Providers that participate in a health maintenance organization (HMO) network are required to arrange and deliver medically necessary services in a timely manner consistent with state and federal time frames and geographic access standards. In urgent situations, individuals must also be able to receive timely access to medical and behavioral care, regardless of whether it is in network, out of network, or out of the service area.

Services that are the financial responsibility of Cigna Healthcare

When your patient requires urgent, medically necessary care by a nonparticipating or out-of-area provider and, based on your medical group’s contracted division of financial responsibility (DOFR), you believe the services rendered are the financial responsibility of Cigna Healthcare, please include the following details when submitting a claim to us:

• Add place of service (POS) code POS-20 to indicate services were rendered in an urgent care facility.
• If applicable, add “Seen by another provider in the office due to urgent care/physician on call covered for assigned PCP.”

Whether Cigna Healthcare or your group is financially responsible for your patient’s urgent, medically necessary care, it is still your responsibility to ensure it is arranged within the time frame and geographic standards required by law.