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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
This new methodology applies to all non-participating practitioners, facilities and ancillary providers.
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.
Please provide your Medicare Identification Number on all claims so they can be
quickly and accurately processed, helping to reduce errors and improve your cash
flow.
Reimbursement with new MRC methodology
As a general rule, we encourage providers to submit according to the
Medicare Submission Policy to ensure correct payment.
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How CIGNA will reimburse |
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Determination of the MRC amount
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The MRC is determined with reference to a CIGNA fee schedule developed using a Medicare-type methodology and applying to it a percentile selected by the plan sponsor (i.e. 110%, 150% and 200%).
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Limit allowed to lesser of charges or MRC
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CIGNA will pay the lesser of the MRC or, as applicable, (i) the billed charge at line level, or (ii) billed charge at claim level for charges billed under a Prospective Payment Systems (PPS).
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Payment for services not covered by Medicare
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Reimbursement is based upon the terms of the patient's benefit plan irrespective of whether the service is covered by Medicare.
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Payment for services received from providers not participating in Medicare program
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The MRC limitation on reimbursement applies to all charges for covered services received from non-participating providers. Where the determination of the MRC requires facility specific information, then the MRC will be determined based on the national average rate.
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Medicare retroactive changes that affect Medicare reimbursement
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CIGNA will not reprocess claims due to Medicare retroactive changes.
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Effect of medical necessity/prior-authorization determinations
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No payment is made for charges for services determined not to be medically necessary.
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Transplants
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The MRC does not apply to charges for covered expenses associated with transplants.
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National Provider Identifier (NPI)
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Hospitals must submit NPI on all non-par claims.
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Taxonomy Code
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Hospitals must submit the taxonomy codes for the sub-part providing the service.
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Eliminate the hassle of manually submitting claims and reduce your paperwork. Sign up for Electronic Claims Submission (EDI) by calling 1.800.88CIGNA (882-4462) today.
Consider joining the CIGNA national network of participating providers. If you are interested, call 1.800.88CIGNA (882.4462).
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