Reimbursement for Non-Network Providers

New maximum reimbursement levels for non-participating provider charges

Most plan sponsors have elected to incorporate in their plan a Maximum Reimbursable Charge (MRC) provision that caps reimbursement for covered services received from non-participating providers. Members who voluntarily decide to use a non-network provider are financially responsible for any amounts over the MRC in addition to their plan deductible, coinsurance and co-payment.

CIGNA offers benefit plan designs that determine the MRC based upon two methodologies:

• The first methodology determines the MRC by reference to a data base of physician billing records collected from multiple payors by a third party (Ingenix). Profiles are established reflecting the range of charges for procedures billed with either CPT codes or Health Care Procedure Coding in a geographic area. A customer elected percentile is then applied to the range of charges for a procedure in the applicable geographic area to determine the MRC. Charges in excess of the MRC amount are not considered in calculating benefits and are the responsibility of the patient.



• CIGNA has begun to offer plan sponsors the option of determining the MRC using a fee schedule developed by CIGNA using a Medicare-type methodology. With this second methodology, the plan sponsor may elect one of the following fee schedule percentiles to determine the MRC:
  • 110% of schedule amount
  • 150% of schedule amount
  • 200% of schedule amount

Make the reimbursement process go smoothly

Eliminate printing and mailing expenses and reduce your paperwork - sign up to electronically submit your claims using Electronic Data Interchange (EDI). You have two options for submitting claims electronically to CIGNA - by directly connecting to CIGNA systems using free software from Post-N-Track, or by using a clearinghouse.

• Post-N-Track software is offered free to CIGNA providers. Contact Post-N-Track at 860.257.2030, or log on to www.Post-N-Track.com and click "Enroll". Post-N-Track is easy to install and the software can be downloaded in less than 5 minutes. No changes are required to your existing claim system. The software is easy to use and no training is necessary.



• If you do not have an existing relationship with a clearinghouse, you can contact Emdeon (formerly WebMD^®) at 1.877.469.3263, or at www.transact.emdeon.com to register.