CIGNA LifeSource Transplant Network

As a CIGNA customer, you'll have access to the CIGNA LIFESOURCE Transplant Network®. It is a network of participating organ and tissue transplant centers. Developed by a team of CIGNA clinical professionals, the transplant network includes respected hospitals and medical centers throughout the country.

Each transplant location is evaluated for favorable rates of patient outcomes, support services and "patient friendly" environments, before it is included in the CIGNA LIFESOURCE Transplant Network.

CIGNA LIFESOURCE hospitals are managed by our broad transplant case management unit. This unit is made up of Registered Nurses. They have clinical experience in transplant, hematology/oncology, home health care, dialysis, critical care plus community care. They are specially trained to manage complex transplant cases.

Help from the Comprehensive Transplant Case Management Unit includes:

• Clinical partnership with doctors
• Consistency in service and coverage administration
• Dedicated resources for complex areas of medicine
• Helping you understand your choices
• Administrative streamlining

Respected Hospitals and Medical Centers Throughout the United States

In some instances a travel payment is offered as a feature of the program. Please be aware that most of these expenses are considered taxable income.

As a CIGNA customer, you can have access to these services when they are handled through your doctor and your transplant case manager.

You may not receive the in-network level of coverage for all types of transplants at all hospitals. In addition, our network of locations changes frequently. For the most current listings with the programs covered at the in-network coverage level, please visit http://www.cignalifesource.com or call CIGNA LIFESOURCE Customer Service at 800.668.9682.

Not all CIGNA LIFESOURCE Transplant Network medical centers are available to customers in all plans. Please call Customer Service at 800.668.9682 for more information. If you are already in transplant case management, please call your case manager directly.

List of Hospitals and Medical Centers

California State Requirements

California Introductory State Disclosure

Some hospitals and other providers do not provide one or more of the following services that may be covered under your plan contract and that you or your family member might need: family planning; contraceptive services, including emergency contraception; sterilization, including tubal ligation at the time of labor and delivery; infertility treatments; or abortion. You should obtain more information before you enroll. Call your future doctor, medical group, independent practice association, or clinic, or call the health plan at (insert the health plan's customer services number or other appropriate number that individuals can call for assistance) to ensure that you can obtain the health care services that you need.

Kentucky State Requirements

Important Information
Note: The following applies only if you are covered under a Kentucky insurance policy issued by CIGNA.

Know How To Voice Your Concerns Or Complaints
CIGNA wants you to be satisfied with your health care plan. That's why we have a process to help address your concerns, and complaints and an appeal process for you to request review of coverage decisions.

Customer Services Can Help
If you have questions about coverage or services or are experiencing a problem, start by calling Customer Services at the number on your ID card. A representative will try to address your questions or resolve your concerns/complaints during the call, except for requests for review of coverage decisions. If Customer Services cannot resolve your concerns, ask the representative for more information about how to have your concerns addressed.

How To Request An Appeal Of A Coverage Decision
The specific appeal process that applies to you is determined by your plan and applicable state and/or federal rules.

The general overview below describes the appeal process for Kentucky residents covered under an insurance policy issued by CIGNA. Consult your Certificate of Coverage, Group Insurance Certificate or Summary Plan Description for a specific description of the appeal process that applies to you.

To begin the process, send your request for a review or call Customer Services at the number on your ID card. You may authorize a representative or a health care professional to request an appeal on your behalf. Show why you believe the first decision should be reviewed again. Include any documentation that supports your appeal with your written appeal request or promptly after you request an appeal by phone.

Your request will be reviewed by someone who was not involved in the initial decision and who can take corrective action. Decisions will be based upon the terms of your plan. A doctor will conduct any review related to medical necessity, and upon your request, a clinical peer of your treating doctor will conduct the review. An appeals committee consisting of at least three people may convene. You will be notified in advance when the meeting will occur, and you or your representative can present your situation to the committee in person, by phone or in writing. You will be notified of the appeal decision within 30 days of submitting your request. If your situation requires urgent care, the review and response will be handled quickly and completed in 72 hours.

An Independent External Review May Be Available
If you are not satisfied with the decision, an independent external review may be available to you, depending on your plan.

If you are covered under an insurance policy, and the appeal involves a coverage denial decision based on your plan limitations or exclusions, you may ask the Kentucky Department of Insurance's Coverage Denial Coordinator to review the decision. If the appeal involves a coverage decision based on issues of medical necessity or experimental treatment, or if the Kentucky Department of Insurance has reviewed a coverage denial decision and informs CIGNA that it believes a medical issue is involved, you can request independent review by an external review organization, also known in Kentucky as an Independent Review Entity.

If external review is available to you, you will be given instructions on how to request this review after the internal appeal is decided. The decision of the external reviewer will be provided within 21 days of the request, or within 35 days if an extension applies, and is binding upon CIGNA but not upon you. If the External Review is handled quickly, a decision will be provided by the external review organization within 24 hours of receiving all the information it needs to conduct the review.

If you are covered under an insurance policy, the Kentucky Department of Insurance may be able to assist you in resolving your dispute. If your plan is self-insured by your employer, your employer may have elected not to offer external review. Ask your employer or check your summary plan description for more options. In most cases, you must complete the CIGNA appeal process described above before pursuing arbitration or legal action. You should consider taking advantage of the independent external review that may be available. To learn more about the appeal process, call Customer Services.

Appointments With Participating Providers
When you need to see your doctor, an appointment will customarily be available with a participating health care professional:

• Within 48 hours for urgent care appointments and
• Within 2 weeks for routine primary care appointments.

Any Willing Provider
Certain types of health care professionals who meet our enrollment criteria and the terms and conditions for participation participate in our network available to persons covered by insurance policies issued by CIGNA.

Participating Providers Will Hold You Harmless
Participating health care professionals agree to look solely to CIGNA or the entity that funds your health benefit plan for compensation for covered services provided to you. That means that you should not receive a bill from a participating health care professional for any costs other than your copayment, deductible, or coinsurance amounts when you have obtained covered services from a participating health care professional. You will be responsible for charges for services that are not covered.

Louisiana State Requirements

HEALTH CARE SERVICES MAY BE PROVIDED TO YOU AT A NETWORK HEALTH CARE FACILITY BY FACILITY-BASED PHYSICIANS WHO ARE NOT IN YOUR HEALTH PLAN. YOU MAY BE RESPONSIBLE FOR PAYMENT OF ALL OR PART OF THE FEES FOR THOSE OUT-OF-NETWORK SERVICES, IN ADDITION TO APPLICABLE AMOUNTS DUE FOR CO-PAYMENTS, COINSURANCE, DEDUCTIBLES, AND NON-COVERED SERVICES. SPECIFIC INFORMATION ABOUT IN-NETWORK AND OUT-OF NETWORK FACILITY-BASED PHYSICIANS CAN BE FOUND AT THE WEBSITE ADDRESS OF YOUR HEALTH PLAN OR BY CALLING THE CUSTOMER SERVICE TELEPHONE NUMBER OF YOUR HEALTH PLAN.

Maine State Requirements

Most pharmacies in Maine contract with CIGNA to allow for 90-day supplies at your local retail store. If you are unsure whether your pharmacy participates, you can call the number on your ID card, or ask your pharmacist if they can process the 90-day supply.

Massachusetts State Requirements

Massachusetts allows Physician Assistants (PA) to be Primary Care Physicians (PCP). Depending on your plan you may be able to choose a PA who is licensed to practice in MA as your personal health care provider or PCP. The doctor must be considered an in-network provider and contracted with Cigna in MA to be covered as a PCP.

When you see a PA as your PCP you'll pay only the PCP copay if your plan has copayments, or the visit will be subject to the (in-network) deductible and/or coinsurance of the medical plan in which you are enrolled. The copay is the amount you pay toward an office visit. The coinsurance is the amount you pay after your plan begins to pay.

If you need help finding a PA in your network or have any questions about your plan and the appropriate copayment, please contact Customer Service at the number on the back of your Cigna ID card.

Michigan State Requirements

Transitional Care
If your health care professional's participation under the plan is terminated, the health care professional may continue your course of treatment as long as you remain eligible under the plan, a) through postpartum care related to the delivery if you were in the second or third trimester of pregnancy at time of notice of health care professional's termination, b) up to 6 months if you have been diagnosed with a terminal illness at the time of termination, or c) up to 90 days after the effective date of termination if you are in an active course of treatment.

Your health care professional shall continue to a) accept as payment for covered services in full the same rates in place prior to termination, b) follow standards for maintaining quality health care and provide all necessary medical information related to your care to CIGNA, and c) abide by CIGNA's policies and procedures including utilization review, referrals, preauthorizations and treatment plans.

Missouri State Requirements

For HMO Participants Only
THIS HMO MAY HAVE RESTRICTIONS REGARDING WHICH DOCTORS OR OTHER HEALTH CARE PROFESSIONALS AN HMO CUSTOMER MAY USE. PLEASE CONSULT YOUR GROUP SERVICE AGREEMENT OR PROVIDER DIRECTORY FOR MORE DETAILS.

New Hampshire State Requirements

Process for Monitoring on an Ongoing Basis Sufficiency of its Network.
CIGNA's goal is to provide a comprehensive, state-wide network of health care professionals ensuring that you have appropriate access to care, according to access standards. We routinely analyze network needs, and actively recruit and contract with health care professionals.

CIGNA continues to contract directly with doctors and other health care professionals, and also with physician-hospital (PHOs), physician's organizations (POs), independent practice associations (IPAs), and doctors in federally qualified health care centers in order to conform to the dynamics of the medical community and ensure that the network meets your needs.

CIGNA's health care professional network is comprehensive and broad. On occasion, network adequacy is reviewed via geo-access plotting and employer group customer requests. Considerable efforts are directed toward promoting beneficial arrangements with New Hampshire PHOs, IPAs, and POs to assure the correct mix of health care professionals and services are available to you in a high quality and efficient manner.

Access and Providing Emergency, Urgent and Specialty Care
CIGNA has specific access standards for routine, emergency, urgent and specialty care as listed below:

• Emergency - immediate
• Urgent - within 48 hours (not emergencies, but require prompt attention)
• Routine - 7-14 days or as specified by your treating doctor (preventive care screenings and routine physicals are within 30 days)

There are different standards for pregnancy:

• Obstetric Prenatal Care:
  • High-risk or urgent: Immediately
  • Non-high risk and non-urgent: 1st trimester, within 14 days; 2nd trimester, within 7 days, 3rd trimester, within 3 days
  • Routine and Symptomatic Diagnostic Testing: Within the timeframe specified by your treating doctor. Appointments for symptomatic testing are usually provided in shorter timeframes than routine testing

After hours care: Health care professional provides 24-hour coverage.

Coordinating Care To Specialists
Coordinating care to specialists for services including social services, behavioral health services and other community resources and ensuring appropriate discharge planning.

Referrals

HMO, Network, and Network Point of Service Plan Participants

• CIGNA no longer requires participating doctors to notify us of referrals to in-network specialists. However, this is only an administrative change, it does not eliminate the referral requirement.
• Depending on your plan, referrals from PCPs may still be required for specialty-care services to be covered at the highest coverage level.
• PCPs are responsible for providing a written referral to the specialist, and for noting the referral in your medical record.
• Specialists also must note the referral in the patient's record.

PCPs must provide referrals for specialty care from participating doctors if you are covered under an HMO, Network Plan, or POS plan.

You may receive services from non-participating health care professionals without a referral from your PCP. However, there is a strong incentive if you obtain a referral and remain within the CIGNA network; you will enjoy the highest benefit levels for covered services and lowest out-of-pocket expenses.

Referrals are never needed in Open Access, PPO and Indemnity plans. Customers may visit any doctor for primary or specialty care.

All CIGNA plans have adopted an "open access" policy for women's health care. Referrals are not needed for visits to CIGNA participating OB/GYNs for covered obstetrical or gynecological services.

What Is Case Management?
A CIGNA nurse provides assistance in coordinating services between health care professionals and across different care settings, such as a hospital, rehabilitation facility and your home. The nurse will also assist with identifying available community resources for services that may not be covered or by providing health care information. Customers may call the number on the CIGNA ID card to determine if the services of a CIGNA Nurse Case Manager might help.

Transitional Care
There may be times when a health care professional becomes unaffiliated with the CIGNA network. In such cases, you will be notified and given assistance in selecting a new health care professional. However, in special circumstances, you may be able to continue seeing your doctor, even though he or she is no longer affiliated with CIGNA. If you have a special circumstance for which you have been receiving care, such as a life-threatening illness or degenerative or disabling disease or condition, you may be eligible to receive "transitional care" from that nonparticipating health care professional for up to 90 days.

You may also be eligible to receive transitional care if you are in the second trimester of pregnancy. In this case, transitional care may continue through delivery and postpartum care. Such transitional care must be approved in advance by CIGNA, and your health care professional must agree to accept our payment rate and to follow CIGNA policies and procedures and quality assurance requirements.

There may be additional circumstances where continued care by a health care professional no longer participating in the CIGNA network will not be available, such as when the health care professional loses his/her license to practice or retires. If you are a new customer with special circumstances for which you have been receiving care, such as a life-threatening illness or degenerative or disabling disease or condition, you may be eligible to receive "continuity of care" from that non-participating health care professional for up to 60 days.

You may also be eligible to receive continuity care if you are in your second trimester of pregnancy. In this case, continuity of care may continue through delivery and post-partum care. Such continuity of care must be approved in advance by CIGNA, and your health care professional must agree to accept our payment rate and to follow CIGNA policies and procedures and quality assurance requirements.

There may be additional circumstances where continued care by a health care professional no longer participating in the CIGNA network will not be available, such as when the health care professional loses his/her license to practice or retires.

New Jersey State Requirements

Board Certified
Any doctor who has completed medical school, an internship, and a residency in a medical specialty and in addition, has successfully completed an examination conducted by a group (or Board) of peers is board certified.

As of the printing of this directory, 79% of New Jersey doctors contracted with CIGNA are board certified in their medical specialty.

Transitional Care
There may be instances in which your health care professional becomes unaffiliated with the CIGNA network of participating providers. In such cases, you will be notified and provided assistance in selecting a new health care professional.

However, in special circumstances, you may be able to continue seeing your doctor, even though he or she is no longer affiliated with CIGNA. If you have a special circumstance for which you have been receiving care, you may be eligible to receive "transitional care" from that non-participating health care professional for up to 120 days. For customers who are pregnant, you may be eligible to receive continued services through delivery, up to six weeks of post-partum.

You may also elect to continue services for post-operative follow-up care for up to six (6) months, and for oncological treatment or psychiatric treatment for up to one year from a participating health care professional who becomes unaffiliated with the CIGNA network.

Such transitional care must be approved in advance by CIGNA, and your health care professional must agree to accept our payment rate and to follow CIGNA policies and procedures and quality assurance requirements. Continued care will be provided at the same copayment and coverage levels that apply to care received from participating health care professionals. Continued care will not be available from a doctor who is subject to disciplinary action by the State Board of Medical Examiners, loses his/her license or retires.

If you are a new customer who has a special circumstance for which you have been receiving care, such as an acute illness, pregnancy or injury for which care started on or before your effective date with CIGNA, you may be eligible to receive "transition care" from that non-participating health care professional. This transition care must be approved in advance by CIGNA.

New York State Requirements

Office Of Professional Medical Conduct
The Office of Professional Medical Conduct (OPMC) provides a toll-free number to address inquiries and requests for information about any disciplinary actions against doctors and Physician Assistants. You may contact the OPMC at 1.800.663.6114 Monday through Friday, from 8:30 AM to 5:00 PM.

Board Certified
Any doctor who has completed medical school, an internship, and a residency in a medical specialty and in addition, has successfully completed an examination conducted by a group (or Board) of peer doctors is board certified. As of the printing of this directory, 80% of New York doctors contracted with CIGNA are board certified in their medical specialty.

Transitional Care
There may be instances in which your health care professional becomes unaffiliated with the CIGNA network. In such cases, you will be notified and provided assistance in selecting a new health care professional.

However, in special circumstances, you may be able to continue seeing your doctor, even though he or she is no longer affiliated with CIGNA. If you have a special circumstance for which you have been receiving care, such as a life-threatening illness or degenerative or disabling disease or condition, you may be eligible to receive "transitional care" from that nonparticipating health care professional for up to 90 days.

You may also be eligible to receive transitional care if you are in your second trimester of pregnancy. In this case, transitional care may continue through your delivery and post-partum care. Such transitional care must be approved in advance by CIGNA, and your doctor must agree to accept our payment rate and to follow CIGNA policies and procedures and quality assurance requirements. There may be additional circumstances where continued care by a health care professional no longer participating in the CIGNA network will not be available, such as when the health care professional loses his/her license to practice or retires.

If you are a new customer who has a special circumstance for which you have been receiving care, such as a life-threatening illness or degenerative or disabling disease or condition, you may be eligible to receive "continuity of care" from that non-participating health care professional for up to 60 days. You may also be eligible to receive continuity care if you are in your second trimester of pregnancy. In this case, continuity of care may continue through your delivery and post-partum care. Such continuity of care must be approved in advance by CIGNA, and your doctor must agree to accept our payment rate and to follow CIGNA policies and procedures and quality assurance requirements. There may be additional circumstances where continued care by a health care professional no longer participating in the CIGNA network will not be available, such as when the health care professional loses his/her license to practice or retires.

South Carolina State Requirements

HMO Participants

Enrolling in CIGNA of South Carolina, Inc. does not guarantee services by a particular health care professional on this list. If you wish to receive care from specific health care professionals listed, you should contact the HMO to be sure that the particular provider is participating in CIGNA of South Carolina, Inc. on the date you enroll. There is no guarantee that the provider will continue to participate during the entire term of your enrollment in CIGNA of South Carolina, Inc.

Texas State Requirements

NOTICE OF RIGHTS UNDER A NETWORK PLAN (PPO)

You have the right to an adequate network of preferred providers (also known as in-network providers).

• If you believe that the network is inadequate, you may file a complaint with the Department of Insurance.
• If you relied on materially inaccurate directory information, you may be entitled to have an out-of-network claim paid at the in-network percentage level of reimbursement and your out-of-pocket expenses counted toward your in-network deductible and out-of-pocket maximum.

You have the right, in most cases, to obtain estimates in advance:

• from out-of-network providers of what they will charge for their services; and
• from your insurer of what they will pay for the services.

You may obtain a current directory of preferred providers at www.cigna.com or by calling 1.888.992.4462 for assistance in finding available preferred providers.

• If the directory is materially inaccurate, you may be entitled to have an out-of network claim paid at the in-network level of benefits.
• If you are treated by a provider or hospital that is not a preferred provider, you may be billed for anything not paid by the insurer. If the amount you owe to an out-of-network hospital-based radiologist, anesthesiologist, pathologist, emergency department physician, or neonatologist is greater than $1,000 (not including your copayment, coinsurance, and deductible responsibilities) for services received in a network hospital, you may be entitled to have the parties participate in a teleconference, and, if the result is not to your satisfaction, in a mandatory mediation at no cost to you. You can learn more about mediation at the Texas Department of Insurance website: www.tdi.texas.gov/consumer/cpmmediation.html.

NOTICE OF RIGHTS UNDER A NETWORK PLAN (EPO)

An exclusive provider benefit plan provides no benefits for services you receive from out-of-network providers, with specific exceptions as described in your policy and below.

You have the right to an adequate network of preferred providers (known as in-network providers).

• If you believe that the network is inadequate, you may file a complaint with the Department of Insurance.
• If your insurer approves a referral for out-of-network services because no preferred provider is available, or if you have received out-of-network emergency care, your insurer must, in most cases, resolve the non-preferred provider’s bill so that you only have to pay any applicable coinsurance, copay and deductible amounts.

You may obtain a current directory of preferred providers at www.cigna.com or by calling 1.888.992.4462 for assistance in finding available preferred providers. If you relied on materially inaccurate directory information, you may be entitled to have an out-of network claim paid at the in-network level of benefits.

Texas Open Access Plus (OAP) Introductory State Disclosure
Texas Managed Care Introductory State Disclosure

Texas Service Area Maps and Directories
Participating health care professionals and facilities are located throughout the service areas. Look under specific listings in these directories for the addresses of physicians and hospitals that participate in your network.

Texas Managed Care Service Area Maps
Texas East Open Access Flex Network
Texas Houston Flex Network POS
Texas Austin HMO POS
Texas Austin OA Flex Network
Texas Austin OA HMO POS
Texas Corpus Christi HMO
Texas Corpus Christi OA Flex Network
Texas Corpus Christi Open Access HMO
Dallas – Ft. Worth HMO
Dallas OA Flex Network POS
Dallas Open Access HMO/POS
Dallas Open Select HMO
El Paso OA Flex Network POS
TX - Golden Triangle HMO/POS
TX - Golden Triangle OA Flex Network
TX - Golden Triangle HMO/POS
TX - Houston HMO
TX - Houston Kelsey Seybold HMO
TX Houston OA Flex Network
TX Houston HMO/POS
TX San Antonio HMO/POS
TX San Antonio OA Flex Network POS
TX San Antonio HMO/POS
TX Waco HMO/POS
TX Waco Network/POS
TX Waco OA HMO/POS

Texas Open Access Plus (OAP) and Preferred Provider Organization (PPO) Service Area Maps
Texas Western Open Access Plus
Texas Southern Texas PPO
Texas Southern Open Access Plus
Texas Northern PPO
Texas Northern Open Access Plus
Texas Western PPO

Hospitals
CIGNA has relationships with leading hospitals. The following hospitals participate in the CIGNA Open Access Plus Network.

NOTICE: Although health care services may be or have been provided to you at a health care facility that is a member of the CIGNA network used by your health benefit plan, other professional services may be or have been provided at or through the facility by doctors and other health care professionals who are not customers of that network. You may be responsible for payment of all or part of the fees for those professional services that are not paid or covered by your health benefit plan.

OB-GYN Care For Network and HMO Plans
You do not need a referral to your OB/GYN for an annual well woman exam. Your Primary Care Physician (PCP) may also provide OB/GYN care.

You can change your PCP at any time, for any reason. In addition, if you have a chronic, disabling or life-threatening illness, you may apply to the CIGNA Medical Director to request that your treating specialist become the coordinator of all of your care. In order for the CIGNA Medical Director to approve this request, your specialist must participate in the CIGNA network and must agree to become coordinator of all your care. Your specialist must agree to meet and accept all CIGNA requirements and payment schedules for PCPs, and must sign your request. If you are not satisfied with the Medical Director's response, you may appeal the response in accordance with the CIGNA Complaints and Grievance Policy.

Kelsey Seybold
Important plan information for: The Greater Houston Area
Primary Care Doctors
You may choose your personal primary care physician (PCP) from the following list of Kelsey-Seybold doctors specializing in Family Medicine, Internal Medicine or Pediatrics. Remember, you can select a different doctor for each member of your family. You can directly access any Kelsey-Seybold Clinic specialist (Kelsey-Seybold will appear below the name in the specialist section of the directory) including any participating obstetrician/gynecologist without a primary care physical referral. However, a referral by a Kelsey-Seybold Clinic physician is required for other participating specialists.

Specialists
For Specialty care provided by a Kelsey-Seybold Clinic doctor, you will not need a referral. (In this directory, _Kelsey-Seybold_ appears below the name of Kelsey-Seybold Clinic specialists.) For Specialty care provided by a doctor who is not a Kelsey-Seybold Clinic doctor, you will need a referral. In those situations, your PCP will recommend a participating specialist affiliated with Kelsey-Seybold.

For well-woman exams and obstetrical and gynecological exams, you do not need a referral, and you may visit any participating obstetrician/gynecologist, including those who are not Kelsey-Seybold Clinic doctors, as long as he or she is participating in this network. Please see your Summary of Benefits for information about referrals or other requirements.

Most non-emergency hospital care will be provided at St. Luke's Episcopal Hospital, St. Luke's Episcopal Hospital-The Woodlands, Methodist Willowbrook, Methodist Sugar Land, Clear Lake Regional, Woman's Hospital of Texas (OB/GYN services only) and Texas Children's Hospital.

PRECERTIFICATION
Our goal is to help make sure that you have access to the appropriate care, in the appropriate setting. We have established a wide network of doctors and we continuously contract with new health care professionals to help make sure that you have access to care from credentialed health care professionals.

Your plan may require that you choose a Primary Care Physician (PCP) for yourself and your covered dependents. Your PCP is your personal doctor who can coordinate your medical care and keep your medical history. If your plan does not require you to choose a PCP, you can still choose a PCP or a personal doctor for yourself and your covered dependents to help coordinate your care. Your first stop should be your PCP or personal doctor. He or she can help determine if you need specialty care or hospitalization.

What Is Precertification?
Precertification is a review process where CIGNA nurses, pharmacists and/or doctors work with your doctor to determine:

• Whether a procedure, treatment or service is covered by your plan.
• What your coverage will be for a procedure, treatment or service if you use a health care professional who is not in the CIGNA network.

How Does The Process Work?
Your plan may require precertification for hospital admissions and selected outpatient services. When precertification is required, a CIGNA nurse evaluates the request using nationally recognized guidelines. These guidelines are consistent with sound clinical principles and processes and have been developed with involvement from actively practicing health care professionals. CIGNA nurses determine what services are covered based on your plan and using these guidelines. When guidelines do not exist, clinical resource tools based on clinical evidence are used.

Anytime a CIGNA nurse is unable to approve coverage for clinical reasons, the case is referred to a CIGNA doctor who considers each case on an individual basis. The CIGNA doctor may speak with your doctor to obtain additional information. You and your doctor will be notified in writing if a request for a precertification number cannot be approved based on the information we received and your plan benefits.

When Does The Review Occur?
The review process can occur at three different times:

• Prospective review is when CIGNA receives a request before you receive care. Determinations are made within two business days of receiving all necessary information. You and your health care professional will be notified verbally or electronically and by mail.
• Concurrent review is when CIGNA receives a request while you are receiving care or in a hospital, skilled nursing facility or rehabilitation facility. Determinations are made within one business day of receiving all necessary information. You and your health care professional will be notified verbally or electronically and by mail
• Retrospective review is when CIGNA receives a request after you have received care. Determinations related to these services are made within thirty days after receiving all necessary information. You and your health care professional will be notified verbally or electronically and by mail.

If your situation requires that a determination is made right away, then CIGNA will perform a quick review. This determination will be completed within one business day.

Licensed doctors will determine coverage denials when clinical reasons are the reason for the denial. Denial letters will explain the reason for the decision and details on how to submit additional information and/or proceed through the formal Appeals Process, if you disagree with the coverage decision.

If your doctor is part of the CIGNA network, then he or she is responsible for contacting CIGNA to start the precertification process. If you use a doctor who is not part of the CIGNA network, then you are responsible for contacting CIGNA to start the precertification process. It is important for you to review your benefit plan or contact CIGNA at the number on your CIGNA ID card to understand which services require precertification.

Vermont State Requirements

What Is Case Management?
Case Management is when a CIGNA nurse provides you with assistance in coordinating services between your health care professionals and across different care settings, such as a hospital, rehabilitation facility and your home. The nurse will also assist you with identifying available community resources for services that may not be covered by your benefit plan or by providing you with health care information. If you think the services of a CIGNA Nurse Case Manager might help you, call the number on your CIGNA ID card.

What is Disease Management?
CIGNA has programs to assist you with chronic conditions like heart disease, diabetes, and asthma. You can enter a program by calling, or from a referral by your doctor, or by answering your Personal Health Assessment questionnaire with information on a chronic problem. We will call you to talk about your needs, send you reading materials or help you learn more about your condition online. We want you to feel better and do more each day. If you think the services of these programs might help you, call 1-800-CIGNA24 (1.800.244.6224).

Standing Referrals
You or your PCP may ask for a standing referral to a specialist or care center if you have a condition or disease that:

• Needs care over a long period of time
• Is life-threatening, degenerative or disabling.

We will give you a standing referral to one of these doctors if your primary care physician (PCP) talks to the doctor and the plan medical director. If they both feel that the special care is medically necessary, a referral will be issued. A treatment plan will be asked for and reviewed.

Specialist Doctor Serving as Primary Care Physician for a Life-Threatening, Degenerative or Disabling Condition
In Vermont, a customer may, upon CIGNA approval, use a Specialist as their PCP for a life-threatening, degenerative or disabling condition. The request must include a signed statement from the customer requesting the Specialist to serve as the customer's PCP and certification from the Specialist of the medical need to serve as the customer's PCP.

Upon receipt of this documentation:

• A CIGNA Medical Director validates the medical necessity of the request.
• A decision is made within 10 business days or less from receiving the request.
• If approved, CIGNA will get a signed statement from the Specialist accepting responsibility to serve as the customer's PCP, coordinate customer care needs and accept the PCP contracted payment rate for primary care services.
• If the CIGNA Medical Director denies the request for a Specialist to serve as the customer's PCP, the denial notification includes the reason(s) for denial, appeal rights and confirmation that the decision was made by a CIGNA Medical Director.
• The customer will be notified in writing within 21 to 30 business days of the decision.

Mailing Address:
CIGNA
4100 International Pkwy
Suite 1010
Carrollton, TX 75007

Mental Health / Substance Abuse
These health care professionals and services also participate with CIGNA.

CIGNA believes that needed care should be available to you in a timely way. However, it may take up to 10 business days to be seen by a therapist. It is important to note that a health care professional's availability to new patients may change frequently. If you feel you need more urgent help or if you need assistance in locating a health care professional, please call the toll free number on the back of your ID card.

You don't need an authorization for most visits to a therapist or psychiatrist in your network for routine, outpatient care. Pre-authorization is needed for Hospital Care and Other Specialty Services; call the number on the back of your ID card.

If your provider of mental health or substance abuse services is not currently listed in this directory, please ask your health care professional if he/she wishes to apply to join the network. Any health care professional willing to meet the terms and conditions for participation in CIGNA's network may apply for contracted status and may become contracted after successful completion of credentialing. The provider application as well as terms and conditions can be found online at: http://apps.cignabehavioral.com/web/basicsite/provider/customerService/joinOurNetwork.jsp.

Naturopathic Providers
Vermont allows naturopathic doctors to be Primary Care Physicians (PCP). Depending on your plan you may be able to choose a naturopathic doctor who is licensed to practice in VT as your personal health care provider or PCP. The doctor must be considered an in-network provider and contracted with Cigna in VT to be covered as a PCP.

When you see a naturopathic doctor as your PCP you’ll pay only the PCP copay if your plan has copayments, or the visit will be subject to the (in-network) deductible and/or coinsurance of the medical plan in which you are enrolled. The copay is the amount you pay toward an office visit. The coinsurance is the amount you pay after your plan begins to pay.

If you need help finding a naturopathic doctor in your network or have any questions about your plan and the appropriate copayment, please contact Customer Service at the number on the back of your Cigna ID card.

PRECERTIFICATION
Our goal is to help make sure that you have access to the appropriate care, in the appropriate setting. We have established a wide network of health care professionals and we continuously contract with new doctors to help make sure that you have access to care from credentialed health care professionals.

Your plan may require that you choose a Primary Care Physician (PCP) for yourself and your covered dependents.. Your PCP is your personal doctor who can coordinate your medical care and keep your medical history. If your plan does not require you to choose a PCP, you can still choose a PCP or a personal doctor for yourself and your covered dependents to help coordinate your care. Your first stop should be your PCP or personal doctor. He or she can help decide if you need specialty care or hospitalization.

What Is Precertification?
Precertification is a review process where CIGNA nurses, pharmacists and doctors work with your own doctor to decide:

• Whether a procedure, treatment or service is covered by your plan.
• What your coverage will be for a procedure, treatment or service if you use a health care professional who is not in the CIGNA network.

How Does The Process Work?
Your plan may require precertification for hospital admissions and selected outpatient services. When precertification is required, a CIGNA nurse evaluates the request using nationally recognized guidelines. These guidelines are consistent with sound clinical principles and processes and have been developed with involvement from actively practicing health care professionals.

CIGNA nurses decide what services are covered under your plan and using these guidelines.

When guidelines do not exist, clinical resource tools based on clinical evidence are used. Anytime a CIGNA nurse is unable to approve coverage for clinical reasons, the case is referred to a CIGNA doctor who considers each case on an individual basis. The CIGNA doctor may speak with your doctor to obtain additional information. You and your doctor will be notified in writing if a request for a precertification number cannot be approved based on the information we received and your plan benefits.

When Does The Review Occur?
The review process can occur at three different times:

• Prospective review is when CIGNA receives a request before you receive care. Decisions are made within two business days of receiving all necessary information. You and your health care professional will be notified verbally or electronically and by mail.
• Concurrent review is when CIGNA receives a request while you are receiving care or in a hospital, skilled nursing facility or rehabilitation facility. Decisions are made within one business day of receiving all necessary information. You and your health care professional will be notified verbally or electronically and by mail.
• Retrospective review is when CIGNA receives a request after you have received care. Decisions related to these services are made within thirty days after receiving all necessary information. You and your health care professional will be notified verbally or electronically and by mail.

If your situation requires that a decision is made right away, then CIGNA will perform a quick review. This decision will be completed within one business day.

Licensed doctors will decide coverage denials when clinical reasons are the basis for the denial. Denial letters will explain the reason for the decision and details on how to submit additional information and/or proceed through the formal Appeals Process, if you disagree with the coverage decision. If you need more information on the Appeal Process you can check your Handbook or certificate or you can contact CIGNA at the number on your CIGNA ID card.

If your doctor is part of the CIGNA network, then he or she is responsible for contacting CIGNA to start the precertification process. If you use a doctor who is not part of the CIGNA network, then you are responsible for contacting CIGNA to start the precertification process. It is important for you to review your plan or contact CIGNA at the number on your CIGNA ID card to understand which services require precertification.

How Do I Get An Approval?
If your doctor is part of the CIGNA network, then he or she is responsible for contacting CIGNA to start the precertification process. If you use a doctor who is not part of the CIGNA network, then you are responsible for contacting CIGNA to start the precertification process.

If you are unable to locate an In-Network health care professional in your area who can provide you with a service or supply that is covered under this plan, you must call the number on the back of your ID card to obtain authorization for Out-of-Network coverage. If you obtain approval for services provided by an Out-of-Network health care professional, those services will be covered at the In-Network coverage level. It is important for you to review your benefit plan or contact CIGNA at the number on your CIGNA ID card to understand which services require precertification.

Wisconsin State Requirements

Important Notice: Preferred Provider Plan Notice To Customers

You are strongly encouraged to contact us to verify the status of the providers involved in your care including, for example, the anesthesiologist, radiologist, pathologist, facility, clinic or laboratory when scheduling appointments or elective procedures to determine whether each provider is a participating or nonparticipating provider...Such information may assist in your selection of providers and will likely affect your copayment, deductible and amount of coinsurance applicable to the care you receive.

The information contained in this directory may change during your plan year. Please contact Customer Services at the number on your ID Card to learn more about the participating providers in your network and the implications, including financial, if you decide to receive your care from nonparticipating providers.

How Health Care Professionals Are Paid

CIGNA pays health care professionals in ways that are intended to emphasize preventive care, promote quality care and ensure the appropriate and cost effective use of covered medical services and supplies. CIGNA reinforces this philosophy through utilization management decisions made by its medical directors and Health Services staff. CIGNA employees are encouraged to promote appropriate utilization of covered health care services and to discourage under-utilization.

The same rules apply for doctors eligible to receive additional payments based on their performance. Doctor's pay and incentives encourage medically necessary care. CIGNA considers the doctor's quality of care, quality of service and appropriate use of medical services prior to awarding any bonuses and incentives.

The methods by which participating health care professionals agree to be paid are described generally here. The amount and type of payment a health care professional agrees to accept may vary depending upon the type of plan. For example, a hospital may agree to accept less for services provided to patients enrolled in an HMO plan than to patients enrolled in other types of plans. In addition, CIGNA may attempt in various ways to promote the use of those participating doctors who are the most cost effective, while assuring quality and access to covered services and supplies.

Discounted Fee For Service

Payment for services is based on an agreed-upon discounted amount from the health care professional's bill.

Capitation

By mutual agreement, network doctors, provider groups or physician/hospital organizations (PHOs) are paid a fixed amount (capitation) at regular intervals for each customer assigned to the provider, group or PHO, whether or not services are provided. This payment covers doctor and/or, where applicable, hospital or other services covered under the plan. Medical groups and PHOs may in turn pay health care professionals using a variety of methods.

Capitation offers health care professionals a predictable income and encourages those professionals to keep people well through preventive care. It eliminates the financial incentive to provide services that will not benefit the patient and reduces paperwork.

Health care professionals paid on a capitation basis may participate in a risk-sharing arrangement with CIGNA; they agree on a target amount for the cost of certain services and share all or some of the amount whether costs are over or under the target.

Health care services are monitored using criteria that may include accessibility, quality of care, customer satisfaction and appropriate and cost effective use of medical services and supplies.

CIGNA may also work with third parties that administer payments to participating health care professionals. Under these arrangements, CIGNA pays the third party a fixed monthly amount for these services. Health care professionals are compensated by the third-party for services provided to CIGNA plan customers from the fixed amount. Payment arrangements vary but generally depend on overall utilization.

Salary Bonuses and Incentives

Salary
Doctors and other health care professionals who are employed to work in a CIGNA staff-model medical facility are paid a salary. The salary is decided in advance each year and is guaranteed regardless of the services provided. Doctors are eligible for a bonus at the end of the year based on performance, which is evaluated using measurements that may include quality of care, quality of service and appropriate and cost effective use of medical services and supplies.

Bonuses and Incentives
Some health care professionals may receive additional payments based on their performance, which measures quality of care, quality of service and appropriate and cost effective use of medical services and supplies. Health care professionals may also receive financial and/or non-financial incentives that promote utilization of cost effective participating health care professionals (such as hospitals, labs, specialists and vendors) and covered drugs and supplies.

Per Diem

A specific amount is paid to a hospital per day for all health care received. The payment may vary by type of service and length of stay.

Case Rate

A specific amount is paid for all health care received in the hospital for a particular hospital stay (such as for a normal maternity delivery).

If you would like to find out which payment method applies to services you receive from a health care professional, just ask his or her administrative staff. CIGNA Customer Service is available to help with general questions at the toll-free number on your CIGNA ID card.

CIGNA Corporate Names

We reference CIGNA and Great-West Healthcare to accommodate all customers. CIGNA customers, please disregard Great-West Healthcare references.

"CIGNA," the "Tree of Life" logo and "CIGNA LifeSOURCE Transplant Network" are registered service marks of CIGNA Intellectual Property, Inc., licensed for use by CIGNA Corporation and its operating subsidiaries. All products and services are provided exclusively by such operating subsidiaries and not by CIGNA Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company (CGLIC), CIGNA Health and Life Insurance Company (CHLIC), and HMO or service company subsidiaries of CIGNA Health Corporation and CIGNA Dental Health, Inc. In Arizona, HMO plans are offered by CIGNA HealthCare of Arizona, Inc. In California, HMO and Network plans are offered by CIGNA HealthCare of California, Inc. In Connecticut, HMO plans are offered by CIGNA HealthCare of Connecticut, Inc. In North Carolina, HMO plans are offered by CIGNA HealthCare of North Carolina, Inc. All other medical plans in these states are insured or administered by CGLIC or CHLIC.

The information on this page is subject to change.