Network Adequacy Provision (NAP) - (UM-20)

Cigna authorizes out‑of‑network providers or facilities to be reimbursed at in‑network benefit levels only when no qualified participating provider is available within the applicable state/CMS mileage or appointment‑availability standards (state mandates supersede Cigna), excluding urgent/emergent care and telemedicine, and facility exceptions must be requested separately. Approvals require a medical‑necessity review with supporting clinical documentation, evidence searches/outreach to a minimum of three contracted providers showing no in‑network option, adherence to state‑ and plan‑specific time/distance standards, timely decisioning, and separate review for certain specialized services (e.g., gene therapy, transplants).

"If at least one (1) participating health care professional is not available within the established mileage specifications from the customer's home, or in certain states, from the customer's home or..."