How Long Does Cigna Approval Take ?

[bella143 8]

Oh yes' date=' they approve on the first time too. Believe it or not.

My case was a little different. I'm a revision: previously had a band (under UHC), had the band removed (under Cigna, first time approval) and then submitted for a sleeve (denied by Cigna first time, approved on appeal).

They denied me because I didn't prove mechanical failure, and I didn't prove compliance with the post-op diet. Well -- my band had a "profound" slip. It was considered uncorrectable, and my choices were pretty much removal, or live with it slipped. Slip is a nice term for the stomach prolapsing through the band, btw, so we aren't really talking about comfortable living conditions. It was clearly visible in the xray and I had an EGD as well, and 2 years of GERD and aother slip symtoms which can cause their own complications (I had aspiration pneumonia from the GERD twice, basically inhaled vomit and it gave me pneumonia... not to mention it is gross, and hurts like a mutha). So how they figure I didn't prove that it was a mechanical failure, I have no idea.

As for required diet - there isn't one with the band, so how do you prove that? Gah. That one took some work. I was only with Cigna for about 2 years, but I absolutely hated them.[/quote']

Oh Cigna approved you the first time?? I'm still freaking out.

[islandmom 10]

I have Cigna and was approved for my revision in just over a week! I was worried because I was self pay for my band in Mexico in 2006 and started the revision process in April 2011. I jumped through all their hoops and Dr. Kim's insurance coordinators are awesome!! Btw I did not have any slippage or erosion...dr just stated that the band inserted was too small. :-)

[bella143 8]

That's great! Does anyone know what's the difference between getting an authorization or pre determination?

[HopeThruFaith 30]

I hate Cigna as well. They denied me last year for the band but I think it may have been with the ins coordinator at my old surgeon's office. My new surgeon submitted my paperwork on Feb 15 and was told in three days that my claim for the sleeve was denied because I had been denied for the band (different surgeon mind you) and that I needed to wait a year to resubmit for a WLS and that my policy does not permit an appeal process. WRONG. I called back and spoke to two different reps (just to be sure) and was assured that since I am using a different surgeon that my old denial holds no weight with getting my new request approved. I was also told that it would take 30 business days for a decision and there was no way to expedite it. I'm on pens and needles because my surgery date is March 20 and I've already gotten my medical leave at work approved. Keep us posted if you hear anything.

[cmd1109 85]

I had no co-morbities. I believe I was approved within 5 days (including the weekend). I honestly think that the insurance person for my Doc is extremely good at her job, and made sure every piece of info that was needed was included. I called the day after submission and got the auth number, I then continued to call back everyday until I received a response.

To be completely honest I work for them, not in utilization review, but I know what it's like trying to do my job and having to pend my work until the provider submits additional info. Try not to get too frustrated, but when you call ask if they have all documentation needed, or are they waiting on something. Almost bet that if it's taking a really long time they (Cigna) are waiting for some more info.

[BABEwiththePOWER 16]

I had no co-morbities. I believe I was approved within 5 days (including the weekend). I honestly think that the insurance person for my Doc is extremely good at her job, and made sure every piece of info that was needed was included. I called the day after submission and got the auth number, I then continued to call back everyday until I received a response.

To be completely honest I work for them, not in utilization review, but I know what it's like trying to do my job and having to pend my work until the provider submits additional info. Try not to get too frustrated, but when you call ask if they have all documentation needed, or are they waiting on something. Almost bet that if it's taking a really long time they (Cigna) are waiting for some more info.

What are your thoughts on appeals with Cigna? I posted another topic earlier about what was deemed an "appeal" because we were resubmitting the request with more documentation (the 6month dr checkups) - I thought it would just be a new claim, but it was submitted by the same surgeons office, etc. I called today and all Cigna could tell me was it was pending and they go as fast as they can. The woman was pleasant, but didn't offer any further info. The appeal was submitted on Feb 15th, and my tentative surgery date is April 2nd. I sure hope it works out in time...

[bella143 8]

I had no co-morbities. I believe I was approved within 5 days (including the weekend). I honestly think that the insurance person for my Doc is extremely good at her job' date=' and made sure every piece of info that was needed was included. I called the day after submission and got the auth number, I then continued to call back everyday until I received a response.

To be completely honest I work for them, not in utilization review, but I know what it's like trying to do my job and having to pend my work until the provider submits additional info. Try not to get too frustrated, but when you call ask if they have all documentation needed, or are they waiting on something. Almost bet that if it's taking a really long time they (Cigna) are waiting for some more info.[/quote']

It's been 16 business days since my papers were submitted into Cigna.. I'm getting worried now. My insurance nav told me yesterday we are waiting for a predetermination approval number for the hospital..? What ever that means. He told me with my plan i didn't need approval just the predetermination auth number for the hospital. I have no Clue what that means. Someone said the longer Cigna takes the worse it may be and most likely it will be a denial. I'm so stressed and upset. I was thinking of Fallon Cigna today myself.

[bella143 8]

BABE I hope it works out for u too.. I feel like I'm In the same boat as you. the waiting is torture! I think I may call Cigna myself today n see what's going on. I called last week and the girl started out being klnice then the. Went into being firm and a little nasty and just trying to get me off the phone. She said there's nothing they can do to speed up the process m it can take 45 business days. Ugh!

[Wheetsin 714]

To clarify (I may have misstated something) CIGNA approved me the first time to have my band removed, but DID NOT approve me the first time to have my sleeve. I had to appeal.

Predetermination is an estimate of benefits (what's payable, what you will pay, etc.). Does not guarantee payment.

Preauthorization determines whether or not the procedure are a covered benefit. Often it guarantees payment as long as the treatment given is the same as the treatment submitted, and that it occurs within some time frame from when the preauthorization is given, usually about 60 days. But some places will still state that it does not guarantee payment (legal red tape).

You might also hear "precertification," which determines medical necessaity and what and duration (e.g. is it a medically necessary procedure and how long are you allowed to stay in the hospital).

IIRC. You can get specific definitions here.

[bella143 8]

To clarify (I may have misstated something) CIGNA approved me the first time to have my band removed' date=' but DID NOT approve me the first time to have my sleeve. I had to appeal.

Predetermination is an estimate of benefits (what's payable, what you will pay, etc.). Does not guarantee payment.

Preauthorization determines whether or not the procedure are a covered benefit. Often it guarantees payment as long as the treatment given is the same as the treatment submitted, and that it occurs within some time frame from when the preauthorization is given, usually about 60 days. But some places will still state that it does not guarantee payment (legal red tape).

You might also hear "precertification," which determines medical necessaity and what and duration (e.g. is it a medically necessary procedure and how long are you allowed to stay in the hospital).

IIRC. You can get specific definitions here.

Wow thanks for the info!! So what r the chances of getting an approval for predetermination? Does it mean that the actual prosedure (sleeve) is covered and they need to determin the hospital covered costs now?

[Wheetsin 714]

Think of it as a written request for verification of benefits. It's your surgeon asking, "Do you cover this for this person?" If your insurance company approves the predetermination, it's their way of answering, "Based on the info you gave us, this procedure is medically necessary . Usually we pay this. But whether or not we pay for it depends on the person's policy and the exact procedure done."

The department that predetermines does not review your individual policy to see the specifics of your coverage.

[Wheetsin 714]

This might help:

The predetermination of benefits process allows the medical provider -- at the consumer's request -- to send the insurance company a statement listing a proposed treatment or test, or the proposed purchase of medical equipment. Within a few weeks, the insurance company will generally respond with a statement of the amount of reimbursement the company will usually provide for that test, procedure, or equipment.

That process offers the consumer valuable information. It makes it possible for the consumer to review the cost and possible reimbursement for treatments or tests in advance, and allows the consumer to make an appropriate decision before the test or procedure is performed. In addition, if there's a significant difference between the estimated cost and possible reimbursement -- or if the insurer determines that the test or procedure is not covered under the policy -- the predetermination of benefits process offers an opportunity for the consumer to discuss the economic issues with the doctor or the insurer in advance.

The predetermination of benefits process may be helpful in all non-emergency situations that involve significant cost, such as elective surgery, expensive medical tests, or the purchase of medical equipment. In such cases, the predetermination of benefits process can help to prevent situations in which the consumer may be caught in the middle between the medical provider and the insurer.

For example, several years ago I reviewed a claim with a reader of my newspaper column involving a situation in which an individual had several small growths surgically removed at the same time. When the surgery was completed, the surgeon sent the patient a bill that reflected the removal of each of the growths.

However, since the surgeries were performed at the same time, the insurer provided reimbursement for less than half of the total bill in terms of the removal of the second growth on the grounds that the removal of that growth was incidental to the removal of the first growth. That left the individual with a large bill for which he was responsible.

The predetermination of benefits process would have given the consumer information about billing and reimbursement in advance. That would have made it possible for the consumer to discuss those issues with the provider and the insurer prior to surgery.

[bella143 8]

This might help:

Thanks so much! Fingers crossed.

[HopeThruFaith 30]

So, I broke down and called Cigna today (hard to suppress feelings of being anxious) spoke with A rep that advised that the nurse is still going through the 75 pages of info that was faxed in for my approval and she stated since my surgeon called them on Feb 15 that I should know something by March 7; 15 business days instead of the 30 I'm usually quoted. Is this a good sign?

[bella143 8]

Thanks so much! Fingers crossed.

Thank u so much!