Cigna Modified UM-41 Continuity of Care Policy: What Billing Teams Need to Know in 2025
Cigna Healthcare modified UM-41 (um41-continuity-of-care-service-requests), its Continuity of Care Service Requests coverage policy, effective December 20, 2025. Here's what changes for billing teams.
Continuity of care requests sit at one of the riskiest intersections in revenue cycle work: a provider leaves the network, a contract terminates, and your patients are mid-treatment. Under UM-41, Cigna Healthcare establishes the process for evaluating these requests — and changes to that process directly affect whether claims for ongoing services get paid or denied. This update to the um41-continuity-of-care-service-requests policy in the Cigna system clarifies how and when patients can request continued access to an out-of-network provider at in-network rates. This policy does not list specific CPT, HCPCS, or ICD-10 codes — it governs the administrative process, not a procedure category.
Quick-Reference Table
| Field | Detail |
|---|---|
| Payer | Cigna Healthcare |
| Policy | Continuity of Care Service Requests (UM-41) |
| Policy Code | um41-continuity-of-care-service-requests |
| Change Type | Modified |
| Effective Date | December 20, 2025 |
| Impact Level | High |
| Specialties Affected | All specialties — any practice with Cigna-contracted providers at risk of network departure or contract termination |
| Key Action | Audit your workflows for flagging mid-treatment patients when a provider leaves your network before December 20, 2025 |
Cigna Continuity of Care Coverage Policy: What UM-41 Actually Governs in 2025
The Cigna continuity of care coverage policy under UM-41 exists for one core scenario: a Cigna-participating provider or facility leaves the network, and a patient is in active treatment. Cigna also applies this policy in limited cases when a client (employer or plan sponsor) terminates its contract with Cigna.
In those scenarios, patients can request continued access to their out-of-network provider at in-network cost-sharing rates. Cigna's policy sets the process for evaluating those requests — what qualifies, what documentation is needed, and how long coverage continues.
This is not a blanket entitlement. Medical necessity still applies. The fact that a patient wants to keep seeing their departing provider does not automatically mean Cigna will approve the continuity of care request.
Why Prior Authorization Matters Here
Prior authorization is embedded in this process. When a continuity of care request gets approved, Cigna authorizes continued services from the departing provider at in-network rates for a defined period. If your billing team submits claims for those services without a valid authorization tied to the continuity of care approval, expect a claim denial.
The real billing risk is timing. Authorization must be in place before the services are rendered — not requested after the fact. Your team needs to know the moment a provider leaves the network so you can initiate the request immediately.
The "Limited Circumstances" Language Is Doing Heavy Lifting
The policy applies in two situations. The first — a provider leaving the network — is straightforward. The second, client contract termination, is narrower and applies in "limited circumstances." That language matters. It means you cannot assume continuity of care coverage whenever a plan change happens at an employer level. Talk to your compliance officer if you are billing Cigna-covered patients whose employer plan is in transition.
Cigna Continuity of Care Eligibility and Medical Necessity Requirements 2025
Continuity of care billing under Cigna is not just about the provider relationship. The services themselves must meet medical necessity criteria. Cigna evaluates requests against the clinical circumstances — a patient in active chemotherapy is not the same situation as a patient who had an annual physical.
Medical necessity review determines whether the services requiring continuity are clinically appropriate and whether an interruption in care would cause harm. Your documentation should address both the ongoing nature of the treatment and the risk of disruption.
Here is what drives approval or denial under UM-41:
| # | Covered Indication |
|---|---|
| 1 | Active treatment status. The patient must be mid-course in treatment, not simply established with the provider. "Established patient" alone does not satisfy medical necessity for continuity of care. |
| 2 | Nature of the condition. Acute, serious, or complex conditions carry more weight. A patient undergoing surgery or receiving ongoing infusion therapy has a stronger case than a patient in routine monitoring. |
| 3 | Timeframe. Continuity of care coverage is temporary — typically through a course of treatment or a defined transition period, not indefinitely. |
Your billing team should document these clinical factors in every continuity of care request file. If the approval comes through and claims are later audited, you need to show why the continuity of care designation was appropriate.
Coverage Indications at a Glance
The UM-41 policy governs an administrative process rather than specific clinical procedures, so indication-level coverage tables by diagnosis code do not apply here. The table below summarizes the core scenarios and their coverage status under the policy.
| Scenario | Status | Notes |
|---|---|---|
| Patient mid-treatment when Cigna-participating provider leaves network | Eligible for continuity of care review | Medical necessity must be established; prior authorization required |
| Patient mid-treatment when employer client terminates Cigna contract | Eligible in limited circumstances only | Narrower eligibility; confirm with Cigna before billing |
| Established patient (not in active treatment) when provider leaves network | Not automatically covered | "Established" status alone does not satisfy medical necessity |
| New patient requesting care from a departing provider | Not covered under UM-41 | UM-41 applies to ongoing, active treatment only |
| Indefinite continuation of care with departed provider | Not covered | Continuity of care approval is time-limited by nature |
No CPT, HCPCS, or ICD-10 codes are specified in this policy. Coverage applies to medically necessary services already in progress, across all procedure categories.
Cigna Continuity of Care Billing Guidelines and Action Items 2025
The effective date is December 20, 2025. Your team should move on these items now, before that date arrives.
| # | Action Item |
|---|---|
| 1 | Map your current Cigna-contracted providers against any known network departures. If a provider in your group or facility is leaving Cigna's network, identify every active Cigna patient they are treating. Do this before December 20, 2025 — not after claims start denying. |
| 2 | Build a continuity of care flag into your scheduling and billing intake workflow. When a provider's Cigna contract ends, your front-end team needs a trigger to initiate UM-41 requests before the first claim is submitted under out-of-network status. A missed flag means a claim denial and a reimbursement delay that is hard to recover. |
| 3 | Document medical necessity at the time of the continuity of care request — not after. Cigna's evaluation hinges on medical necessity. Pull clinical notes, treatment plans, and referring physician documentation before you submit the request. Retroactive documentation is a red flag in audits and weakens your case. |
| 4 | Get the authorization number before billing. Every claim submitted under a continuity of care approval needs the Cigna authorization tied to that request. Without it, the claim processes as out-of-network and adjudicates at a lower reimbursement rate — or denies outright. Continuity of care billing without authorization is a consistent audit finding. |
| 5 | Track the approval period and set expiration alerts. Continuity of care coverage is time-limited. When the approval period ends, Cigna stops treating that provider as in-network for that patient. Set calendar alerts at 30 days and two weeks before expiration. If treatment is still ongoing, you may need to request an extension — and that request has its own lead time. |
| 6 | Treat employer contract terminations differently. The "limited circumstances" language in UM-41 for client contract terminations means this pathway is narrower. Do not assume it works the same way as a provider network departure. If you are in this situation, call Cigna's provider relations line and document the conversation. If you are unsure how this applies to your patient mix, loop in your compliance officer before the effective date. |
| 7 | Train your billing team on claim submission for approved continuity of care cases. Claims for these services go through the same submission process as other Cigna claims, but they need the authorization number and must be submitted within Cigna's timely filing window. Out-of-network claims have different filing requirements than in-network — confirm which rules apply to your approved continuity of care cases. |
| Previous Version | Current Version |
|---|---|
| Coverage is considered experimental and investigational for all indications | Coverage is considered medically necessary when specific criteria are met |
| Prior authorization is not required | Prior authorization is required for initial treatment |
| Documentation must include clinical history | Documentation must include clinical history |
| Re-review every 24 months | Re-review every 12 months with updated clinical documentation |
CPT, HCPCS, and ICD-10 Codes for Continuity of Care Services Under um41-continuity-of-care-service-requests
This policy does not list specific CPT, HCPCS, or ICD-10 codes. UM-41 governs the administrative process for continuity of care requests — it applies across all procedure categories and specialties, not to a defined set of codes.
The billing guidelines and authorization requirements in this policy apply to whatever codes are already on your claims for the patient's active treatment. The continuity of care designation changes the network status and reimbursement tier for those services — it does not alter the codes themselves.
What this means for your charge capture: Do not add or change procedure codes because of a continuity of care approval. Bill the same codes you would bill for in-network services. The authorization tied to the UM-41 approval is what instructs Cigna to process those claims at in-network rates.
If your billing team is accustomed to code-level policy changes, this one requires a different read. The risk here is procedural, not code-specific. A claim denial under UM-41 typically traces back to a missing authorization or an expired approval period — not an incorrect code.
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