessary costs and improve patient satisfaction.
Use AI to prescreen and prioritize requests
Artificial intelligence is starting to take on a supportive role in referral management. For example, some health systems are testing AI models that prescreen referral requests and flag the ones most likely to need urgent specialist care. That means physicians can focus attention on complex cases while routine referrals move more efficiently.
Improve communication and tracking with colleagues
Even the best referral can fail if the patient never makes the appointment—or if the referring doctor never sees the specialist’s notes. Research shows nearly a third of patients over 65 never follow through with their referrals. Better communication between practices, whether through shared EHR systems, referral dashboards, or simple follow-up calls, can close that loop.
and they’ve also pointed out that stronger collaboration between physicians can keep patients from slipping through the cracks.
Document your referral rationale thoroughly
Liability issues around referrals often stem from documentation—or the lack of it. Recording why you referred, what diagnostic steps came first, and whether you received and reviewed the specialist’s notes is crucial. Some practices use a “rule of three,” referring only after three visits without resolution, to provide consistency and documentation clarity.
Availity Portal Issues
It appears that Availity is having some issues.
If you have went in to Availity to complete an action, and it has your physician’s specialty wrong, this is an Availity issue. It seems to be across multiple insurances.
Please call Availity Customer Service (800) 282-4548.
POET is being told, it is not a credentialing or Healthplan issue.
Cigna CoVid Coverage Changes
Changes in coverage effective May 12, 2023
The White House has announced their intent to end both the CoVid-19 National Emergency and Public Health Emergency (PHE) on May 11, 2023.
- Authorizations for facility-to-facility transfers will again be required.
- Patient cost-share will apply to COVID-19 lab tests as well as antiviral and therapeutics approved by the U.S Food & Drug Administration (FDA).
- For most benefit plans, COVID-19 vaccines will be covered at 100 percent under the preventive benefit (same as the flu shot) when customers go to an in-network provider.
- Over-the-counter COVID-19 tests will no longer be covered.
Cigna Coverage Changes
TX Resources for Family
Physicians who frequently refer patients to no- and low-cost state services like health insurance and child care will find that easier now that the state has launched familyresources.texas.gov, a website that puts links to those services all in one place.
Cigna Medicare HSConnect Portal
Cigna MA has reported two known issues with HSConnect.
- Referrals are pending unnecessarily.
- The procedure start and end date are defaulting to the same day.
An expected date for resolution has not been provided.
But there is good news (tongue in cheek) the PHE has been extended. Therefore, referrals are still waived. Those items requiring precertification will continue to need an authorization.
PHE Extended
July 15th, Secretary of Health and Human Services, Xavier Becerra renewed the determination that a public health emergency exists. This will add another 90 days, extending the PHE through October 13, 2022
PHE Extended
Cigna Continues CoVid Accommodations
Over-the-counter testing
Consistent with new federal guidelines for private insurers, Cigna commercial will cover up to eight over-the-counter (OTC) diagnostic COVID-19 tests per month (per enrolled individual) with no out-of-pocket costs for the tests. This coverage began January 15, 2022 and continues through the end of the PHE (currently through April 15, 2022).
Please note that while Cigna Medicare Advantage plans do fully cover the costs for COVID-19 tests performed in a clinical setting, costs of at-home COVID-19 tests are not a covered benefit at this time.
Additionally, we encourage you to remind your patients that the Federal Government is now offering four free at-home test kits per household with no cost. Your patients can order the free at-home COVID-19 testing kits at COVIDtests.gov.
Coverage of COVID-19 treatments
As a reminder, Cigna commercial and Cigna Medicare Advantage cover FDA emergency use authorized (EUA) treatments of COVID-19, including monoclonal antibody treatments. This includes new antiviral medications PaxlovidTM and molnupiravir, as well as Remdesivir infusions when administered in an inpatient or outpatient setting.
Get all the most up-to-date information
We updated our dedicated COVID-19 provider web page on January 21, 2022 to highlight these updates more. You can also access the latest Cigna Medicare Advantage billing guidelines from this page. Please visit the site often to get the latest information.
POET Is Seeing a Trend, UPDATE
On January 5th, Sir Seymore posted on Ink that POET is seeing a trend from Physician Offices that are trying to get a referral from Cigna MA.
Please scroll down to review that post for details.
POET received this information from Cigna MA: “Unfortunately, we’re experiencing a known enterprise-wide issue within the MHK/HSConnect platform that is affecting how many of our participating specialists are reflecting in the dropdown box or search box when attempting to generate a referral. The MHK/HSConnect team is working towards remediation but I have not yet heard when the expected date for completion might be.”
Just a reminder: SCPs do not need a referral due to the Public Health Emergency (PHE). The PHE has been extended until April 16, 2022.
PCPs and SCPs you are welcome to confirm participation with POET or Leslie.
Per Cigna MA, you should be able to manually enter the specialists’ (SCP) name/NPI for a referral.
Cigna MA, REFERRAL ISSUE
HealthSelect ERS
Effective Sept. 1, 2021, HMO plans will no longer be an enrollment option under the Texas Group Benefit Program. All current subscribers and dependents enrolled in one of the HMO plans will be automatically enrolled in HealthSelect of Texas administered by Blue Cross and Blue Shield of Texas, unless they elect otherwise during their summer enrollment period
Participants who are transitioning from an HMO plan will have a 90-day referral grace period and will receive in-network benefits if they see an in-network specialist without a referral during this timeframe. After Nov. 30, 2021, if there is not a referral on file with BCBSTX, the specialist visit will be covered at the out-of-network benefit level, even if the specialist is in-network.
Effective Sept. 1, 2021, certain procedure codes are being removed from the list of services that require prior authorization for HealthSelect of Texas® & Consumer Directed HealthSelectSM participants. You can review a list of the codes being removed here 
. BCBSTX is currently working on system updates to reflect this change.
Remember to use Availity®
or your preferred vendor to check eligibility and benefits before rendering services. This will help you confirm coverage details and prior authorization requirements and determine if you are in-network for the member’s policy. Refer to Eligibility and Benefits for details.
BCBS Update
Re: Cigna MA Referrals
This is a cut and paste from:
(Revised 04/26/21) The current Public Health Emergency (PHE) period has been extended through 07/20/2021. https://www.phe.gov/emergency/news/healthactions/phe/Pages/COVID-15April2021.aspx
Referral Requirements
In-Network Providers: Referral requirements (if required by customer’s benefit plan) are waived for in-network provider services through 07/20/2021.
Out of Network Providers: Referral requirements (if required by customer’s benefit plan) are waived for out-of-network provider services through 07/20/2021.
Cigna MA Referral Requirements
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