CurrentCignaPolicy A005

Emergency room services (administrative coverage)

This administrative policy explains how Cigna administers coverage for emergency room services and defines emergency medical conditions for standard Cigna benefit plans; it applies to administration of benefits rather than clinical treatment recommendations and affects members covered by Cigna benefit plans.

Policy Summary

PayerCigna

PolicyEmergency room services (administrative coverage)

Policy CodePolicy A005

Change TypeNo material change

Effective DateAug 8, 2025

Next Review DateAug 8, 202657d

Key ActionCovered emergency room services do not require prior authorization or referral.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

no prior authorizationNo prior authorization

in-network cost-shareIn-network cost-share

~15 examplesExamples list

A005Policy number

Emergency Room Services Coverage Criteria

Emergency room services coverage criteria

Coverage for emergency room services is subject to the terms, conditions and limitations of the applicable benefit plan and may be subject to state regulations.

Covered emergency room services provided by a non-participating (out of network) provider or facility are eligible for coverage at the in-network cost-share benefit plan level.

Covered emergency room services DO NOT require prior authorization and/or referral by a healthcare provider.

ALL of the following

A physical and/or mental examination and related healthcare services to evaluate an emergency medical condition.
Treatment to stabilize the individual.

Policy Summary

PayerCigna

PolicyEmergency room services (administrative coverage)

Policy CodePolicy A005

Change TypeNo material change

Effective DateAug 8, 2025

Next Review DateAug 8, 202657d

Key ActionCovered emergency room services do not require prior authorization or referral.

SourceLink

On This Page

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Provider Actions and Administrative Requirements

Prior Authorization

Prior authorization not required for covered emergency room services

Covered emergency room services do not require prior authorization or a referral from a healthcare provider. This includes evaluation (physical and/or mental exam and related services) to assess an emergency medical condition and treatment to stabilize the individual.

Applies to covered emergency room services regardless of provider participation status.
Services include a physical and/or mental examination and related healthcare services to evaluate an emergency medical condition, and treatment to stabilize the individual.

Key Definitions

inv-03: Emergency medical condition (prudent layperson standard)

DefinitionEmergency medical condition: circumstances where the individual perceives their symptoms to be so severe that not seeking immediate medical attention could result in serious harm.

ScopeApplies to services provided in emergency rooms for evaluation and treatment to stabilize the individual.

ExamplesConditions a prudent layperson may consider emergent include blurry or loss of vision; confusion; coughing or vomiting blood; difficulty breathing or severe asthma attack; difficulty speaking; head injury; heart attack, chest pain, or chest pressure; loss of consciousness or seizure; major trauma; open fractures; overdose; severe burns; severe or uncontrolled bleeding; sudden numbness or weakness; suicidal thoughts.

inv-04: Prudent layperson

DefinitionPrudent layperson: Cigna defines prudent layperson as one who possesses an average knowledge of health and medicine.

Use in policyStandard used to determine whether an individual’s perception of symptom severity justifies emergency room services.

Relation to coverageDetermination of an emergency medical condition is based on the individual’s perception under the prudent layperson standard, not retrospective clinical outcome.