How do I make sure my services are covered or
reimbursed?
Pre-authorization of benefit coverage is not required for outpatient
routine office visits with a CIGNA Behavioral Health contracted
provider. Refer to your plan design, however, as for most other
levels of care, you may need to call us for referral and benefit
authorization first. We want to help ensure eligible services will
be covered and claims handled for you by your contracted behavioral
health professional. On rare occasions when services are not
reimbursed, call us at the number on the back of your ID card.
To make the most of your services, please consider these points:
- If your plan has a benefit differential, be sure you
understand the difference between in-network and
out-of-network coverage. Seeing a behavioral health
professional who participates in CIGNA Behavioral Health's
network may mean you'll pay less and have no paperwork.
- If you don't understand what is and isn't covered by your
plan, call us. We can help explain your eligible coverage,
deductibles and copays, and tell you how to access the kind
of care you need. In addition, read your benefit plan
summary carefully.
Is medication covered?
CIGNA Behavioral Health does not administer the pharmacy benefits
portion of your health plan, but we will work with you to determine
whether any medication prescribed by your psychiatrist or nurse
practitioner will be covered. Call us at the toll-free number on
your insurance ID card.
How can I get sessions covered that have already
occurred?
Pre-authorization of benefit coverage is not required for routine,
outpatient office visits. For all other levels of care,
pre-authorization of coverage may be required, depending on your
plan. Call the toll-free number on your insurance ID card if your
plan does require pre-authorization of coverage for the level of
care that you are seeking. If you do not obtain pre-authorization of
coverage for services that require it, you may be responsible for
some or all of the cost.
What kinds of behavioral health services are
covered?
Behavioral health services are available and covered for a variety
of mental health and substance abuse problems. Your behavioral
health professional will evaluate your needs and determine
treatment. CIGNA Behavioral Health care management staff will
compare the recommended treatment to established Clinical Practice
Guidelines and determine if benefits are available, in accordance
with standard utilization review procedures.
People occasionally ask us about coverage for the following types of
services:
Weight Loss – Weight loss services are not typically covered.
However, services are covered under your behavioral health benefits
for a mental health or substance abuse diagnosis for which weight
loss may be a symptom.
Light Boxes – This is not covered by CIGNA Behavioral Health.
If this is prescribed by a medical doctor, you may want to check
with your medical carrier to see if they will cover it.
Hypnotherapy ("Hypnosis") – Many behavioral health
professionals use hypnotherapy as part of their treatment services.
If the therapist you see uses hypnotherapy for the treatment of a
covered disorder, it may be covered.
Aromatherapy – This type of treatment is considered to be an
experimental treatment, so it would not be covered under your
benefit plan.
Is court-ordered treatment covered?
Not necessarily. Just because treatment is ordered by the court
doesn't guarantee it will be covered under your particular benefit
plan.
Like all mental health or substance abuse treatment, court-ordered
treatment must meet
medical necessity
standards in order to be covered by your benefit plan. Call us at
the toll-free number on your insurance ID card before your first
visit to determine if the court-ordered behavioral health
professional is covered. If your plan requires it, we will
pre-authorize coverage for the assessment. After that initial visit,
your behavioral health professional will make a recommendation and
determine whether ongoing care is medically necessary.
Are psychological tests covered?
It depends on your plan, the type of test, and
medical necessity.
Tests for learning disabilities and intelligence (IQ) tests are NOT
covered. However, federal law requires public school districts to
offer and perform such tests when they are necessary to determine
whether your child is eligible for special education programs.
Are smoking cessation programs or aids like
nicotine patches covered?
Although smoking cessation programs and aids are
rarely covered under medical plans and are NOT a
covered service under CIGNA Behavioral Health's
EAP, there are many community resources that can
help people who are trying to quit. You can find
out more about local programs by calling your
health care provider or the state or local health
department. Information hotlines also provide
quit-smoking materials and referrals:
To find out more about what benefits are available through your
insurance plan, please call the toll-free number on your insurance
ID card.
My state has a law regarding biologically based benefits. What is that?
Some states have passed laws designed to ensure that covered
participants who are diagnosed with a critical mental health
condition receive the same level of benefits as the participant
would expect to receive with a critical physical illness. These
critical mental health conditions are most often referred to in
state laws as "biologically-based" or "serious"
mental illnesses. The law makers, using the same diagnostic
references that mental health professionals use, typically define
these biologically based mental illnesses as: schizophrenia;
schizo-affective disorder; bi-polar disorder; major depressive
disorder; panic disorder; paranoia, delusional and psychotic
disorders; and obsessive-compulsive disorder. Some states, however,
have expanded the list of “biologically based mental illnesses” to
include other conditions such as anorexia-nervosa, bulimia and
post-traumatic stress disorder. In a few unusual states, the list
includes diagnoses related to alcohol and drug abuse. Your state may
have a variation of this type of law with its own, unique list of
covered mental illnesses whose benefit levels are mandated to be
largely similar to the benefit levels for a physical condition.
Because mental illness conditions are diagnosed and treated
differently than physical illnesses, the legislative interpretations
of this concept, "mental illness benefit levels that are
largely similar to those for physical conditions," varies
significantly from state to state. Generally speaking, if you have a
biologically based benefit law in your state that affects your
health plan, you can expect that your plan's cost-sharing provisions
(i.e., co-pays, co-insurance and deductibles) for biologically based
mental conditions will mirror your plan's cost-sharing provisions
for diagnosis and treatment of physical conditions. The intent of
most states' laws is that you, as a covered participant, are not
faced with a greater financial burden for your mental health care
than you are for your physical health care.
To fully understand the terms and conditions of your mental health
coverage, you should consult your plan's written description of
mental health benefits or call the number on your ID card for a
complete and precise description of how, and whether, the laws in
your state affect the health plan provided to you by your employer
or group.
If I must cancel a scheduled appointment, do I
still have to pay the copayment (or cancellation
fee)?
Once you have established a business relationship
with a CIGNA Behavioral Health contracted
behavioral health professional, you are only
liable for charges (including deductibles,
copayments/co-insurance) if you fail to give at
least 24-hour notice of the cancellation.
It is best to notify your behavioral health
professional well in advance of any need to
cancel, as our contracted professionals have the
right to charge you directly for any appointment
missed without 24-hour cancellation notification.
Do I have to pay the bill if the services are not
covered?
We recommend that you always ask about services you are interested
in to make sure they are covered under your specific plan. You can
do this by calling the toll-free number on your insurance ID card.
We also encourage you to read your benefit plan summary for details
of your coverage as you will likely be liable for services that are
not covered or ones that require pre-certification of coverage,
where none was obtained.
What do I do in the case of an emergency?
If you need emergency services please go to the nearest emergency
room or behavioral health facility. We request that you or a
representative call us as soon as possible, preferably within 48
hours, so that we can help you determine the benefits available to
you under your plan. Your plan benefits will apply to services
needed to evaluate or stabilize treatment for a condition that is
reasonably considered to be an emergency behavioral health
condition. Some plans may have a penalty if you do not call within a
certain time frame after admission. Check with your plan if you are
not sure what the requirements are.
This material is provided by CIGNA Behavioral Health, Inc. for
informational/educational purposes only. It is not intended as
medical/clinical advice. Only a healthcare provider can make a
diagnosis or recommend a treatment plan.
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