Texas: Disclosure Form Must be completed for Out-of-network referrals

When patients with Cigna-administered coverage need a referral, they usually expect that their physician will refer them to a provider that participates in the Cigna network to minimize their costs. Whenever the physician refers the patient to non-participating providers, including freestanding laboratories they must complete a Cigna Out-of- Network Disclosure Form.  The form provides Cigna customers the information needed to make an informed decision regarding the use of participating or non-participating health care providers or facilities. When patients with Cigna administered plans obtain services from a non-participating provider, they will be responsible for the out-of-network charges consistent with their benefit plan, which may be significant. Providers need to complete the form whenever they are making a referral to a provider that does not participate in the Cigna network (they cannot delegate this task). Sign the form and ask the patient to sign it. Then, provide them with a copy, and file the original in their medical file. Please note that use of this form is an administrative requirement that is subject to periodic audits to ensure compliance. It is not necessary to complete the form in emergency situations, or if Cigna determines there are no alternative Cigna-participating health care providers that can render the requested covered services.