We are pleased to announce that, beginning February1, 2015, Cigna-HealthSpring will be participating in the Medicare-Medicaid Alignment Initiative. The goal of this initiative is to better serve both community and institutional based individuals who are eligible for both Medicare-Medicaid (Dual-Eligible enrollees. The initiative is to develop a service delivery model that improves care coordination of services, improves quality of care, and reduces cost.

Providers should use this Provider Manual in conjunction with the Cigna-HealthSpring participating provider agreement.


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Cigna-HealthSpring CarePlan of Illinois offers an integrated care coordination approach, which offers enhanced assessment and management for our members. The processes, oversight committees, provider collaboration, care management and coordination efforts applied to address members needs result in a comprehensive and integrated person-centered plan of care. The care coordination program consists of an integrated team of licensed mental health professionals, licensed social workers, registered nurses and non-licensed staff with backgrounds and experience with broad populations.

The integrated care coordination program addresses the needs of the members who are often frail, elderly, and coping with disabilities, compromised activities of daily living, chronic co-morbid medical/behavioral illnesses, challenging social or economic conditions, and/or end-of-life care issues. The program's combined provider and care coordination activities are intended to improve quality of life, health status, and appropriate treatment. The goal of the program is work collaboratively with the member and their primary care physician and/or other providers to achieve independence, highest level of wellness, and ensure quality of life.

The integrated care coordination program is initiated by a systematic process for identifying members upon eligibility, completing a health risk assessment, and the development and implementation of an individualized, person-centric care plan that includes the member and their family/caregiver. Cigna-HealthSpring CarePlan of Illinois’ care coordinators actively involve the member’s PCP and identifies support services from the community or within the health plan to assist the member. All attempts are made to include the PCP in the creation of the care plan as appropriate to assure that care plan incorporates considerations relating to the member’s medical and/or behavioral health treatment plan and any other observations by their physicians and provider(s). The care coordinators work with the members to ensure services are provided in a holistic approach to address their medical and behavioral health care as well as their social, functional, long term services and supports, and other needs. The integrated care coordination program and care plans address clinical needs, functional status, and barriers to care such as financial, transportation, and lack of support system. The completed care plans are shared with the PCP via mail.

Care Plans:

All high and moderate risk members actively enrolled in Cigna-HealthSpring CarePlan of Illinois’ Integrated Care Coordination Program, including those residing in a nursing facility, will have a care plan developed, implemented and shared with their providers. Additionally, all members receiving Long Term Services and Supports (LTSS) through a Home and Community Based Waiver, regardless of their risk level, will have a care plan developed, integrated with their service plan, implemented, and shared with their providers.

Contact Care Coordination

Cigna-HealthSpring CarePlan of Illinois’ care coordination team is available to assist providers with improving the overall wellness of their members. A provider can contact the care coordination team by calling 1(866)487-3002, option 4. For members receiving Long Term Services and Supports including Home and Community Based Waiver services and members residing in Nursing Facilities, please call 1(866)487-3002, option 7.

For quick reference information about Cigna-HealthSpring and the MMAI program, providers can visit our website at or our provider portal at Please note: Users should not enter “www” prior to entering the web address for the provider portal. Also, providers may call the following resources for more information.

Cigna-HealthSpring Contacts
Phone NumberFax Number 
Behavioral Health Services 1(866)780-8546 1(866)949-4846  
Claims Status Request 1(866)486-6065    
Compliance Hotline 1(800)472-8348    
Cigna-HealthSpring Automated Eligibility
Verification Line
Member Services Department 1(866)487-4331    
Provider Services Department 1(866)486-6065    
Pharmacy Coverage Determination 1(877)813-5595 1(866)845-7267  
Pharmacy Appeals 1(866)845-6962 1(866)593-4482  
Utilization Management
– Service Coordination
– Concurrent Review
– Skilled Nursing Facility
– Home Health
– Inpatient Intake
Option 6
Prior Authorization 1(866)487-3002
Option 3


External Contacts
Phone Number  
24-Hour Nurse Advice Line 1(866)576-8773    
Dental (DentaQuest) 1(800)259-3081    
Vision (Block Vision) Provider: 1-800-243-1401
Member: 1-866-819-4298
Laboratory Services (Quest Diagnostics) 1(866)MYQUEST (866-697-8378)    
Laboratory Services (LabCorp) 1(888)LABCORP (888-522-2677)    
MAXIMUS (Medicaid Managed Care Helpline) 1(877)912-8880    
Illinois Department of Healthcare
and Family Services (HFS)
1(800)526-5812 TDD/TYY

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Provider Information

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Cigna-HealthSpring recognizes and values each provider’s immeasurable contributions to the MMAI program. Without a dedicated team of health care providers, Cigna-HealthSpring could not successfully deliver on its goal of improving access to care, quality of care, and member satisfaction. To ensure providers have access to all resources and tools needed to support Cigna-HealthSpring members, Cigna-HealthSpring employs a provider services team. Provider Services assists providers when daily operations do not go as planned, when they have questions, or when they need to schedule an educational in-service. The in-service will include an overview of the MMAI program, billing, overview of model of care specifying how the ICT coordinates behavioral health and medical, and HCBS providers. It will also specify how HCBS waivers are accessed, and list community supports available. Providers can reach the Cigna-HealthSpring Provider Services Department by calling 1(866)486-6065. Additionally, providers should familiarize themselves with the Cigna-HealthSpring Provider Manual and this section, in particular, to gain a better understanding of how to partner with Cigna-HealthSpring.

The following are important participation requirements for Cigna-HealthSpring providers:

Provider Access and Availability Standards
After Hours Accessibility
Cigna-HealthSpring PCPs are required to maintain after-hours call coverage to ensure members have access to care twenty-four (24) hours per day, seven (7)
days per week. The following are acceptable and unacceptable phone arrangements for contacting PCPs after normal business hours:

Acceptable After-hours Coverage:

Primary Care Access Standards

Appointment Type
 Access Standard 
Urgent/Emergent   Immediately  
Non-urgent/non-emergent   Within one(1) week  
Routine and preventive   Within 30 business days  
On-call response (after hours)   Within 30 minutes for emergency  
On-call response (after hours)   Within 30 minutes for emergency  
Waiting time in office   30 minutes or less  


Specialist Access Standards

Appointment Type
 Access Standard 
Urgent/Emergent   Immediately  
Non-urgent/non-emergent   Within one(1) week  
Elective   Within 30 days  
High index of suspicion of malignancy   Less than seven (7) days  
Waiting time in office   30 minutes or less  

Initial prenatal visits without expressed problems scheduled within two (2) weeks after a request from a customer in her first trimester, within one (1) week for a customer in her second trimester, and within three (3) days for a customer in her third trimester.

Behaviorial Health Access Standards

Appointment Type
 Access Standard 
Emergency and non-life threatening   Within 6 hours of the referral  
Urgent/symptomatic   Within 48 hours of the referral  
Routine   Within ten (10) business days of the referral*  
Waiting time in office   30 minutes or less  

Hours of Operation
Cigna-HealthSpring providers must offer hours of operation that are no less than the hours of operations offered to persons who are not members of Cigna-HealthSpring.

Maximum Panel Size
A Cigna-HealthSpring PCP’s maximum panel size is six hundred (600) members.

Demographic Changes
Providers can ensure their office is properly listed in the Cigna-HealthSpring Provider Directory and that all claims payments are sent to the correct address by providing timely, advance notification of demographic changes.

The following types of demographic changes should be reported to Cigna-HealthSpring provider Services Department at 1(866)486-6065:

  • Tax identification number
  • Office address
  • Billing address
  • Telephone number
  • Changes in practice limits or office hours
  • Specialty
  • New provider additions to an existing practice

The Service Coordinator will work with the provider to arrange for a transfer of care.

Participating providers may not condition the provision of care or otherwise discriminate against a member based on whether the member executed an advance directive. However, nothing in the Patient Self-Determination Act precludes the right under State law of a provider to refuse to comply with an advance directive as a matter of conscience.


  • Cigna-HealthSpring encourages your feedback and suggestions on how service may be improved within the organization.
  • If an acceptable patient-physician relationship cannot be established with a Cigna-HealthSpring member who has selected you as his/her primary care physician, you may request that Cigna-HealthSpring have that member removed from your care.
  • You may appeal any claims submissions that you feel are not paid according to medical policy or in keeping with the level of care rendered.
  • You may request to discuss any referral requests with the Medical Director or Chief Medical Officer at various times in the review process including before and after a decision is rendered.
  • You must cooperate with Cigna- HealthSpring Quality Improvement (QI) activities to improve the quality of care and services and the customers’ experience.
  • You must allow Cigna-HealthSpring to use your performance data; including the collection, evaluation and use of data in the participation of QI programs.
  • You must maintain customer information and records in a confidential and secure manner.
  • As a practitioner or provider of care you affirm to freely and openly discuss with customers all available treatment options regardless of whether the services may be covered under the customer’s benefit plan. This includes all treatment options available to them, including medication treatment options, regardless of benefit limitations.
  • Customers have the right to receive full information from their providers when they receive medical care, and the right to participate fully in treatment planning and decisions about their health care. Cigna-HealthSpring providers must explain treatment choices, planning, and health care decisions in a way that customers can understand. 
  • Customers have the right to know about all of the treatment choices that are recommended for their condition including all appropriate and medically necessary treatment options, regardless of the cost or whether they are covered by Cigna-HealthSpring. This includes the right to know about the different medication management treatment programs Cigna-HealthSpring offers and those in which customers may participate. 
  • Customers have the right to be told about any risks involved in their care. Customers must be told in advance if any proposed medical care or treatment is part of a research experiment and be given the choice to refuse experimental treatments.


A PCP may specialize in the following specialties:

  • General practice
  • Family practice
  • Internal medicine
  • Obstetrics/gynecology (OB/GYN)
  • SNFist provider for members in a SNF

When practicing under the supervision of a participating Cigna-HealthSpring physician, advanced practice nurses (APNs), and certified nurse midwives (CNMs) may serve as PCPs. Additionally, providers such as Rural Health Clinics (RHCs), Federally Qualified Health Centers (FQHCs), and Community Clinics may serve as PCPs. Specialty Care providers serve as PCPs under specific circumstances.

The circumstances under which this may occur are discussed in the Member Services section of this Provider Manual. The PCP serves as the “medical home” or the entry point for access to health care services. The PCP provides or arranges for all medically necessary primary care services and refers member for specialty care when necessary. The medical home, with the PCP as gatekeeper, helps to facilitate Case Management through multiple processes and provides ready access to members for all levels of service except emergent need. This access is regularly monitored by the Integrated Care Team (ICT), which is described more fully further in the document, as well as the Plan. The medical home is trained to provide much of the member’s needed care based on nationally-approved, evidence-based guidelines, such as the American with Disabilities Act guidelines on diabetic care. Should the member require specialized care, the medical home/PCP would provide a referral to a contracted specialist or service within the health plan. The health plan would evaluate this referral for medical necessity using nationally-accepted criteria and then provide authorizations to both the PCP and specialist. The PCP may also reach out to other members of the ICT or the Plan Medical Director, directly to communicate member care needs.

The PCP can participate in the identification and treatment of their member’s behavioral health needs. His/her responsibilities include:

  • Screening and early identification of mental health and substance abuse issues
  • Treating members with behavioral health care needs within the scope of his/her practice and according to established clinical guidelines. These can be members with comorbid physical and minor behavioral health problems or those members refusing to access a mental health or substance abuse provider, but requiring treatment
  • Consultation and/or referral of complex behavioral health patients or those not responding to treatment
  • Communication with other physical and behavioral health providers on a regular basis

Cigna-HealthSpring members must select an in-network primary care provider (PCP) to oversee their care. PCPs are normally selected by the member during the enrollment process. If a member does not select a PCP during the enrollment process, one will be auto-assigned to them based on PCP proximity by the Illinois Department of Health and Family Services’ enrollment broker. Members may change PCPs at any time by calling the Cigna-HealthSpring member Services Department at 1-866-487-4330.

Specialty Care providers play an essential role in caring for Cigna-HealthSpring members. A Cigna-HealthSpring Specialty Care provider is responsible for providing health care services to members who require care beyond the capabilities of a PCP. Specialty Care providers must render covered health services within the scope of their practice and license, in the same manner, according to the same standards, and within the same time availability as offered to their other patients. It is the responsibility of the Specialty Care provider to communicate their findings and recommendations with each member’s PCP in order to promote coordination and continuity of care.

Cigna-HealthSpring Specialty Providers are responsible for the following:

  • Verifying member eligibility prior to rendering services
  • Obtaining authorizations when necessary from Cigna-HealthSpring prior to rendering services (See page 87 for a full list of services requiring prior authorization)
  • Providing continuity of care
  • Providing specialty health care services to members as needed
  • Collaborating with the member’s PCP to ensure continuity of care and appropriate treatment
  • Providing consultative and follow-up reports to the PCP in a timely manner
  • Being culturally and linguistically sensitive to Cigna-HealthSpring members
  • Referring members to participating Cigna-HealthSpring providers
  • Complying with Cigna-HealthSpring’s access and availability standards as outlined in this Provider Manual
  • Complying with Cigna-HealthSpring’s Quality Management and Utilization Management programs
  • Adhering to Cigna-HealthSpring’s medical record standards as outlined in this Provider Manual
  • Using a National Provider Identification (NPI) number
  • Billing services to Cigna-HealthSpring in accordance with the billing procedures outlined in this Provider Manual
  • When billing for services provided, using specific coding to capture the acuity and complexity of a member’s condition and ensuring that submitted codes are supported by the medical record

SpecialCare of Illinois provides comprehensive mental health and substance abuse services to its members. Its goal is to treat the member in the most appropriate, least restrictive level of care possible, and to maintain and/or increase functionality.

SpecialCare of Illinois’s network is comprised of mental health and substance abuse services and providers who
identify and treat members with behavioral health care needs.

Integration and communication among behavioral health and physical health providers is most important. SpecialCare of Illinois encourages and facilitates the exchange of information between and among physical and behavioral health providers. Member follow-up is essential. High risk members are evaluated and encouraged to participate in SpecialCare of Illinois’ Behavioral Health focused Case Management Program where education, care coordination and support are provided to increase member’s knowledge and encourage compliance with treatment and medications. SpecialCare of Illinois works with its providers to become part of the strategy and the solution to provide quality behavioral health services.

SpecialCare of Illinois encourages behavioral health providers to become part of its network. Their responsibilities include but are not limited to:

  • Provide treatment in accordance with accepted standards of care
  • Provide treatment in the least restrictive level of care possible
  • Communicate on a regular basis with other medical and behavioral health practitioners who are treating or need to treat the member.
  • Behavioral health providers must provide the PCP with a written summary report following the initial visit and quarterly thereafter.
  • Direct members to community resources as needed to maintain or increase member’s functionality and ability to remain in the community.
  • Participate in utilization management activities.

Behavioral Health Services are available and provided for the early detection, prevention, treatment and maintenance of the member’s behavioral health care needs. Behavioral Health Services are interdisciplinary and multidisciplinary. A member may need one or multiple types of behavioral health providers, and the exchange of information among these providers is essential. Mental health and substance abuse benefits cover the continuum of care from the least restrictive outpatient levels of care to the most restrictive inpatient levels of care.

Behavioral Health Services include, but are not limited to:

  • Access to SpecialCare of Illinois’ member services for orientation and guidance
  • Routine outpatient services to include psychiatrist, addictionologist, licensed psychologist and LCSWs, and psychiatric Nurse Practitioners and other behavioral health practitioners. PCPs may provide Behavioral Health services within his/her scope of practice
  • Initial evaluation and assessment 
  • Individual and group therapy
  • Psychological testing according to established guidelines and needs
  • Substance Abuse services
  • Inpatient hospitalization
  • Inpatient and out-patient detoxification treatment
  • Medication management 
  • Partial hospitalization programs 
  • Covered Community Mental Health Center services
  • Case Management Services as indicated

MMP Behavioral Health Covered Services
MMP Behavioral Health Services means covered services for the treatment of mental, emotional or substance use disorders. SpecialCare of Illinois provides a behavioral health benefit package to MMP members that includes all medically necessary treatment covered under the Medicare and the traditional, fee-for-service Medicaid programs. Please refer to the Behavioral Health Benefit Grid found in the appendix of this Provider Manual.

SpecialCare of Illinois ensures that behavioral health services are available at the appropriate time and in the most appropriate setting possible, where they can safely be provided without adversely affecting the member’s physical and/or behavioral health or quality of the care.

Communication among behavioral health and physical health providers is key to accomplishing this goal. SpecialCare of Illinois utilizes an integrated system for documenting members’ physical and behavioral health information. This facilitates collaboration among providers, allowing them to work jointly
in the same environment as they coordinate all of the members’ needs efficiently.

Member Access to Behavioral Health Services
SpecialCare of Illinois members may access behavioral health services in three (3) ways:

  1. A PCP may provide treatment within the scope of his or her practice and licensure using the DSM-IV multi-axial classifications
  2. A PCP or specialty care provider may refer a SpecialCare of Illinois member to an in-network behavioral health provider
  3. A member may self-refer for behavioral health services to any in-network behavioral health provider. To identify an in-network behavioral health provider, members can call their Care Coordinator at 866-487-3002 option 4 . Members may also call the SpecialCare of Illinois member services department at 1-866-487-4331, Monday through Friday, 8 a.m. to 5 p.m. CT

Consent for Disclosure and Sharing of Information Between Behavioral Health Provider and PCP
PCPs and behavioral health providers are required to obtain consent for the disclosure of information from the member permitting the exchange of clinical information between the behavioral health provider and the member’s physical health provider.

Provider Coordination of Care
Behavioral Health providers should screen SpecialCare of Illinois members for co-existing physical conditions. Behavioral Health providers may provide physical health services only if they are licensed to do so. After screening, behavioral health providers should obtain member’s consent and refer those with known, suspected or untreated physical health problems or preventive care needs to their PCP. Behavioral health providers should communicate concerns regarding a member’s medical condition to the PCP and work collaboratively on a plan of care.

Information should be shared among SpecialCare of Illinois behavioral health providers and physical health providers to ensure continuity of care and a cohesive and holistic treatment plan.  The primary care and behavioral health providers are encouraged to share pertinent history and test results in a timely manner and document review of the information received in the clinical record.

Continuity of Care Follow-Up
When a member does not keep a scheduled appointment, the behavioral health provider should contact the member to reschedule the missed appointment within twenty-four (24) hours. Providers should not bill members for missed appointments. To ensure continuity of care, SpecialCare of Illinois requires its behavioral health providers to follow-up with members on an outpatient basis within seven (7) days after discharge from an inpatient setting. Also, behavioral health providers should follow-up telephonically or face-to-face with members who are non-adherent with medications and/or treatment. Providers are encouraged to contact SpecialCare of Illinois so appropriate and timely care coordination and intervention activities can occur.

Medical record and documentation
When filing claims for behavioral health services, providers must use DSM 5 diagnosis codes. Behavioral health services require the development of a treatment plan. Documentation must always indicate date of service. Co-morbid physical health conditions should be noted as part of the diagnosis.

Notification and Prior Authorization Requirements for Behavioral Health Services
Behavioral health providers should notify SpecialCare of Illinois when they are initiating treatment. The notification process provides an opportunity to:

  • Verify eligibility
  • Confirm benefits
  • Obtain Prior Authorization if necessary
  • Inform the member’s care coordinator

The Following Behavioral Health Services Require Prior Authorization from SpecialCare of Illinois:

  • Inpatient Psychiatric
  • Inpatient Detoxification
  • Residential Detoxification 
  • Substance Abuse Residential 
  • Mental Health Residential 
  • SA Day Treatment
  • SA Partial Hospitalization 
  • MH Partial Hospitalization 
  • SA Intensive Outpatient 
  • MH Intensive Outpatient 
  • Electroconvulsive/Repetitive Transcranial Magnetic Stimulation Therapy
  • Psychological tests 
  • *Neuropsychological testing (through medical UM  review)
  • Assertive Community Treatment 
  • Community Support Individual/Group
  • Community Support Residential
  • Community Support Team

Prior Authorization forms for behavioral health services can be obtained by visiting our provider portal at or calling Health services at 1(800)511-6932.

SpecialCare of Illinois will continue to offer the outpatient services listed below without the requirement of a Prior Authorization.
Any service not listed will utilize the standard authorization process.

Services Requiring No Authorization By Participating Provider

Service Name Code 
Admission and Discharge Assessment    H0002  
Medication Monitoring    H2010  

Individual - Therapy/Counseling, Substance Abuse
Group - Therapy/Counseling, Substance Abuse    H0005  
Individual - Intensive Outpatient, Substance Abuse    H0004  
Group - Intensive Outpatient, Substance Abuse    H0005



CPT CodeDescriptionReport with Psychotherapy
add-on codes
90791 Psychiatric diagnostic evaluation (no medical services)    
(or New Patient E & M codes)
Psychiatric diagnostic evaluation
with medical services
Out Patient


Nursing Facility

New Patient Visit (10-60 min)
Established Patient (5-25 min)


New Patient Visit (10-45 min)
Established Patient (10-35 min)

Psychotherapy Add On Codes: (when appropriate)
90833-30 min
90836-45 min
90838-60 min
90832 Psychotherapy (30 min)    
90834 Psychotherapy (45 min)    
90846 Family Psychotherapy (without patient present)  


90847 Family Psychotherapy (with patient present)    
90853 Group Psychotherapy (other than of a multiple–family group)
Physicians Office Only ~ Facilities Require Prior Authorization.


Q3014 Telehealth    
Community Mental Health Services (Rule 132) Only ACT and CSI, CST, CSR require authorization.
Other Rule 132 services do not require authorization.  *replace with the table above


FunctionPhone/AddressDescription of Services 
Member Eligibility/Benefits 1-800-453-4464 (*IVR)
 Verification of coverage and benefits; for facility admissions and other facility services, consult the Common Working
File if member does present ID card.
Authorization Line 1-866-780-8546
Fax: 1-866-949-4846
Prior authorization is required for services not listed above.


Inpatient Admissions 1-866-780-8546
Fax: 1-866-949-4846
Notification is required within 24 hours of admissions;
clinical staff available 24 hours a day/7 days a week to
assist with notifications and precertification.
Claims Submission (paper) Cigna-HealthSpring Claims Dept.
P.O. Box 981804
El Paso, TX 79998


Claims Submission (electronic) Clearing Houses:
Emdeon, Relay Health, Capario, DST, Gateway EDI, Office Ally, SSI Group,
Zirmed, MedAssets
Payor Id #63092
Claim Status Inquires 1-800-453-4464 (*IVR)


*(IVR) Interactive Voice Response System

Members may access behavioral health services as needed:

  • Members may self-refer to any in-network behavioral health provider for initial assessment and evaluation,and ongoing out-patient treatment
  • Members may access their PCP and discuss their behavioral health care needs or concerns and receive treatment that is within their PCP’s scope of practice. They may request a referral to a behavioral health practitioner. Referrals, however, are not required to receive most in-network mental health or substance abuse services
  • Members and providers can call Cigna-HealthSpring Customer Service to receive orientation on how to access behavioral health services, provider information, and prior authorizations at 1-866-487-4330 for members and 1-866-486-6065 for providers.

When requesting prior authorization for specific services or billing for services provided, behavioral health providers must use the DSM-IV multi-axial classification system and document a complete diagnosis until DSM-V is effective.

The provision of behavioral health services requires progress note documentation corresponds with day of treatment, the development of a treatment plan, and discharge plan, as applicable for each member in treatment.

Continuity of Care is essential to maintain member stability. Behavioral health practitioners and PCPs, as applicable, are required to:

  • Evaluate member if he/she was hospitalized for a behavioral health condition within 7 days post-discharge
  • Provide members receiving care with contact information for any emergency or urgent matter arising that necessitates communication between the member and the provider
  • Evaluate member needs when the member is in acute distress
  • Communicate with the member’s other healthcare providers
  • Identify those members necessitating follow-up and refer to Cigna-HealthSpring’s behavioral health focused Case Management program as necessary
  • Discuss cases as needed with a peer reviewer
  • Make request to Cigna-HealthSpring for authorization for member in an active course of treatment with a non-participating practitioner


Cigna-HealthSpring’s Health Services Department coordinates behavioral health care services to ensure appropriate utilization of mental health and substance
abuse treatment resources. This coordination assures promotion of the delivery of services in a quality-oriented, timely, clinically-appropriate, and cost-effective manner for the members. Cigna-HealthSpring Utilization Management staff base their utilization-related decisions on the clinical needs of members, the member’s Benefit Plan, Interqual Criteria, the appropriateness of care, Medicare National Coverage Guidelines, health care objectives, and scientifically-based clinical criteria and treatment guidelines in the context of provider and/or member-supplied clinical information and other relevant information.

LTSS providers deliver care covering Home and Community Based Waiver Services (HCBS) and Long Term Care (LTC).  LTSS, delivered in combination with care coordination, medical health, behavioral health, disease management and other non-covered services, provides for more stable health opportunities while maintaining the member’s highest level of independent functioning as possible.

Cigna-HealthSpring CarePlan of Illinois is responsible for managing and coordinating the benefits for the following five Medicaid Waivers:

  • Supportive Living Facilities
  • Persons who are Elderly
  • Persons with Disabilities
  • Persons with HIV or AIDS
  • Persons with Brain Injuries.

For members residing in Long Term Care facilities, Cigna-HealthSpring CarePlan of Illinois is responsible for managing and coordinating room and board.
LTSS providers are responsible for providing covered services to members, within the scope of their Cigna-HealthSpring CarePlan of Illinois participating provider agreement and within the scope of their license (if applicable).   Providers are required to adhere to the member’s Person-Centered Care Plan and Service Plan.  Other LTSS responsibilities include:

  • Verifying member eligibility prior to rendering services, as well as monthly, if the provider is providing on-going treatment or services
  • Obtaining authorizations from Cigna-HealthSpring prior to rendering services (with exception to room and board for members residing in Nursing facilities)
  • Providing continuity of care
  • Being culturally and linguistically sensitive to Cigna-HealthSpring members
  • Ensuring on-going continuity of care between the member’s Service Coordinator and his/her PCP
  • Notifying Cigna-HealthSpring of a change in the member’s physical condition or eligibility
  • Notifying Cigna-HealthSpring CarePlan of Illinois when there is a break in HCBS services for any reason
  • Using a National Provider Identification (NPI) number or the Cigna-HealthSpring CarePlan of Illinois-issued Alternative Provider Identification (API) number, whichever is appropriate
  • Billing and reporting services in compliance with the LTSS HCPCS Codes

Cigna-HealthSpring has no network limitations on referrals from PCPs to in-network Specialty Care providers or Ancillary providers. Members must select a PCP or be referred to a Specialty Care provider within the Cigna-HealthSpring network. Additionally, female members may seek obstetrical and gynecological services from any participating OB/GYN without a referral from their PCP. A female Cigna-HealthSpring member also may choose an OB/GYN as her PCP from
the list of participating Cigna-HealthSpring providers.

The below is a general guideline to assist Cigna-HealthSpring providers who have contracted with multiple Medicare-Medicaid plans and are accepting Medicare FFS patients in determining what marketing and patient outreach activities are permissible under the CMS guidelines. CMS has advised Medicare-Medicaid plans to prohibit providers from steering, or attempting to steer an undecided potential enrollee toward a specific plan, or limited number of plans, offered either by the plan sponsor or another sponsor, based on the financial interest of the provider or agent. Providers should remain neutral parties in assisting plans to market to beneficiaries or assisting in enrollment decisions.


The provider can:

  • Mail/call their patient panel to invite patients to general Cigna-HealthSpring-sponsored educational events to learn about the Medicare and/or Medicare-Medicaid program. This is not a sales/ marketing meeting. No sales representative or plan materials can be distributed. Sales representative cards can be provided upon request
  • Mail an affiliation letter one time to patients listing only Cigna-HealthSpring
  • Have additional mailings (unlimited) to patients about participation status but must list all participating Medicare-Medicaid plans and cannot steer towards a specific plan. This letter may not quote specific plan benefits without prior CMS approval and the agreement of all plans listed
  • Notify patients in a letter of a decision to participate in a Cigna-HealthSpring sponsored programs
  • Utilize a physician/patient newsletter to communicate information to patients on a variety of subjects. This newsletter can have a Cigna-HealthSpring corner to advise patients of Cigna-HealthSpring information
  • Provide objective information to patients on specific plan formularies, based on a patient’s medications and health care needs
  • Refer patients to other sources of information, such as the State Health Insurance Assistance programs, Cigna-HealthSpring marketing representatives, State Medicare-Medicaid, or Illinois Client Enrollment Services, 1-800-Medicare to assist the patient in learning about the plan and making a healthcare enrollment decision
  • Display and distribute in provider offices Cigna-HealthSpring MA and MA-PD marketing materials, excluding application forms. The office must display or offer to display materials for all participating MA plans
  • Notify patients of a physician’s decision to participate exclusively with Cigna-HealthSpring for Medicare-Medicaid or to close panel to original Medicare FFS if appropriate
  • Record messages on our auto dialer to existing Cigna-HealthSpring members as long as the message is not sales related or could be construed as steerage. The script must be reviewed by Cigna-HealthSpring Legal /Government programs
  • Have staff dressed in clothing with the Cigna-HealthSpring logo
  • Display promotions items with the Cigna-HealthSpring logo
  • Allow Cigna-HealthSpring to have a room/space in provider offices completely separate from where patients have a prospect of receiving health care, to provide beneficiaries access to a Cigna-HealthSpring sales representative


The provider cannot:

  • Quote specific health plan benefits or cost share in patient discussions
  • Urge or steer towards any specific plan or limited set of plans
  • Collect enrollment applications in physician offices or at other functions
  • Offer inducements to persuade beneficiaries to enroll in a particular plan or organization
  • Health Screen potential enrollees when distributing information to patients, health screening is prohibited
  • Expect compensation directly or indirectly from the plan for beneficiary enrollment activity
  • Call members who are dis-enrolling from the health plan to encourage re-enrollment in a health plan
  • Mail notifications of health plan sales meetings to patients
  • Call patients to invite patients to sales and marketing activity of health plan
  • Cannot advertise using Cigna-HealthSpring’s name without Cigna-HealthSpring’s prior consent and potentially CMS approval depending upon the content of the advertisement

A provider may terminate from the Cigna-HealthSpring network according to the Cigna-HealthSpring participating provider agreement, which details the written notification timeframes and other termination provisions. If a provider agreement is terminated, Cigna-HealthSpring will notify affected members in writing at least fifteen (15) days prior to the effective date of the termination. Affected members include all members in a PCP’s panel and all members
who have been receiving ongoing care from the terminated provider, where ongoing care is defined as two (2) or more visits for home-based or office-based care in the past twelve (12) months.

In the event that a member is receiving covered services at the time a provider agreement is terminated, the provider must continue to provide covered services until the treatment is completed. Once treatment is complete, Cigna-HealthSpring will coordinate the transition of care to another participating Cigna-HealthSpring provider.

Cigna-HealthSpring Primary Care Physicians have a limited right to request a member be assigned to a new Primary Care Physician. A provider may request to have a member moved to the care of another provider due to the following behaviors:

  • Fraudulent use of services or benefits
  • The member is disruptive, unruly, threatening or uncooperative to the extent that his/her membership seriously impairs Cigna-HealthSpring’s or the provider’s ability to provide services to the member or to obtain new members and the aforementioned behavior is not caused by a physical or behavioral health condition.
  • Threats of physical harm to a provider and/or his/her office staff
  • Receipt of prescription medications or health services in a quantity or manner which is not medically beneficial or not medically necessary.
  • Repeated refusal to comply with office procedures essential to the functioning of the provider’s practice or to accessing benefits under the managed care plan
  • The member is steadfastly refusing to comply with managed care restrictions (e.g., repeatedly using the emergency room in combination with refusing to allow the managed care organization to coordinate treatment of the underlying medical condition)

The provider should make reasonable efforts to address the member’s behavior which has an adverse impact on the patient/physician relationship, through education and counseling, and if medically indicated, referral to appropriate specialists.

If a provider identifies a non-compliant member, the provider should call Cigna-HealthSpring provider Services at 1(866)486-6065 to report the concern. Cigna-HealthSpring will research the concern and decide if the situation warrants requesting a new PCP assignment. If so, Cigna-HealthSpring will document all actions taken by the provider and Cigna-HealthSpring to cure the situation. 

This may include member education and counseling. A Cigna-HealthSpring PCP cannot request a disenrollment based on adverse change in a member’s health status or utilization of services medically necessary for treatment of a member’s condition.



  • Once it has been determined that the physician/patient relationship has been irreparably harmed, the member will receive a minimum of thirty (30) days notice that the physician/patient relationship will be ending. 
  • Notification must be in writing, by certified mail and Cigna-HealthSpring must be copied on the letter sent to the patient
  • The physician will continue to provide care to the member during the thirty (30) day period or until the member selects or is assigned to another physician. Cigna-HealthSpring will assist the member in establishing a relationship with another physician
  • The physician will transfer, at no cost, a copy of the medical records of the member to the new PCP and will cooperate with the member’s new PCP in regards to transitioning care and providing information regarding the member’s care needs

A member may also request a change in PCP for any reason. The PCP change that is requested by the member will be effective the first (1st) of the month following the receipt of the request, unless circumstances require an immediate change

From time to time, Cigna-HealthSpring may amend, alter, or clarify its policies. Examples of this include, but are not limited to, regulatory changes, changes in medical standards, and modification of Covered Services. Specific Cigna-HealthSpring policies and procedures may be obtained by calling our Provider Services Department at 1-866-486-6065.

Cigna-HealthSpring will communicate changes to the Provider Manual through the use of a variety of methods including but not limited to:

  • Annual Provider Manual Updates
  • Letter
  • Facsimile
  • Email
  • Provider Newsletters

Providers are responsible for the review and inclusion of policy updates in the Provider Manual and for complying with these changes upon receipt of these notices.

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Covererd Services

Cigna-HealthSpring provides a benefit package to MMAI members that includes all medically necessary services covered under the traditional, fee-for-service Medicare-Medicaid program. The following list provides an overview of these benefits. providers can refer to the member’s Evidence of Coverage (EOC) for a more inclusive listing of limitations and exclusions.

  • Ambulance services
  • Behavioral Health Services
  • Birthing services provided by a physician or Advanced Practice Nurse in a licensed birthing center
  • Birthing services provided by a licensed birthing center
  • Chiropractic services
  • Dialysis
  • Durable medical equipment and supplies
  • Emergency services
  • Family planning services
  • Home health care services
  • Hospital services 
  • Laboratory
  • Mastectomy, breast reconstruction, and related follow-up procedures, including:
    • Out-patient services provided at an out-patient hospital and ambulatory health care center as clinically appropriate; and physician and professional services provided in an office, in-patient, or out-patient setting for:
      • External breast prosthesis for the breast(s) on which medically necessary mastectomy procedure(s) have been performed
      • All stages of reconstruction on the breast(s) on which medically necessary mastectomy procedure(s) have been performed
      • Surgery and reconstruction on the other breast to produce symmetrical appearance
      • Treatment of physical complications from the mastectomy and treatment of lymphedemas
      • Prophylactic mastectomy to prevent the development of breast cancer
  • Podiatry
  • Prenatal care
  • Primary care services
  • Preventive services including an annual adult well check for members 21 years of age and over
  • Radiology, imaging, and x-rays
  • Specialty physician services
  • Therapies – physical, occupational and speech
  • Transplantation of organs and tissues

When a member does not keep a scheduled appointment, the Behavioral Health provider should contact the member to reschedule the missed appointment within twenty-four (24) hours. Providers should not bill members for missed appointments.

To ensure continuity of care, Cigna-HealthSpring requires its Behavioral Health providers to follow-up with members on an out-patient basis within seven (7) days after discharge from an in-patient setting. Also, Behavioral Health providers should follow-up telephonically or face-to-face with members who are non-compliant with medications and/or treatment. Providers are encouraged to contact Cigna-HealthSpring so appropriate and timely care coordination and intervention activities can occur.

When filing claims for behavioral health services, providers must use the DSM-IV multi-axial classification system and report a complete diagnosis using the five (5) Axes. Behavioral health services require the development of a treatment plan. Documentation must always indicate date of service. Comorbid physical health conditions should be noted in Axis 3 of the diagnosis.

The Illinois Department of Healthcare and Family Services (HFS) in collaboration with Illinois Department on Aging and Illinois Department of Human Services has a variety of waiver services available for people who qualify.  Cigna-HealthSpring CarePlan of Illinois is responsible for managing five of these waivers in order to facilitate independence by supporting individuals to remain in their own homes or to live in a community setting thus reducing need for institutional living. These waivers provide additional benefits in addition to traditional fee for service Medicaid benefits.  Cigna-HealthSpring CarePlan of Illinois manages the following five waivers:

  • Persons who are Elderly Waiver:The Persons who are Elderly Waiver is for those people 60 years or older that live in the community and are at risk of nursing facility placement. Services include: 
    • Adult Day Care Services
    • Transportation to an Adult Day Care center
    • Homemaker services
    • Personal Emergency Response System
  • Persons with Disabilities Waiver: The Persons with Disabilities Waiver is for individuals with disabilities who are under age 60 at the time of application and are at risk of placement in a nursing facility.  Individuals 60 years or older, who began services before age 60, may choose to remain in this waiver.  Services include:
    • Adult Day Care Services
    • Personal Emergency Response System
    • Home modifications
    • Home-delivered meals
    • Home health aide
    • Homemaker services
    • Occupational therapy
    • Personal Assistant
    • Physical therapy
    • Respite
    • Skilled nursing
    • Intermittent Nursing
    • Specialized medical equipment and supplies
    • Speech therapy
  • Persons with HIV or AIDS Waiver: The Persons with HIV or AIDS Waiver is for individuals of any age who are diagnosed with Human Immune Deficiency Virus (HIV) or Acquired Immune Deficiency Syndrome (AIDS) and are at risk of placement of a nursing facility. Services include:
    • Adult Day Care
    • Personal Emergency Response System
    • Home modifications
    • Homemaker services
    • Home-delivered meals
    • Personal assistant
    • Physical therapy
    • Occupational therapy
    • Respite
    • Skilled nursing
    • Intermittent Nursing
    • Home health aide
    • Speech therapy
    • Specialized medical equipment and supplies
  • Persons with Brain Injury Waiver: The Persons with Brain Injury Waiver is for individuals with brain injury, of any age, who are at risk of nursing facility placement due to functional limitations resulting from the brain injury. Services include:
    • Adult Day Care
    • Cognitive Behavioral Therapies Day Habilitation 
    • Home modifications
    • Home-delivered meals
    • Homemaker services
    • Occupational therapy
    • Personal assistant/
    • Personal Emergency Response System
    • Physical Therapy
    • Prevocational services
    • Respite
    • Skilled nursing/Home health aide
    • Intermittent Nursing
    • Specialized medical equipment and supplies
    • Speech therapy
    • Supported employment services
  • Supportive Living Facilities Waiver: The Supportive Living Facilities Waiver is for individuals age 22-64 with a physical disability or persons age 65 or over in a Supportive Living Facility (SLF). The following services may be provided to you directly by the Supportive Living Facility.:
    • Nursing services
    • Personal care
    • Medication assistance
    • Health promotion and exercise programming
    • Meals and snacks
    • Laundry
    • Housekeeping
    • Maintenance
    • 24-hour response/security staff
    • Emergency call system
    • Well-being check
    • Ancillary services
    • Management of resident funds, if applicable


To ensure that members have the freedom of choice to apply for and, if eligible, to receive available Long Term Services and Support benefits  members have a right to choose nursing facility placement, supportive facility placement or Home and Community Based Services (HCBS).  Members also have a right to choose not to receive the above mentioned LTSS services.  Members also have the right to choose an appropriate authorized provider(s) that is willing and qualified in their geographic area of residence to receive services needed by the member.

In addition to traditional MMAI benefits, Cigna-HealthSpring CarePlan of Illinois offers certain “value-added” services to its members. Value-added services are benefits that only Cigna-HealthSpring CarePlan of Illinois’ members receive. These benefits have been added to Cigna-HealthSpring CarePlan of Illinois in order to promote healthy lifestyles and improve health outcomes for members.

Initially, Cigna-HealthSpring CarePlan of Illinois notifies new members regarding the available value-added services and how to access them in their Welcome Kit. Thereafter, benefit education materials are sent to the members annually, outlining the available value-added services and how to access them. Additional details about value-added services are available at Cigna-HealthSpring CarePlan of Illinois members can get assistance accessing value-added services from their Care Coordinator by calling 1(866)487-3002 and selecting option 4 for Care Coordination services or option 7 for members enrolled in LTSS. Cigna-HealthSpring CarePlan of Illinois’ value-added services are listed below.

  • 24 Hour Nurse Advice Line: Toll-free access to experienced registered nurses, 24 hours a day, 365 days per year, for immediate reliable information for any health concern.
  • Dental: Additional preventive and comprehensive dental care for adults
  • Vision: Routine eye exam and eyewear allowance
  • Hearing Services: Routine hearing exam, fittings and hearing aids
  • OTC: Members can get $10 each month in over-the-counter items from the OTC catalog.
  • Fitness: Gym membership at participating fitness location
  • Meals: After a member is discharged from a hospital stay (for traumatic or chronic illness), Cigna-HealthSpring CarePlan of Illinois will have 20 frozen nutritional meals consisting of 10 lunches and 10 dinners delivered to their home.
  • Transportation: Unlimited transportation to and from member’s Doctor. Also transportation to network pharmacy immediately after a doctor visit.

The following are definitions for routine, urgent, and emergent care:

  • Routine care: Routine care means health care for covered preventive and medically necessary health care services that are non-emergent or non-urgent.

  • Urgent Condition: Urgent condition means a health condition, including an urgent behavioral health situation, that is not an emergency but is severe or painful enough to cause a prudent layperson, possessing an average knowledge of medicine, to believe that his or her condition requires medical treatment evaluation or treatment within twenty-four (24) hours by the member’s PCP or PCP designee to prevent serious deterioration of the member’s condition or health.

  • Emergency Services: Emergency Services are covered in-patient and out-patient services furnished by a provider that is qualified to furnish such services and that are needed to evaluate or stabilize an Emergency Medical Condition and/or an Emergency Behavioral Health Condition, including Post-stabilization Care Services. Emergency care is covered for Cigna-HealthSpring members twenty-four (24) hours a day, seven (7) days a week. Prior authorization is not required for Emergency Services.

  • Emergency Behavioral Health Condition: Emergency Behavioral Health means any condition, without regard to the nature or cause of the condition, which in the opinion of a prudent layperson possessing an average knowledge of health and medicine: (1) requires immediate intervention and/or medical attention without which members would present an immediate danger to themselves or others, or (2) which renders members incapable of controlling, knowing or understanding the consequences of their actions.

  • Emergency Medical Condition: Emergency Medical Condition means a medical condition manifesting itself by acute symptoms of recent onset and sufficient severity (including severe pain), such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical care could result in: (1) placing the patient’s health in serious jeopardy; (2) serious impairment to bodily functions; (3) serious dysfunction of any bodily organ or part; (4) serious disfigurement; or (5) in the case of a pregnant women, serious jeopardy to the health of a woman or her unborn child.

  • Except for Emergency Services, members are encouraged to contact their PCP prior to seeking care. In the case of an Emergency Medical Condition, a Cigna-HealthSpring member may access care at any provider office or hospital. Members should contact Cigna-HealthSpring or their PCP by the close of the next business day to notify Cigna-HealthSpring of the Emergency Medical Condition.

When a member has an Emergency Medical Condition as defined above, emergency transportation is covered at the basic life support (BLS) level. Prior authorization from Cigna-HealthSpring is not required for emergency transportation. Facility-to-facility transport may be considered an emergency if the emergency treatment is not available at the first facility and the member still requires Emergency Services.

Non-emergent ambulance transportation is a covered benefit in the Medicare-Medicaid program for members who are severely disabled or have limited mobility.
All non-emergent, ambulance transportation requires prior authorization from Cigna-HealthSpring. For more information about obtaining prior authorization, providers should reference the Medical Management section of this Provider Manual.

MMAI Eligibilty & Enrollment

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The Demonstration will be available to individuals who meet all of the following criteria:

  • Beneficiaries who reside in coverage area
  • Age 21 and older at the time of enrollment
  • Entitled to benefits under Medicare Part A and enrolled under Medicare Parts B and D, and receiving full Medicare-Medicaid benefits
  • Enrolled in the Medicare-Medicaid Aid to the Aged, Blind, and Disabled (AABD) category of assistance

Eligible populations include:

  • Beneficiaries who meet all other Demonstration criteria and are in the following Medicaid 1915(c) waivers: 
    • Persons who are Elderly
    • Persons with Disabilities
    • Persons with HIV/AIDS
    • Persons with Brain Injury
    • Persons residing in Supportive Living Facilities
  • Individuals with End Stage Renal Disease (ESRD) at the time of enrollment.

The following populations will be excluded from enrollment:

  • Individuals under the age of 21
  • Individuals receiving developmental disability institutional services or who participate in the HCBS waiver for Adults with Developmental Disabilities 
  • The Medicare-Medicaid Spend-down population 
  • Beneficiaries in the Illinois Medicare-Medicaid Breast and Cervical Cancer program 
  • Individuals enrolled in partial benefit programs 
  • Individuals enrolled in both Medicare-Medicaid who have Comprehensive Third Party Insurance

Once a client is determined by HHSC to be eligible for MMAI, he/she will receive an enrollment packet in the mail from the Client Enrollment Broker (CEB). The packet contains information about the MMAI program, instructions for completing the enrollment form, and information about the HMOs available in his/her service delivery area. The CEB processes MMAI applications, assists members who are transitioning from their former plan into the MMAI program,
and assists members in selecting an HMO and a PCP. Members who need assistance can contact an enrollment counselor by calling the CEB Helpline at 1(877)912-8880.

Because MMAI members may change health plans, lose Medicare-Medicaid eligibility, or change PCPs routinely,
it is crucial for providers to verify member eligibility prior to rendering services. If a provider does not verify eligibility prior to rendering services and the member is determined later not to be a Cigna-HealthSpring member, then Cigna-HealthSpring cannot reimburse the provider for his/her services. Eligibility verification prior to every visit is essential to ensuring providers receive payment for services rendered.

Eligibility can be verified in a variety of different ways: through member identification cards, through Cigna-HealthSpring on the provider portal at or telephone verification process, or through State sources such as the MEDI System.

Cigna-HealthSpring Member Identification Cards
Cigna-HealthSpring issues an identification card (ID) to all members upon Cigna-HealthSpring receiving State eligibility files. This card identifies the member as a Cigna-HealthSpring member. Also, it gives providers quick access to important information such as the member’s name and identification number, the PCP’s name and phone number, the Cigna-HealthSpring claims filing address, and the phone number for prior authorizations and Member Services. Providers should ask members to present this ID card at the time of service. An example of the Cigna-HealthSpring ID card is provided in Appendix A of this Provider Manual.

Telephonic and Electronic Eligibility Verification
Once the provider has made a copy of the member’s identification cards, the next step is to verify eligibility telephonically or electronically. As mentioned previously, members can change PCPs anytime and change HMOs monthly resulting in member identification cards being outdated almost as soon as they are printed. Telephonic and electronic verification give providers access to “real time” eligibility information and provide another level of assurance that the provider’s claim can be processed quickly.

Providers can call Cigna-HealthSpring at 1(866)486-6065 from 8 a.m. – 5 p.m. CST, Monday – Friday to speak with a representative who can verify eligibility or they can use [Cigna-HealthSpring’s Automated Eligibility Verification Line by calling 1(866)486-6065. This system is available twenty-four (24) hours a day, seven (7) days a week.] A third option for verifying eligibility through Cigna-HealthSpring is through the provider portal at

On a monthly basis, Cigna-HealthSpring supplies each PCP with a member panel report. The report contains a listing of all members assigned to the PCP’s membership panel and is sent to PCPs upon Cigna-HealthSpring receiving State eligibility files. The PCP is responsible for providing and/or coordinating care for the all members on the report according to the requirements outlined in this Provider Manual and the Cigna-HealthSpring participating provider agreement.

PCPs may access their panel report online at If a member does not appear on the PCP’s panel report, the PCP can call the Cigna-HealthSpring Provider Services Department at 1(866)486-6065 to verify the member’s PCP assignment.

Member disenrollment from Cigna-HealthSpring may occur if the member:

  • Selects another MMAI HMO
  • Moves out of the service delivery area
  • Is no longer eligible for MMAI
  • Opted out of the program

A member may request a disenrollment through the Client Enrollment Broker. If the member contacts Cigna-HealthSpring to request a disenrollment, Cigna-HealthSpring will direct the member to contact MAXIMUS at 1(877)912-8880.

If a provider identifies a non-compliant member, the provider should call the Cigna-HealthSpring provider Services Department at 1(866)486-6065 to report the concern. Cigna-HealthSpring will document all attempts by the provider and Cigna-HealthSpring to rectify the situation. This may include member education and counseling.

Members disenrolled due to temporary ineligibility for Medicare-Medicaid will be automatically re-enrolled with their previously selected HMO and PCP when they regain eligibility status. Temporary loss of eligibility is defined as a loss of eligibility for a period of six (6) months or fewer. Members can opt to change HMOs at the time of automatic re-enrollment or at any other time through the Client Enrollment Broker by calling MAXIMUS at 1(877)912-8880.

Members can change HMOs monthly by calling MAXIMUS at 1(877)912-8880.

If a member calls to change health plans on or before the 15th of the month, the change will take place on the first day of the next month. If he/she calls after the 12th of the month, the change will take place the first day of the second month after that. For example:

  • If the member asks to change plans on or before April 12, the change will take place on May 1.
  • If the member asks to change plans after April 12, the change will take place on June 1.

Members can change PCPs at any time by calling the Cigna-HealthSpring member Services Department at 1(866)487-4331. PCP changes are effective on the next business day, following a member request.

Member eligibility is subject to retroactive changes for various reasons. If a member’s eligibility in Cigna-HealthSpring is retroactively terminated, the Cigna-HealthSpring Claim Recovery Department will request a refund for all previously paid claims from the provider. It is the provider’s responsibility to re-verify eligibility to determine the member’s coverage for the date(s) of service in question and then file the claim with the appropriate payer.

Medical Management

Cigna-HealthSpring CarePlan of Illinois will perform medical management functions for members enrolled with our health plan. Cigna-HealthSpring CarePlan of Illinois coordinates physical health, behavioral health, LTSS and specialty services to ensure quality, timely, clinically-appropriate, and cost-effective care that results in clinically desirable outcomes.

Cigna-HealthSpring CarePlan of Illinois’ goal is to improve the members’ health and well-being through effective ambulatory management of chronic conditions, resulting in a reduction of avoidable in-patient admissions. The Utilization Management (UM) process provides an opportunity for Cigna-HealthSpring CarePlan of Illinois to:

  • Determine the appropriateness of the services
  • Ensure that services are provided at the most appropriate level of care
  • Ensure authorized services are provided timely
  • Ensure the services are provided by the most appropriate provider and in the most appropriate setting
  • Ensure that services are covered under the member’s benefit plan
  • Verify and coordinate other insurance benefits
  • Monitor participating providers’ practice patterns
  • Improve utilization of resources by identifying and correcting patterns of over and under utilization
  • Identify high-risk members
  • Provide utilization data for use in the re-credentialing process

Cigna-HealthSpring CarePlan of Illinois works with CMS and HFS to determine eligibility of our members. Once eligibility has been determined a member of the care coordination team will contact the member, including those members that live in the community, reside in long term nursing facilities or supportive living facilities, and those receiving Home and Community Based Waiver Services. Cigna-HealthSpring CarePlan of Illinois has internal processes to ensure transition to and from other plans such as another managed care organization and agencies such as Department on Aging, Department of Human Services, Division of Rehabilitative Services and the Department Healthcare and Family Service.  Cigna-HealthSpring CarePlan of Illinois provides 180 days of continuity of services for members newly enrolled in managed care and 90 days of continuity of care for members enrolled from another MCO.  Cigna-HealthSpring CarePlan of Illinois will not adjust services without the member’s consent during this time.

Cigna- HealthSpring CarePlan of Illinois’ care coordination  staff will assist in the coordination of medical care and support services for members across the delivery system (whether in or out of the network) and to assure continuity of care after discharge from an in-patient and skilled nursing facility setting.

Utilization review decisions are made in accordance with currently accepted medical or health care practices, taking into account the special circumstances of each case that may require deviation from the norm as stated in the screening criteria. Cigna-HealthSpring utilizes InterQual Criteria and other state specific criteria for approving medically necessary physical and behavioral health services. At least annually, Cigna-HealthSpring assesses the consistency with which reviewers apply the criteria. Criteria are available for review and inspection by the Illinois Department of Insurance Commissioner or designated representative and, upon written request for a specific case, to individual providers.

All medical necessity denials for coverage of health care services or reductions in the scope, duration or amount of services requested by a member or provider, are reviewed by the Medical Director. Only a Medical Director has the authority to render adverse determinations for medical necessity requests. Special circumstances include, but are not limited to, a person with a disability, acute condition, or life-threatening illness.

Utilization review decision-making is based only on appropriateness of care and service. Cigna-HealthSpring’s compensation to providers, associates, or other individuals conducting utilization review on its behalf does not contain incentives, direct or indirect, to approve or deny payment for the delivery of any health care service.

Cigna-HealthSpring members should access care through their PCPs. If the PCP determines that specialty care, diagnostic testing, or other ancillary services are required, the PCP should refer the member to an in-network provider. The use of a specific referral form is not necessary for in-network referrals. Approval from Cigna-HealthSpring for in-network referrals is not necessary, unless the requested service is listed in Appendix D of this Provider Manual. Appendix D is Cigna-HealthSpring’s list of Prior Authorization Services. This list is also referenced on the provider tab on Cigna-HealthSpring’s website at The list of Prior Authorization Services is intended to provide an overview of services requiring authorization. If a member requires a service that is not listed in Appendix D, the provider should contact Health Services to inquire about the need for prior authorization. The presence or absence of a procedure or service on the list does not determine a member’s coverage or benefits.

To initiate the prior authorization process, providers should follow the procedures listed below.

    1. The provider evaluates a Cigna-HealthSpring member and determines that a “prior authorization service” is required.

    1. At least five (5) business days prior to the requested date of service, the provider completes an Out-patient Prior Authorization Request Form which is found in Appendix E of this Provider Manual. The provider should include all pertinent information such as results of any diagnostic tests or laboratory services results, if available. Failure to request authorization five (5) days prior to the date of service could result in an Adverse Determination.

  1. The provider faxes the completed form to Cigna-HealthSpring at one of the following numbers which are confidential fax lines and are available twenty-four (24) hours per day, seven (7) days per week:
    • Behavioral Health In-patient and Out-patient services: 1(866)949-4846
    • In-patient, Skilled Nursing Facility, and Home Health: 1(847)993-1995
    • Other Out-patient Authorization Requests: 1(855)552-0701

Alternatively, providers may initiate a prior authorization request through Cigna-HealthSpring’s provider portal at or by calling the Cigna-HealthSpring Prior Authorization Department at 1(866)487-3002, option 3.

The Prior Authorization Department is available Monday – Friday from 8 a.m. - 8 p.m. CST. When calling for a prior authorization, providers should be prepared to provide the following information over the telephone:

  • Member name and identification number
  • Location of service e.g., hospital or surgery center setting
  • PCP name
  • Servicing/Attending physician name;
  • Date and units of service
  • Diagnosis
  • Service/Procedure/Surgery description and CPT or HCPCS code
  • Clinical information supporting the need for the service to be rendered

Regardless of the method by which a physician requests prior authorization, Cigna-HealthSpring prioritizes all prior authorization requests according to medical necessity. Cigna-HealthSpring reviews requests made after hours on the following business day.

A prior authorization request may be referred to a nurse or other clinical staff who completes the medical necessity screening. It may be necessary to collect additional information from the ordering provider such as projected itemized costs or clinical information that is necessary to make the decision.

If the prior authorization request is approved, Cigna-HealthSpring will issue an authorization number that can be used when billing for the approved services. Cigna-HealthSpring will fax the approved Prior Authorization Request Form, along with the authorization number, back to the requesting provider according to the following timeframes:

    • Standard Request: If all required information is submitted at the time of the request, Cigna-HealthSpring will respond to a Prior Authorization Request Form within two (2) business days of receipt of the request

    • Urgent Request: An urgent request can be requested if/when the provider believes that waiting for a decision under the standard request timeframe could place the member’s life, health, or ability to regain maximum function in serious jeopardy. For these cases, providers may make an urgent request. Cigna-HealthSpring will respond to an urgent prior authorization request within one (1) business day or sooner if required

    • Emergency Admissions and Services: Prior authorization is not required for Emergency Services. However, providers must notify Cigna-HealthSpring of Emergency Services within twenty-four (24) hours or by the next business day, whichever is later.

  • Post-Stabilization Request: Post-stabilization requests can be made for covered services related to an Emergency Medical Condition provided after a member has been stabilized. These are services to maintain the stabilized condition or, under certain circumstances, are not pre-approved but are administered to maintain, improve, or resolve the member’s stabilized condition. Cigna-HealthSpring will respond to post-stabilization requests within one (1) hour.

If the request for authorization does not meet medical necessity requirements, the request will be denied. The ordering provider will be notified of the denial by phone and in writing. The member will be notified of the denial in writing.

Authorizations for acute care services are usually issued for thirty (30) days. Authorizations for LTSS are issued for up to twelve (12) months depending on the service requested. It is the provider’s responsibility to check the member’s eligibility every month, as the member’s coverage is subject to change.
Failure to obtain prior authorization for services that require authorization may result in non-payment of services. It is important to note that prior authorization does not guarantee payment.

Cigna-HealthSpring members may access the following services without seeking direction from their PCP first:

  • OB/GYN
  • Specialty Care Provider
  • Family Planning
  • Behavioral Health
  • Value-Added services

If a service is not available within Cigna-HealthSpring’s provider network, a PCP may refer out-of-network. Prior to referring out-of-network, the PCP should document the justification for out-of-network services and obtain prior authorization from Cigna-HealthSpring according to the Prior Authorization Process described above.

Cigna-HealthSpring ensures that new members transition smoothly into Cigna-HealthSpring and that care is not interrupted unnecessarily. New members in active treatment by a Specialty Care Provider or Behavioral Health Provider require special attention to ensure continuity of care and to ensure their health is not jeopardized.

    • Pregnant Women: Pregnant members with sixteen weeks or fewer remaining before the expected delivery date must be allowed to remain under the care of their current OB/GYN through the member’s post- partum checkup if the OB/GYN Provider is, or becomes out-of-network. The member also may select an OB/GYN within the network, if she chooses to do so and if the new OB/GYN Provider agrees to accept her.

    • Member Moves Out of Service Area: Members who move out of the service delivery area are responsible for obtaining a copy of their medical records from their current provider on behalf of their new PCP. Participating Cigna-HealthSpring providers are required to furnish members with copies of their medical records.

    • Pre-existing Conditions: Cigna-HealthSpring does not have a pre-existing condition limitation. Cigna-HealthSpring provides all covered services to new members beginning on the member’s date of enrollment into Cigna-HealthSpring, regardless of any pre-existing conditions, prior diagnoses and/or receipt of prior health care services.

    • Active Course of Treatment: Cigna-HealthSpring makes special provisions for new members who are considered in an “Active Course of Treatment.” An Active Course of Treatment is a planned program of services rendered by a provider that starts on the date a provider first renders services to correct or treat the diagnosed condition. An Active Course of Treatment covers a defined number of services or a period of treatment.

    • For members in an Active Course of Treatment with an out-of-network provider at the time of enrollment: Cigna-HealthSpring will authorize out-of-network services until the member’s records, clinical information and care can be transferred to an in-network provider or until one hundred eighty (180) days from enrollment in Cigna-HealthSpring, the active course of treatment is completed, or the member is no longer enrolled in Cigna-HealthSpring, whichever of the three is shortest.

  • Cigna-HealthSpring Medical Management will coordinate all necessary referrals and pre-certifications to ensure care is not interrupted during a new member’s transition. Out-of-network providers who continue treating Cigna-HealthSpring members during a transition period must:
    • Continue to provide the members’ treatment and follow-up
    • Accept Cigna-HealthSpring reimbursement rates
    • Share information regarding the treatment plan with Cigna-HealthSpring 
    • Refer in-network for laboratory, radiology services, or hospital services

All requests for out-of-network, continuity of care are reviewed on a case-by-case basis by Cigna-HealthSpring.

All requests not meeting the conditions for continuity of care will be forwarded to the Medical Director who will review the request on a priority basis.

In-patient medical and behavioral health services are covered benefits for MMAI members. For in-patient services, Cigna-HealthSpring is responsible for medical management functions, such as prior authorization and concurrent review. Cigna-HealthSpring members should access in-patient services at in-network facilities. For a listing of in- network facilities, providers should refer to the Cigna-HealthSpring provider Directory which is available at

For in-patient behavioral health services, Cigna-HealthSpring is responsible for all medical management functions, such as prior authorization and concurrent review.

Concurrent Review is the process of initial assessment and continual reassessment of medical necessity and appropriateness of in-patient care during an acute care hospital admission, rehabilitation admission, or skilled nursing facility admission. Concurrent review helps ensure that covered services are provided at the most appropriate level of care.

Hospital providers are required to provide Cigna-HealthSpring with notification of the following types of admissions:

  • Elective Admissions
  • ER and Urgent Admissions
  • Transfers to acute rehabilitation, long-term acute care facilities (LTACs) and skilled nursing facilities (SNFs)
  • Admissions following out-patient procedures
  • Admissions following Observation Status

Notifications must be made within twenty-four (24) hours of admission or by the next business day, whichever is later. If the admission occurs during a holiday or weekend, then notification must be made by close of the next business day. Admission notification may be made by calling Cigna-HealthSpring’s Health Services Department at 1(866)87-3002 and requesting to speak with the In-patient Intake Unit or by faxing an In-patient Prior Authorization Form to 1-(847)993-1995. The “In-patient Prior Authorization Request Form” can be found in Appendix F of this Provider Manual.

If notification is not provided according to the guidelines above, authorization will not be granted and claims for services will be denied. Denials for no authorization may be appealed and will be subject to retrospective medical review. It may be necessary to provide documentation of the reason for failing to provide timely notification as well as clinical documentation.

Once Cigna-HealthSpring has been notified of the admission, Cigna-HealthSpring’s preferred method for concurrent review is a dialogue between the concurrent review nursing staff and the facility’s UM staff. The dialogue should take place within twenty-four (24) hours of notification or on the last covered day. If clinical information is not received within seventy-two (72) hours of admission or by the last covered day, the case will be reviewed for medical necessity with the information Cigna-HealthSpring has available.

Following an initial determination, the concurrent review nurse will request additional updates from the facility on a case-by-case basis. Cigna-HealthSpring will render a determination within twenty-four (24) hours of receipt of pertinent clinical information. A Cigna-HealthSpring nurse will make every attempt to collaborate with the facility’s case management staff and request additional clinical information in order to provide a favorable determination. Providers should fax clinical updates to the Cigna-HealthSpring Concurrent Review Department at 1(847)993-1995 twenty-four (24) hours prior to the next review and Behavioral Health at 1(866)780-8546. All in-patient or institutional days, which do not meet medical necessity criteria, are communicated verbally to the facility case managers. A Cigna-HealthSpring medical director will make the final decision on cases not meeting medical necessity criteria. If the Cigna-HealthSpring medical director deems that the confinement does not meet criteria, he/she will issue a denial. Cigna-HealthSpring encourages, and will provide contact information for, peer-to-peer communication between the attending physician and Cigna-HealthSpring medical director to discuss the lack of medical necessity and appropriateness of continued in-patient stay. Following this peer-to-peer discussion, the medical director will make a determination to approve or deny the admission or service in question.

Discharge Planning is a critical component of the UM process that begins upon admission with an assessment of the member’s potential discharge care needs. It includes preparation of the member and his/her family for continuing care needs and initiation of arrangements for placement or services needed after acute care discharge.

Examples of medical and behavioral health care that can be arranged in the discharge planning phase include:

  • Home health care
  • Physical therapy
  • Speech therapy
  • Occupational therapy
  • Skilled nursing facility placement
  • Rehabilitation therapy facility placement
  • Home infusion therapy
  • Durable medical supplies as well as coordination with community agencies when applicable

The member’s assigned Care Coordinator participates in the discharge planning process to ensure seamless transition to appropriate providers and services.

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Billing and Claims Administration

As indicated in the table below, providers should submit claims based on the type of services provided.

Type of Service
 Claims Addresses
Acute care and LTSS services except in-patient hospital services
Behavioral health services (including in-patient behavioral health claims)
In-patient hospital services(except behavioral health in-patient claims which
will be submitted to Cigna-HealthSpring – see above “Behavioral Health Services
Paper Claims:
Attn: Claims
PO Box 981804
El Paso, TX 79998

Electronic Claims:
Payor ID: 63092
Dental services (DentaQuest)  

Paper Claims:
DentaQuest of Illinois
12121 N. Corporate Parkway
Mequon, WI 53092

Electronic Claims can be
submitted through:
DentaQuest’s website at
HIPAA Compliant 837D file
A clearinghouse using Payer ID CX014

Vision services
(Block Vision)

Paper Claims:
Block Vision Attn: Claims
939 Elkridge Landing Rd.,
Suite 200
Linthicum, MD 21090

Electronic Claims:
Online via


Providers must submit claims to Cigna-HealthSpring within one-hundred and twenty (120) days from the date the covered service was rendered. If the claim is not filed with Cigna-HealthSpring within one-hundred and twenty (120) days from the date of service, the claim will be denied. The required data elements for Medicare-Medicaid claims must be present for a claim to be considered clean. If Cigna-HealthSpring is the secondary payer, providers must include the primary payer’s explanation of payment.
Encounter Data

If Cigna-HealthSpring is paying a provider under a capitation arrangement, the provider must submit claims to Cigna-HealthSpring on either a CMS 1500 or a UB-04 form. These claims, referred to as “Encounter Data,” are processed within Cigna-HealthSpring’s claims payment system like a claim; however, no payment is issued. Encounter data enables Cigna-HealthSpring to:

  • Track utilization
  • Analyze member care patterns
  • Adhere to State and federal HMO regulations
  • Support quality assurance studies

Cigna-HealthSpring accepts claims in both hard copy and electronic formats. Acceptable hard copy claim formats are either the CMS 1500 or UB-04 claim forms. Electronic claims are the preferred method of submission. Electronic claims can be submitted to Cigna-HealthSpring through either Emdeon (formerly WebMD Envoy) or Availity (formerly T.H.I.N.), or PayerPath. Both the CMS-1500 and the UB-04 forms are accepted. The Cigna-HealthSpring Payer ID is 63092.

Providers are required to submit either their NPI or API number, whichever is applicable, to Cigna-HealthSpring. An NPI number is a standard, nationally-assigned, “non-intelligent” provider identifier that is required to be used in all electronic health care transactions effective May 27, 2008. Providers who do not have an NPI number can obtain one by calling 1-800-465-3203 (TTY 1-800-692-2326) or by emailing

Providers also may obtain an NPI by writing to NPI Enumerator, P.O. Box 6059, Fargo, ND 58108-6059. The information required for attestation includes the provider’s:

  • TPI
  • NPI or API
  • Taxonomy
  • Physical Address
  • National Plan and Provider Enumeration System Data

When filing electronic claims, providers must submit their NPI or API number, whichever is applicable, and their taxonomy code. Some LTSS providers are not eligible for an NPI. These providers must request an API number from Cigna-HealthSpring.

When a MMAI member has other insurance benefits, the provider must bill the other insurance carrier prior to billing Cigna-HealthSpring. Providers must supply the following information to Cigna-HealthSpring within 365 days of the
date of service:

  • Name and address of the primary payer
  • Date the primary payer was billed
  • Statement signed and dated by the provider indicating that disposition has not been received from the primary payer within 365 days of the date the claim was filed

Providers should submit the claim as soon as disposition is received from the other insurance company to ensure the payment deadlines are not missed.

If a provider renders services that require prior authorization without first obtaining prior authorization, then the claim
will be denied.

Cigna-HealthSpring processes clean claims, as defined by the Cigna-HealthSpring participating provider agreement, within thirty (30) days of receipt of the claim. Cigna-HealthSpring providers are reimbursed in accordance with their Cigna-HealthSpring participating provider agreements.

Cigna-HealthSpring also supports the Primary Care Provider Incentive Payment program in accordance with state regulations and requirements.

Provider Services can assist providers with questions concerning eligibility, benefits, claims and claims status. To check claims status, providers can call the provider Services Department at TBD or access the provider portal at If a claim needs to be reprocessed for any reason, provider Services will coordinate reprocessing with the Claims Department.

Participating Cigna-HealthSpring providers are prohibited from balance billing MMAI members including, but not limited to, situations involving non-payment by Cigna-HealthSpring, insolvency of Cigna-HealthSpring, or Cigna-HealthSpring’s breach of its Agreement. Provider shall not bill, charge, collect a deposit from, seek compensation or reimbursement from, or have any recourse against members or persons, other than Cigna-HealthSpring, acting on behalf of members for covered services provided pursuant to the Cigna-HealthSpring participating provider agreement. The provider is not, however, prohibited from collecting copayments, co-insurances or deductibles for non-covered services in accordance with
the terms of the applicable member’s benefit plan.

In the event that a provider refers a member to a non-participating provider without prior authorization from Cigna-HealthSpring, if required, or provides non-covered services to a member, the provider must inform the member in advance, in writing: (i) of the service(s) to be provided; (ii) that Cigna-HealthSpring will not pay for or be liable for said service(s); and (iii) that the member will be financially liable for such services. In the event the provider does not comply with the requirements of this section, the provider shall be required to hold the member harmless as described above.

Cigna-HealthSpring will initiate and maintain any action necessary to stop a network provider or employee, agent, assign, trustee or successor-in-interest of network provider from maintaining an action against HHSC, an HHS agency or any member to collect payment from HHSC, an HHS agency or any member above an allowable copayment or deductible, excluding payment services not covered by MMAI.

If a Cigna-HealthSpring member decides to go to an out-of-network provider or chooses to get services that have not been authorized or are not a covered benefit, the member must document his/her choice by signing the member Acknowledgement Statement provided in Appendix I of this manual. Once the member signs a member Acknowledgment Statement, the provider may bill the member for any service that is not a benefit under Cigna-HealthSpring or MMAI.

If a member elects to be a “private pay” patient, the provider must advise the member at the time of service that he/she is responsible for paying for all services received. The provider should require the member to sign the Private Pay Form provided in Appendix J of this manual. This documents that the member has been properly notified of the private pay status. Providers are allowed to bill members as private pay patients if retroactive Medicare-Medicaid eligibility is not granted. If the member becomes eligible retroactively, the member must notify the provider of the change in status. The provider must refund money paid by the member and file claims to the appropriate payer for all services rendered.

Ultimately, the provider is responsible for filing MMAI claims in a timely manner.

Below is the minimum data required to process a claim on a CMS 1500 form. Any missing or invalid data will result in a claim denial. Claim information must match the referral/authorization information. Providers can obtain a copy of a blank CMS 1500 form in Appendix H of this manual.

Field Name
Box #
Description of Information to Provide

Insured ID number  1a  Member’s Medicare-Medicaid ID number  
Name  2  Cigna-HealthSpring MMAI member name  
Patient’s Birth Date  3  Date of birth and gender  
Patient’s Address
 5  Member’s address  
Patient’s Authorization
 12, 13  Member’s authorization (signature on file)  
Name of Referring Physician  17, 17a  Provider’s name and NPI number  
 21-24e  ICD-9 diagnosis codes – always bill to 4th or 5th digit when required  
Authorization Number  23  Cigna-HealthSpring authorization number  
Itemization of Service


24a, b





Itemize the services provided to Cigna-HealthSpring MMAI member

Dates and place of service

CPT or HCPCS codes, with modifier when applicable

Diagnosis code(s) specific to the procedure


Days or units

Taxonomy Code 24ja Provider’s assigned taxonomy code  
NPI 24jb Provider NPI number  
Federal Tax ID Number 25 Federal tax ID number must match W-9 submitted  
Total Charges 28 Total charges from column 24f  
Physician Signature/Date 31 Provider’s signature and date (signature stamp is acceptable)  
Facility Information 32 Address where services were rendered  
Provider’s Name and Address 33 Provider’s name and billing address  
Provider Pay-to NPI 33a Pay-to Provider NPI number/API number  
Rendering Provider TPI number 33b Rendering Provider TPI numbe  

Below is the minimum data required to process a claim on a UB-04 form. Any missing or invalid data will result in a claim denial. Claim information must match the referral/authorization information. Providers can obtain a copy of a blank UB-04 form in Appendix G of this manual.

Field Name
Box #
Description of Information to Provide

Provider's Name and Address
1 Name and address as it appears on provider-specific W-9 form and as defined in Cigna-HealthSpring’s claims system  
Bill Type
4 40digit bill type
Federal Tax ID
5 Provider's Federal tax ID
Date of Service (Start & End Dates)
6 From and to dates of services authorized
Patient's Name
8b Member's name
Patient Address
9a-d Member's home address
Birthday 10 Member's date of birth
Sex 11 Member's gender
Revenue Code


Revenue code (as required by contract)  
Description 43 The description of the revenue code billed on the claim
44 HCPCS/Rate/HIPPS code
Service Units
46 The number of units at the specific level
Total Charges 47 Total charges for service dates
Payer 50 Cigna-HealthSpring MMAI
Payer ID
51 Provider's Cigna-HealthSpring MMAI Payer ID number
NPI 56 Provider's NPI number
TPI 57
Provider's TPI number
Member ID
Member's Cigna-HealthSpring ID Number
Diagnoisis Codes
67 - 91
ICD-9_CM diagnoses codes and written diagnoses codes – bill to the 4th or 5th digit when required
  • If two identical claims are received for the same service on the same date for the same member, one of the claims will be denied as an ‘exact’ duplicate;
  • For CMS 1500 claims, each separate date of service must be itemized on its own line
  • The correct Cigna-HealthSpring member ID number must be on the claim
  • Use only valid procedure codes by consulting the current CPT® book, HCPCS Manual and/or the LTSS HCPCS Codes and MMAI Modifiers Matrix. CPT® books are available at most book stores or they can be ordered by contacting the American Medical Association at 1(312)464-5000 or toll free at 1(800)621-833 ICD-9-CM diagnosis code books can be found at most book stores or by contacting the American Hospital Association at 1(312)422-3000 or toll free at 1(800)242-2626
  • When using a modifier, place it immediately following the 5-digit procedure code. Do not insert a space or a dash
  • CMS 1500 claim forms may be obtained at many book stores or by contacting the American Medical Association at 1(312)464-5000 or toll free at 1(800)621-8335
  • Claims should be submitted for one member and one provider per claim form
  • Multiple visits rendered over several days should be itemized by date of service
  • Unlisted procedures codes should be submitted only when a specific code to describe the service is not available or when indicated in the contract. Submit these codes with a complete description indicated on the CMS 1500 form
  • Providers who bill multiple units of the same procedure code should use the unit column on the CMS 1500 form
  • Assistant surgical procedures must be billed with modifiers 80, 81, 82, or AS
  • Anesthesia procedures must be billed modifiers AA, AD, QK, QS, QX, QY, or QZ
  • Professional components of laboratory, radiology or radiation therapy procedures must be billed with modifier 26
  • Technical components of laboratory, radiology or radiation therapy procedures must be billed with modifier TC
  • Providers billing as a group must list the:
    • Rendering provider’s NPI in the unshaded portion of box 24j
    • Rendering Provider’s TPI in the shaded portion of box 24j
    • Group Provider’s NPI in box 32a
    • Group’s TPI in box 32b
  • Providers should list only one authorization number per claim form
  • CMS 1500 claims must be billed with a valid place of services identifier
  • All V-diagnoses codes are acceptable as diagnoses codes except non-specific codes

Cigna Home Delivery Pharmacy

One of the most important ways to improve the health of your patients is to make sure they receive and take their medications as you prescribe. Cigna Home Delivery Pharmacy can help. Our members have 20% higher adherence rates when compared to those who use retail pharmacies alone. We send a three-month supply in one fill, making it easier for your patient by only having to fill four times a year – many times at a lower cost. Please note, specialty medications are limited to a 30 day supply per fill. Lastly, our members have access to our QuickFill service which sends automatic reminders via email, phone or SMS text message, making it easier for patients to refill their prescriptions so they don’t miss a dose. Talk to your patients today about Cigna Home Delivery Pharmacy for better health and health care spending. Doctors and staff can reach us at 1(800)285-4812 (option 3) or fax prescriptions to 1(800)973-7150.

Pharmacy Prescription Benefit

Formulary listings, utilization management criteria, and formulary changes for Cigna-HealthSpring formularies can
be found at:

Cigna-HealthSpring utilizes the USP classification system to develop Part D drug formularies that include drug categories and classes covering all disease states. Each category must include at least two drugs, unless only one drug is available for a particular category or class. Cigna-HealthSpring includes all or substantially all drugs in protected classes, as defined by CMS. All formularies are reviewed for clinical appropriateness by the national Cigna Pharmacy and Therapeutics (P&T) Committee, including the utilization management edits placed on formulary products. Cigna-HealthSpring submits all formulary changes to CMS according to the timelines designated by CMS.

A Part D drug is a drug that meets the following criteria: may be dispensed only by prescription; is approved by the FDA; is used and sold in the US; is used for a medically-accepted indication; includes FDA-approved uses; includes uses approved for inclusion in the American Hospital Formulary Service Drug Information (AHFS DI), Micromedex, National Comprehensive Cancer Network (NCCN), Clinical Pharmacology, plus other authoritative compendia that the Secretary of Health and Human Services identifies, as off-label uses described in peer-reviewed literature are insufficient on their own to establish a medically accepted indication; and finally includes prescription drugs, biologic products, vaccines that are reasonable and necessary for the prevention of illness, insulin, and medical supplies associated with insulin that are not covered under Parts A or B (syringes, needles, alcohol, swabs, gauze, and insulin delivery systems).

Drugs excluded under Part D include the following:

  • drugsfor which payment as so prescribed or administered to an individual is available for that individual under Part A or Part B;
  • drugs or classes of drugs, or their medical uses, which may be excluded from coverage or otherwise restricted under Medicare-Medicaid (with the exception of smoking cessation products);
  • drugs for anorexia, weight loss or weight gain;
  • drugs to promote fertility;
  • drugs for cosmetic purposes and hair growth;
  • drugs for symptomatic relief of coughs and colds;
  • vitamins and minerals (except for prenatal vitamins and fluoride preparations);
  • non-prescription drugs;
  • out-patient prescriptions for which manufacturers require the purchase of associated tests or monitoring services as a condition for getting the prescription (manufacturer tying arrangements);
  • agents used for treatment of sexual or erectile dysfunction (ED) (except when prescribed for medically-accepted indications such as pulmonary hypertension).


Cigna-HealthSpring formularies include utilization management requirements that include prior authorization, step therapy and quantity limits.

  • Prior Authorization (PA): For a select group of drugs, Cigna-HealthSpring requires the member or their physician to get approval for certain prescription drugs before the member is able to have the prescription covered at their pharmacy.
  • Step Therapy (ST): For a select group of drugs, 
  • Cigna-HealthSpring requires the member to first try certain drugs to treat their medical condition before covering another drug for that condition.
  • Quantity Limits (QL): For a select group of drugs,

Cigna-HealthSpring limits the amount of the drug that will be covered without prior approval. The Centers for Medicare and Medicaid Services (CMS), in collaboration with the Pharmacy Quality Alliance (PQA), has identified certain medications as high risk when used in the elderly. This list is based upon the American Geriatrics Society (AGS) 2012 Updated Beers Criteria. All medications on the list are ones for which the AGS Expert Panel strongly recommends avoiding use of the medication in older adults. Use of these medications in the elderly may result in increased rates of adverse drug events, potential drug toxicity, and an increased risk of falls and/or fractures. Due to these safety concerns, Cigna-HealthSpring requires prior authorization for these medications in all members aged 65 and older in order to confirm that the benefits outweigh the risks, and that safer alternatives cannot be used.

As part of the CarePlan of Illinois pharmacy benefit, Cigna-HealthSpring will provide coverage under Medicare-Medicaid for certain over-the-counter medications.
A complete list of these products can be found in the “Medicare-Medicaid Covered OTC Drug Listing” section of the plan formulary. Coverage will not be provided for any over-the-counter product or Medicare Part D excluded drug that is not included on the formulary.

A Coverage Determination (CD) is any decision that is made by or on behalf of a Part D plan sponsor regarding payment or benefits to which an enrollee believes he or she is entitled. Coverage determinations may be received orally or in writing from the member’s prescribing physicians. For the Provider Call Center, please call 1(877)813-5595 or fax 1(866)845-7267. The address is:

Coverage Determination & Exceptions
PO Box 20002
Nashville, TN 37202

The Provider Call Center is open from 8 a.m. - 8 p.m. CST, Monday – Friday. Any call received after 8pm CST will be routed to a voicemail box and processed daily.

To ensure timely review of a CD and that the prescriber is aware of what Cigna-HealthSpring requires for the most commonly requested drugs, forms are available online at or by requesting a fax when calling 1(877)813-5595.

A provider will receive the outcome of a Coverage Determination by fax no later than seventy-two (72)hours after receipt for standard requests or receipt of the supporting statement and no later than twenty-four (24) hours after receipt for urgent requests or receipt of the supporting statement. The following information will be provided: 1) the specific reason for the denial, taking into account the member’s medical condition, disabilities and special language requirements, if any; 2) information regarding the right to appoint a representative to file an appeal on the member’s behalf; and 3) a description of both the standard and expedited redetermination processes and timeframes including conditions for obtaining an expedited redetermination and the appeals process. The fax cover sheet includes the peer-to-peer process if a Provider has questions and wants to review with a clinical pharmacist.

A Part D appeal can be filed within 60 calendar days after the date of the coverage determination decision, if unfavorable. Cigna-HealthSpring will ask for a statement and select medical records from the prescriber if a member requests a Part D appeal. For an expedited appeal, Cigna-HealthSpring will provide a decision no later than seventy-two (72) hours after receiving the appeal, and for a standard appeal, the timeframe is seven (7) days. If the request is regarding payment for a prescription drug the member already received, an expedited appeal is not permitted.


Part D appeals may be received orally or in writing from the member’s prescribing physicians by calling 1(866)845-6962 or fax 1(866)593-4482. The mailing address is:

Part D appeals
PO Box 24207 Nashville
TN 37202−9910.

Pharmacy Quality Programs

Members with potential over-utilization or inappropriate utilization of narcotics are identified based on approved criteria and reports are produced monthly. Members with at least three (3) controlled opioid pharmacy claims, three (3) different prescribers, three (3) different pharmacies and 120mg MED (morphine-equivalent dose) for 90 consecutive days within the reporting period of 120 days are included for case management. Any individual with cancer or on hospice care
is excluded from the program. The Cigna-HealthSpring Clinical staff review claims data and determine whether further investigation with prescribers is warranted. If intervention is deemed appropriate, the case manager will send written notification to all prescribers by fax, requesting information pertaining to the medical necessity of the current narcotic regimen. Cigna-HealthSpring will reach out to discuss the case and consensus must be reached by the prescribers
if action is required. In the most severe cases, to assist with control of over-utilization, point-of-sale edits may be implemented if the prescriber desires.

Medication Therapy Management (MTM)-eligible members are offered a comprehensive medication review (CMR) annually. In the welcome letters sent to the eligible members, Cigna-HealthSpring encourages each member to call to complete his/her CMR before their annual comprehensive visit with their primary care provider so the member can take their medication list to the appointment. After the completion of the CMR, any potential drug therapy problems (DTPs) that are identified are sent to the prescribing provider and/or primary care provider by mail or fax. Along with DTPs, the provider also receives a list of the member’s prescription history through the previous 6 months. If the member has any questions or comments about the DTP recommendations, a fax and phone number are provided for follow up. In addition to the CMR, providers may also receive targeted medication reviews (TMRs) quarterly. The TMRs are completed electronically to look for specific DTPs. If any DTPs are identified, a letter may be mailed or faxed to the provider.

Cigna-HealthSpring completes a monthly review of drug utilization data in order to determine the effectiveness, potential dangers and/or interactions of the medication(s). Retrospective Drug Utilization Review (rDUR) evaluates past data and Concurrent Drug Utilization Review (cDUR) ensures that a review of the prescribed drug therapy is performed before each prescription is dispensed, typically at the point-of-sale or point of distribution. Cigna-HealthSpring
tracks and trends all drug utilization data on a regular basis to enable clinical staff to determine when some type of intervention may be warranted.
Targeted providers and/or members will receive information regarding quality initiatives by mail. Current Retrospective Drug Utilization Review (rDUR) studies that may be communicated to members or providers include:

  • Over-utilization of medications (≥10 drug prescriptions per month)
  • Failure to refill prescribed medications
  • Drug-to-drug interactions
  • Therapeutic duplication of certain drug classes
  • Narcotic safety including potential abuse or misuse
  • Use of medications classified as High Risk for use in the older population
  • Members with a probable diagnosis of diabetes and Hypertension without a prescription for an ACE or 
  • ARB medication
  • Use of multiple antidepressants, antipsychotics, or insomnia agents concurrently
  • Multiple prescribers of the same class of psychotropic drug
  • Underutilization of certain drug classes as determined by failure to meet a PDC (Proportion of days covered) ≥ 80%

Letters to members will focus on the rationale for medication adherence and/ or the safety issues involved. Letters to providers will include the rationale of the particular concern being addressed and will include all claims data for the selected calendar period applicable to that initiative. From any initiative, if a provider indicates that they did not write a prescription that has been associated with them or that they were not providing care for the member at the time the prescription under investigation was written please notify Cigna-HealthSpring using the contact information on the letter.

A multidisciplinary team develops and determines the direction of pharmacy quality initiatives and the initiatives come from a variety of sources, including but not limited to, claims data analysis, Centers for Medicare-Medicaid Services (CMS) guidance, Pharmacy Quality Alliance (PQA), Food and Drug Administration (FDA) notifications, drug studies, and publications.

Provider Responsibilities

It is essential that Cigna-HealthSpring CarePlan of Illinois providers communicate with each other to ensure appropriate and timely member access to care. When referring members for care, PCPs should provide physical health and/or Behavioral Health providers with all relevant clinical information regarding the member’s care. This includes results of diagnostic tests and laboratory services. After seeing members, providers should forward to the member’s PCP a summary of the visit, clinical findings, and treatment plan. PCPs should document this information appropriately in the member’s medical records.

After Hours Accessibility

Cigna-HealthSpring PCPs are required to maintain after-hours call coverage to ensure members have access to care twenty-four (24) hours per day, seven (7)
days per week. The following are acceptable and unacceptable phone arrangements for contacting PCPs after normal business hours:

Acceptable After-hours Coverage:

  • Office telephone is answered after-hours by an answering service, which meets the language requirements of the provider’s patient population, and can contact the PCP or another designated provider. All calls answered by an answering service must be returned within thirty (30) minutes.
  • Office telephone is answered after normal business hours by a recording, which meets the language requirements of the provider’s patient population and directs the member to call another number to reach the PCP or another provider designated by the PCP. Someone must be available to answer the designated provider’s telephone. Another recording is not acceptable.
  • Office telephone is transferred after office hours to another location where someone will answer the telephone and be able to contact the PCP or another designated provider. All calls must be returned within 30 minutes.

Unacceptable After-hours Coverage:

  • Office telephone is answered only during office hours
  • Office telephone is answered after-hours by a recording that tells members to leave a message
  • Office telephone is answered after-hours by a recording that directs members to go to an emergency room for services needed
  • Calls are not returned within thirty (30) minute

Appointment Accessibility
All Cigna-HealthSpring providers are required to offer timely appointments to members as indicated in the following Appointment Availability Standards:

Primary Care Access Standards:

Appointment type Access standard 
   Within one (1) week  
Routine and preventive
   Within 30 business days  
On-call response (after hours)
   Within 30 minutes for emergency  
Waiting time in office
   30 minutes or less  



Specialist Access Standards:

Appointment type Access standard 
   Within one (1) week  
   Within 30 days  
High index of suspicion of malignancy
   Less than seven (7) days  
Waiting time in office
   30 minutes or less  


Initial prenatal visits without expressed problems scheduled within two (2) weeks after a request from a customer in her first trimester, within one (1) week for a customer in her second trimester, and within three (3) days for a customer in her third trimester.


Behavioral Health Access Standards:

Appointment type Access standard 
Emergency and non-life threatening
  Within 6 hours of the referral  
  Within 48 hours of the referral  
  Within ten (10) business days of the referral*  
Waiting time in office
   30 minutes or less  



Hours of Operation

Cigna-HealthSpring providers must offer hours of operation that are no less than the hours of operations offered to persons who are not members of Cigna-HealthSpring.

Maximum Panel Size

A Cigna-HealthSpring PCP’s maximum panel size is six hundred (600) members.


The Service Coordinator will work with the provider to arrange for a transfer of care. Participating providers may not condition the provision of care or otherwise discriminate against a member based on whether the member executed an advance directive. However, nothing in the Patient Self-Determination Act precludes the right under State law of a provider to refuse to comply with an advance directive as a matter of conscience.

Providers can ensure their office is properly listed in the Cigna-HealthSpring Provider Directory and that all claims payments are sent to the correct address by providing timely, advance notification of demographic changes.

The following types of demographic changes should be reported to Cigna-HealthSpring provider Services Department at 1(866)486-6065:

  • Tax identification number
  • Office address
  • Billing address
  • Telephone number
  • Changes in practice limits or office hours
  • Specialty
  • New provider additions to an existing practice


The Federal Patient Self-Determination Act ensures the patient’s right to participate in health care decision-making,including decisions about withholding resuscitative services or declining/withdrawing life sustaining treatment. In accordance with guidelines established by the Centers for Medicare-Medicaid Services (CMS), HEDIS®* requirements, and Cigna-HealthSpring policies and procedures, participating Cigna-HealthSpring providers are required to have a process that complies with the Patient Self Determination Act. Cigna-HealthSpring monitors provider compliance with this requirement by conducting periodic medical record reviews confirming the presence of required documentation.

A Cigna-HealthSpring member may inform his/her providers that he/she has executed, changed, or revoked an advance directive. At the time services are provided, providers should ask members to provide a copy of their advance directives.

If a provider cannot, as a matter of conscience, fulfill a member’s written advance directive, he/she must advise the member and the Cigna-HealthSpring Service Coordinator. The Service Coordinator will work with the provider to arrange for a transfer of care.

Participating providers may not condition the provision of care or otherwise discriminate against a member based on whether the member executed an advance directive. However, nothing in the Patient Self-Determination Act precludes the right under State law of a provider to refuse to comply with an advance
directive as a matter of conscience.

Cigna-Healthspring Provider Compliance and Fraud, Waste, and Abuse Policy

Cigna-HealthSpring’s Compliance program monitors compliance with federal and state laws, including health care fraud, waste, and abuse statutes and regulations.The Compliance program is designed to prevent violations of federal and State laws. In the event violations occur, the Compliance program promotes early and accurate detection, prompt resolution and disclosure to governmental authorities, when appropriate.

Cigna-HealthSpring expects all contracted providers to be ethical and compliant. Cigna-HealthSpring encourages its own employees as well as each provider’s employees, contractors, and other parties to report suspected violations of law and policy, without fear of retribution.

If you suspect a person who receives benefits or a provider (a doctor, dentist, counselor, etc.) has committed fraud, waste, or abuse, you have a responsibility and a right to report it.

Cigna-HealthSpring has policies and procedures to identify fraud, waste, and abuse in its network, as well as other processes to identify overpayments within its network to properly recover such overpayments. These procedures allow us to report potential fraud or misconduct related to the Medicare program to the appropriate government authority as specified at42 C.F.R. § 422.503(b)(4)(vi) and 42 C.F.R. § 423.504(b)(4)(vi)(H), and Cigna-HealthSpring has policies
and procedures in place for cooperating with CMS and law enforcement entities.

The evaluation and detection of fraudulent and abusive practices by Cigna-HealthSpring encompasses all aspects of Cigna-HealthSpring’s business and its business relationship with third parties, including health care providers and members. All employees, contractors, and other parties are required to report compliance concerns and suspected or actual misconduct without fear of retaliation for reports made in good faith.

Reports may be filed in the following manner:

  • To report suspected or detected Medicare program non-compliance, please contact Cigna-HealthSpring’s Compliance Department at:

Attn: Compliance Department
9009 Carothers Parkway, Suite B-100
Franklin, TN 37067

  • To report potential fraud, waste, or abuse, please contact Cigna-HealthSpring’s Benefit Integrity Unit:

–    By mail:

Attn: Benefit Integrity Unit
500 Great Circle Road
Nashville, TN 37228

–    By phone:

1(800)230-6138, 8:00 a.m. to 6:00 p.m. CST

All such communications will be kept as confidential as possible, but there may be times when the reporting individual’s identity may become known or need to be disclosed to meet requirements of any governmental review actions. Any employee, contractor, or other party that reports compliance concerns in good faith can do so without fear of retaliation.

In addition, as part of an ongoing effort to improve the delivery and affordability of health care to our members, Cigna-HealthSpring conducts periodic analysis of all levels of Current Procedural Terminology (CPT), ICD-9 and HCPCS, codes billed by our providers. The analysis allows Cigna-HealthSpring to comply with its regulatory requirements for the prevention of fraud, waste, and abuse (FWA), and to supply our providers with useful information to meet their own compliance needs in this area. Cigna-HealthSpring will review your coding and may review medical records of providers who continue to show significant variance from their peers. Cigna-HealthSpring endeavors to ensure compliance and enhance the quality of claims data, a benefit to both Cigna-HealthSpring’s medical management efforts and our provider community. As a result, you may be contacted by Cigna-HealthSpring’s contracted partners to provide medical records to conduct reviews to substantiate coding and billing.

In order to meet your FWA obligations, please take the following steps:

You may request a copy of the Cigna-HealthSpring Compliance program document by contacting your Cigna-HealthSpring Provider Relationship Representative.

To report fraud, waste, or abuse, gather as much information as possible.

  • When reporting about a provider (a doctor, dentist, counselor, etc.) include the:
    • Name, address, and phone number of provider
    • Name and address of the facility (hospital, nursing home, home health agency, etc.)
    • Medicare-Medicaid number of the provider and facility, if you have it 
    • Type of provider (doctor, dentist, therapist, pharmacist, etc.)
    • Names and phone numbers of other witnesses who can help in the investigation
    • Dates of events
    • Summary of what happened
  • When reporting about someone who receivesbenefits, include:
    • The person’s name
    • The person’s date of birth, Social Security number, or case number if you have it
    • The city where the person lives
    • Specific details about the waste, abuse or fraud


Cigna-HealthSpring shall comply with all health, safety and welfare monitoring and reporting required by state or federal statute or regulation, but not limited to, the following: critical incident reporting regarding Abuse, Neglect, and Exploitation (ANE); critical incident reporting regarding any incident that has the potential to place an Enrollee, or an Enrollee’s services, at risk, but which does not rise to the level of abuse, neglect, or exploitation; and performance measures relating to the areas of health, safety and welfare and required for operating and maintaining a HCBS Waiver.

Cigna-HealthSpring trains all of Cigna-HealthSpring’s employees, Affiliated Providers, Affiliates, and subcontractors to recognize potential concerns related to ANE, on your responsibility to report suspected or alleged ANE, and how you can report. If you, in good faith, report suspicious or alleged ANE to the appropriate authorities, you shall not be subjected to any adverse action from Cigna-HealthSpring, its Affiliated Providers, Affiliates or subcontractors. As part of its provider education, Cigna-HealthSpring shall include information related to identifying, preventing and reporting abuse, neglect, exploitation, and critical incidents.

Reporting Hotlines:

  • Reports regarding enrollees who are age eighteen (18) and older and living in the community are to be made to the Illinois Department on Aging by utilizing the Adult Protective Services (APS) Hotline number at 1(866)800-1409 (voice) and 1(888)206-1327 (TTY)
  • Reports regarding enrollees aged 18-59 receiving mental health or developmental disability services in DHS operated, licensed, certified or funded programs are to be made to the Illinois Department of Human Services Office of the Inspector General Hotline at 1(800)368-1463 (voice and TTY)
  • Reports regarding enrollees in Nursing Facilities must be made to the Department of Public Health’s nursing home Complaint Hotline at 1(800)252-4343
  • Reports regarding enrollees in Supportive Living Facilities (SLF) must be made to the Department of Healthcare and Family Services’ SLF Complaint Hotline at 1(800)226-0768

Reporting shall occur within 4 hours of discovery. See the following sections for examples of reportable events.

  • Death, HSP Member: All deaths will be reported via incident reporting, and will be reported to the DHS Office of Inspector General. Follow-up will be provided on deaths of an unusual nature per OIG direction. Criteria for investigating such incidents and reporting via the incident reporting system may include a recent allegation or abuse/neglect/exploitation,member was receiving home health services at time of passing, etc.
  • Death, Other parties: Events that result in a significant event for member. For example, member’s caregiver dies in the process of giving member a bath, thereby leaving member stranded in home without care for several days. If the passing of an immediate family member of the member is not a Critical Incident that results in the member not receiving care or is harmful to the member, it does need to be reported
  • Physical abuse of member: Non-accidental use of force that results in bodily injury, pain or impairment. Includes, but not limited to, being slapped, burned, cut, bruised or improperly physically restrained
  • Verbal/Emotional abuse of member: Includes, but is not limited to, name calling, intimidation, yelling and swearing. May also include ridicule, coercion, and threats
  • Sexual abuse of member: Unwanted touching, fondling, sexual threats, sexually inappropriate remarks or other sexual activity with an adult with disabilities
  • Exploitation of member: The illegal use of assets or resources of an adult with disabilities. It includes, but is not limited to, misappropriation of assets or resources of the alleged victim by undue influence, by breach of fiduciary relationship, by fraud, deception, extortion, or in any manner contrary to law 
  • Neglect of member: The failure of another individual to provide an adult with disabilities with, or the willful withholding from an adult with disabilities of, the necessities of life including, but not limited to, food, clothing, shelter, or medical care
  • Sexual Harassment by provider: Unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature that tends to create a hostile or offensive work environment
  • Sexual Harassment by member: Unwelcome sexual advances, requests for sexual favors, and other verbal or physical conduct of a sexual nature that tends to create a hostile or offensive in-office or in-home
  • Sexually problematic behavior: Inappropriate sexual behaviors exhibited by either the member or individual provider which impacts the in-office or in-home environment adversely 
  • Significant Medical event of provider: A recent event to a provider that has the potential to impact a member’s care
  • Significant Medical Event of member: This includes a recent event or new diagnosis that has the potential to impact on the member’s health or safety. Also included are unplanned hospitalizations or errors in medication administration by provider
  • Member arrested, charged with or convicted of a crime: In instance where the arrest, charge, or conviction has a risk or potential risk upon the member’s health and safety should be reported.
  • Provider arrested, charged with or convicted of a crime: In instance where the arrest, charge, or conviction has a risk or potential risk upon the member’s health and safety should be reported
  • Fraudulent activities or theft on the part of the member or the provider: Executing or attempting to execute a scheme or ploy to defraud the Home Services program, or obtaining information by means of false pretenses, deception, or misrepresentation in order to receive services from our program. Theft of member property by a provider, as well as theft of provider property by a member are included
  • Self-Neglect: Individual neglects to attend to their basic needs, such as personal hygiene, appropriate clothing, feeding, or tending appropriately to medical conditions
  • Member is missing: member is missing or whereabouts are unknown for provision of services
  • Problematic possession or use of a weapon by a member: Members should never display or brandish a weapon in staff’s presence. Any perceived threat through use of weapons should be reported. In some cases, persons with serious mental illness (SMI) are not allowed to possess firearms and this should be documented if observed
  • Member displays physically aggressive behavior: Member uses physical violence that results in harm or injury to the provider 
  • Property damage by member of $50 or more: Member causes property damage in the amount of $50 or more to provider property
  • Suicide attempt by member: Member attempts to take own life
  • Suicide ideation/ threat by member: An act of intended violence or injurious behavior towards self, even if the end result does not result in injury 
  • Suspected alcohol or substance abuse by member: Use of alcohol or other substances that appears compulsive and uncontrolled and is detrimental to member’s health, personal relationships, safety of self and others. 
  • Seclusion of a member: Seclusion is defined as placing a person in a locked or barricaded area that prevents contact with others
  • Unauthorized Restraint of a member: Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely
  • Media involvement/media inquiry: Any inquiry or report/article from a media source concerning any aspect of a member’s case should be reported via an incident report. Additionally, all media requests will be forwarded to the DHS Office of Communications for response
  • Threats made against DRS/HSP Staff: Threats and/or intimidation manifested in electronic, written, verbal, physical acts of violence, or other inappropriate behavior
  • Falsification of credentials or records: To falsify medical documents or other official papers for the expressed interest of personal gain, either monetary or otherwise
  • Report against DHS/HSP employee: Deliberate and unacceptable behavior initiated by an employee of DRS against a member or provider in HSP
  • Bribery or attempted bribery of a HSP employee: Money or favor given to an HSP employee in exchange to influence the judgment or conduct of a person in a position of authority
  • Fire / Natural Disaster: Any event or force of nature that has catastrophic consequences, such as flooding, tornados, or fires



Elder abuse refers to the following types of mistreatment to any Illinois resident 60 years of age or older who lives in the community and must be committed by another person on the elder:

  • Physical Abuse means causing the inflictions of physical pain or injury to an older person
  • Sexual Abuse means touching fondling, sexual threats, sexually inappropriate remarks, or any other sexual activity with an older person when the older person is unable to understand, unwilling to consent, threatened, or physically forced to engage in sexual activity
  • Emotional Abuse means verbal assaults, threats of maltreatment, harassment, or intimidation intended to compel the older person to engage in conduct from which he or she wishes and has a right to abstain, or to refrain from conduct in which the older person does not wish and has a right to not engage
  • Confinement means restraining or isolating, without legal authority, an older person for other than medical reasons, as ordered by a physician
  • Passive Neglect means a caregiver’s failure to provide an eligible adult with the necessities of life including, but not limited to, food, clothing, shelter, or medical care. This definition does not create any new affirmative duty to provide support to eligible adults; nor shall it be construed to mean that an eligible adult is a victim of neglect because of health care services provided or not provided by licensed health care professionals
  • Willful Deprivation means willfully denying medications, medical care, shelter, food, therapeutic devices, or other physical assistance to a person who, because of age, health, or disability, requires such assistance and thereby exposes that person to the risk of physical, mental, or emotions harm because of such denial; except with respect to medical care or treatment when the dependent person has expressed an intent to forego such medical care or treatment and has the capacity to understand the consequences
  • Financial Exploitation means the misuse or withholding of an older person’s resources by another person to the disadvantage of the older person or the profit or advantage of a person other than the older person

Examples of incidents that must be reported to the Department include, but are not limited to, the following:

  • Abuse or suspected abuse of any nature by anyone, including another resident, staff, volunteer, family,friend, etc.
  • Allegations of theft when a resident chooses to involve local law enforcement
  • Elopement of residents/missing residents
  • Any crime that occurs on facility property
  • Fire alarm activation for any reason that results in on-site response by local fire department personnel. This does NOT include fire department response that is a result of resident cooking mishaps, that only cause minimal smoke limited to a resident’s apartment and that do not result in any injuries or damage to the apartment. Examples of what do not need to be reported include, but are not limited to: burnt toast or burnt popcorn
  • Physical injury suffered by residents during a mechanical failure or force of nature
  • Loss of electrical power in excess of an hour
  • Evacuation of residents for any reason


All telephone complaints received by Cigna-HealthSpring’s Customer Service department will be resolved on an informal basis, except for complaints that involve “appealable” issues. These appealable issues will be placed in either the expedited or standard appeals process. In situations where a member remains dissatisfied with the informal resolution, the member must submit in writing a request for reconsideration of the informal resolution. All other written letters of complaint received by Cigna-HealthSpring will be logged in our tracking system and automatically placed within either the appeal or grievance process, whichever is appropriate.

Members of Cigna-HealthSpring have the right to file a complaint, also called a grievance, about problems they observe or experience with the health plan.

Situations for which a grievance may be filed include, but are not limited to:

  • Complaints about services in an optional Supplementary Benefit package
  • Complaints regarding issues such as waiting times, physician behavior or demeanor, and adequacy of facilities and other similar member concerns
  • Involuntary disenrollment situations
  • Complaints concerning the quality of services a member receives
  • Members of Cigna-HealthSpring have the right to appeal any decision about Cigna-HealthSpring’s failure to provide what they believe are benefits contained in the basic benefit package. These include:
    • Reimbursement for urgently needed care outside the service area or emergency services worldwide
    • A denied claim for any other health services furnished by a non-participating provider or supplier they believe should have been provided, arranged for, or reimbursed by Cigna-HealthSpring 
    • Services they have not received, but believe are the responsibility of Cigna-HealthSpring to pay for
    • A reduction in or termination of services a member feels are medically necessary

In addition, a member may appeal any decision to discharge his or her from the hospital. In this case, a notice will be
given to the member with information about how to appeal and he/she will remain in the hospital while the decision is reviewed. The member will not be held liable for charges incurred during this period, regardless of the outcome of the review.

Provider Claim Appeal
A Provider Claim Appeal is a claim that has been previously adjudicated as a clean claim and the provider is appealing the disposition through written notification to Cigna-HealthSpring in accordance with the provider Claim Appeal Process as defined in the subsequent “Provider Claims Appeals to
Cigna-HealthSpring” section of this page.

Provider Complaints to Cigna-HealthSpring
Provider complaints can be filed verbally or in writing by contacting Cigna-HealthSpring as follows:

Cigna-HealthSpring Appeals & Grievance Department
–    By mail:

Attn: Grievance Department
175 W. Jackson Street, Suite 1750
Chicago, IL 60604

–    By Fax:


If a provider complaint is received verbally, Cigna-HealthSpring’s Provider Services Representatives collect detailed information about the complaint and
route the complaint electronically to the Appeals and Grievances Department for handling. Within five (5) business days from receipt of a complaint, Cigna-HealthSpring will send an acknowledgement letter to the provider. Cigna-HealthSpring will resolve the complaint within thirty (30) days from the date the Compliant was received by Cigna-HealthSpring.

Provider Claims Appeals to Cigna-HealthSpring
An appeal is a reconsideration of a previous decision not to approve or pay for a service, including a level of care decision; Includes not just outright denials, but also “partial” ones. Your appeal will receive an independent review (made by someone not involved in the initial decision). Requesting an appeal does not guarantee that your request will be approved or your claim paid. The appeal decision may still be to uphold the original decision. Requests for reconsideration of claim payment (under/overpayment or coding issues) should be sent to the Provider Services Department.

An appeal must be submitted to the address/fax listed below within 60 days from the original decision or the time frame specified in your contract of the receipt of the decision. You must include with your appeal request a copy of your denial, any medical records that would support why the service is needed, and if for a hospital stay, a copy of the insurance verification done at the time of admission.

Part C Appeals Addresses and Fax Numbers
–    By mail:

Attn: Appeals
PO Box 24087
Nashville, TN 37202-4087

–    By Fax:


Quality Management

The primary objective of the Quality Improvement program is to promote and build quality into the organizational structure and processes to meet the organization’s mission of improving the health of the community we serve by delivering the highest quality and greatest value in health care benefits and services. The goals the organization has established to meet this objective are:

  • Maintain an effective quality committee structure that:
    • Fosters communication across the enterprise 
    • Corroboratively works towards achievement of established goals 
    • Monitors progress of improvement efforts to established goals
    • Provides the necessary oversight and leadership reporting
    • Ensures patient care and service is provided according to established goals and metrics
  • Ensures identification and analysis of opportunities for improvement with implementation of actions and follow-up as needed
  • Promotes consistency in quality program activities
  • Ensures the QI program is sufficiently organizationally separate from the fiscal and administrative management to ensure that fiscal and administrative management does not unduly influence decision-making regarding organizational determinations and/or appeals of adverse determinations of covered benefits
  • Assures timely access to, and availability of safe, and appropriate physical and behavioral health services forthe population served by Cigna-HealthSpring
  • Ensures services are provided by qualified individuals and organizations, including those with the qualifications and experience appropriate to service members with special needs
  • Promotes the use of evidence-based practices and care guidelines
  • Improves the ability of all Cigna-HealthSpring staff to apply quality methodology through a program of education, training, and mentoring
  • Establishes a rigorous delegation oversight process.
  • Ensures adequate infrastructure and resources to support the Quality Improvement program
  • Assures provider involvement in maintaining and improving the health of Cigna-HealthSpring members, through a comprehensive provider partnership


The overarching goals of Cigna-HealthSpring’s Quality Improvement program are detailed within the Quality Improvement program description. Additional goals and objectives specific to Cigna-HealthSpring’s Illinois Medicare-Medicaid plan are:

  • Goal: Assure timely access to, and availability of, appropriate services.
    • Objective: Establish and maintain a comprehensive network of providers (primary care, specialty care, facility, ancillary, behavioral health, etc.) in adequate numbers necessary to meet the needs and expectation of the plan’s enrollees.
    • Objective: Ensure enrollees have timely access in accordance with their care needs by implementing policies that establish accessibility standards and procedures for adherence to those standards.
  • Goal: Ensure the health plan’s Medicare-Medicaid enrollees receive safe and effective patient centered care that is consistent with established standards.
    • Objective: Ensure that clinical services are provided by qualified individuals and organizations including those with the qualifications and experience appropriate to service members with special needs.
    • Objective: Ensure the safety of all members in all treatment settings.
    • Objective: Improve the medical and mental health of the plan’s enrollees.
  • Goal: Encourage and support a culture of quality improvement internally, for providers, and for members.
    • Objective: Improve member and provider service levels and satisfaction. 
    • Objective: Educate members, providers and internal stakeholders on scope and purpose of quality improvement activities.

The Quality Improvement Committee (QIC) is responsible for the overall design and implementation of Cigna-HealthSpring’s QI program, as well as for the oversight of QI activities carried out by other committees. The QIC reports to the Board of Directors. The QIC ensures that all QI tasks and functions include member and provider involvement and that they are conducted in compliance with all applicable regulatory and accreditation requirements.

The Corporate Delegation Oversight Committee (CDOC) will provide assessment and oversight of entities who have been delegated health plan functions through a process designed to ensure compliance with all operational and regulatory requirements governing the performance of these delegated functions which may include, but not be limited to, claims, utilization management, credentialing, customer service, pharmacy benefits management, appeals and grievances and quality improvement. The CDOC meets monthly and is overseen by the Corporate Quality Improvement Committee.

The provider Advisory Committee (PAC) provides clinical peer review, and makes clinical recommendations such as clinical practice guidelines and utilization management criteria. Members of the PAC are selected to reflect the geographic distribution of Cigna-HealthSpring’s membership.

Clinical Practice Guidelines

Expand All / Collapse All

Cigna-HealthSpring’s practice guidelines are based on evidenced-based, clinical findings. These practice guidelines are reviewed and updated annually by the PAC. New guidelines are added to meet member needs and changes in membership. The Clinical Practice Guidelines, which are also available on Cigna-HealthSpring’s website at  are based on resources such as:


Resource Website 
American Heart Association  
American Medical Association  
American Diabetes Association  
Global Initiative
for Chronic Obstructive
Lung Disease  
American Academy
of Pediatrics  

Healthcare Effectiveness Data and Information Set (HEDIS®) is developed and maintained by the National Committee for Quality Assurance (NCQA), an accrediting body for managed care organizations. The HEDIS® measurements enable comparison of performance among managed care plans. The sources of HEDIS® data include administrative data (claims/encounters) and medical record review data. HEDIS® measurements related to MMAI include measures such as comprehensive diabetes care, controlling high blood pressure, and anti-depressant medication management.

Cigna-HealthSpring’s HEDIS® measures are reported annually and represent a mandated activity for MMAI HMOs. Each spring, Cigna-HealthSpring Representatives are required to collect copies of medical records from providers to establish HEDIS® scores. Selected provider offices will be contacted and requested to assist in these medical record collections. All records are handled in accordance with Cigna-HealthSpring’s privacy policies and in compliance with the Health Insurance Portability and Accountability Act (HIPAA) Privacy rules. Only the minimum necessary amount of information, which will be used solely for the purpose of this HEDIS® initiative, will be requested. HEDIS® is considered a quality-related health care operation activity and is permitted by the HIPAA Privacy Rule (see 45 CFR 164.501 and 506).

Cigna-HealthSpring HEDIS® results are available upon request. To request information regarding those results, contact our Quality Improvement Department by mail at:

Cigna-HealthSpring, Inc.
Attn: Quality Improvement Department
500 Great Circle Road
Nashville, TN 37228

Providers shall keep members’ medical records confidential, in compliance with state and federal laws regarding confidentiality of medical records. However, nothing shall limit timely dissemination of such records to authorized providers and consulting physicians, to governmental agencies as required and permitted by law, to accrediting bodies, to committees of provider, and to Cigna-HealthSpring for administrative purposes. To the extent permitted by law, Cigna-HealthSpring shall have the right to inspect at all reasonable times any medical records maintained by provider pertaining to Cigna-HealthSpring members.

A provider agrees to maintain all medical records pertaining to treatment of members for a period of ten (10) years or, for minors, ten years past the attainment of age 21 years.

Medical Records shall not be removed or transferred from a provider except in accordance with general provider policies, rules, and regulations. Providers agree to furnish members timely access to their own records. Cigna-HealthSpring may audit a provider’s medical records for Cigna-HealthSpring members, as a component of Cigna-HealthSpring’s quality improvement, credentialing, and re-credentialing processes. In accordance with AM, guidance, NCQA guidelines, and medical records must be legible with current details organized and comprehensive in order to facilitate the assessment of the appropriateness of care rendered. Documentation audits are performed to assure that PCPs and high-volume Specialty Care providers maintain a medical record system that permits prompt retrieval of information. Audits are also performed to assure that medical records are legible, contain accurate and comprehensive information, and are readily accessible to health care providers. Medical record review also provides a mechanism for assessing the appropriateness and continuity of health care services. Applicable regulations mandate medical record review by Cigna-HealthSpring. Criteria (indicators) to be evaluated include the following:

  • Demographic/personal data are noted in the record, complete member name, date of birth, home address and phone number, sex, marital status, insurance, and member identification number
  • An emergency contact person’s names, address, and phone number, or that there is no contact person is noted in the medical record
  • Each page of the medical record contains the member’s name or member identification number
  • All entries are legible, signed and dated by the author and include credentials and title
  • Signature may be handwritten stamped, or electronic
  • Significant illness, medical and psychological conditions are indicated on the problem/medical list and are listed in the front of the medical record
  • Prescribed medications, including dosage, date of initial and/or refill prescriptions are listed
  • There is evidence of member/caregiver education including medication review with every visit
  • Allergies and adverse reactions to medications are prominently noted in the record
  • The history and physical examination records indicate subjective and objective information pertinent to the member’s presenting complaints
  • Past medical history, including serious accidents, surgeries and illnesses are noted in the medical record
  • Working diagnoses are consistent with the findings
  • Treatment plans are consistent with the diagnosis and are noted in every visit note
  • There is documentation that the member participated in the formulation of the treatment plan
  • All diagnostic and therapeutic services for which a member was referred by a provider are in the medical record and there is evidence that the provider reviewed these reports
  • There is explicit notation in the medical record of follow-up plans related to consultation, abnormal laboratory, and imaging study results
  • Chronic and/or unresolved problems from previous visits are addressed in subsequent visits
  • There is no evidence that the patient is placed at risk by a diagnostic or therapeutic procedure
  • There is evidence that medical care is offered in accordance with Cigna-HealthSpring clinical care guidelines
  • The medical record contains appropriate notation concerning use of alcohol, cigarettes, and any substance abuse
  • There is notation regarding follow-up care, calls, or visits
  • The specific time of return is noted in days, weeks, months, or as needed
  • There is a separate medical record for each patient
  • The documentation is consistent with the assigned ICD-9 codes
  • Only authorized staff has access to medical records
  • Medical records are easily located and retrieved
  • Forms used for documentation are consistent in all records
  • There is a completed immunization record in accordance with Cigna-HealthSpring child and adult preventive guidelines
  • The chart is orderly
  • Child and adult preventive screenings and services are offered/recommended
  • There is documentation of a discussion of a living will or advance directives for patients 18 years of age or older/or patients with life threatening conditions
  • Clinical findings and evaluations are documented
  • Behavioral Health providers must have communicated with a member’s PCP initially and quarterly through a written summary report to advise the PCP of member’s treatment and medications, if any. This will be part of the Behavioral Health provider medical record review

Providers must meet these requirements for medical record keeping. If opportunities for quality improvement are identified, Cigna-HealthSpring will present these opportunities and implement interventions.

HEDIS (The Health Care Effectiveness Data and Information Set) is developed and maintained by the National Committee for Quality Assurance (NCQA), an accrediting body for managed care organizations. The HEDIS measurements enable comparison of performance among managed care plans. The sources of HEDIS data include administrative data (claims/encounters) and medical record review data. HEDIS measurements include measures such as Comprehensive Diabetes Care, Adult Access to Ambulatory and Preventive Care, Glaucoma Screening for Older Adults, Controlling High Blood Pressure, Breast Cancer Screening, and Colorectal Cancer Screening. Plan-wide HEDIS measures are reported annually and represent a mandated activity for health plans contracting with the Centers for Medicare and Medicaid Services (CMS).

Each Spring, Cigna-HealthSpring Representatives are required to collect from practitioner offices copies of medical records to establish HEDIS scores. Selected practitioner offices will be contacted and requested to assist in these medical record collections.

All records are handled in accordance with Cigna-HealthSpring’s privacy policies and in compliance with the Health Insurance Portability and Accountability Act (HIPAA) Privacy rules. Only the minimum necessary amount of information, which will be used solely for the purpose of this HEDIS initiative, will be requested during HEDIS Medical Record Review. This information can be faxed to our Stars Department at 877-440-9344 or emailed to HEDIS is considered a quality-related health care operation activity and is permitted by the HIPAA Privacy Rule [see 45 CFR 164.501 and 506].

Timeline of HEDIS Medical Record Review

HEDIS Medical Review process


Cigna-HealthSpring’s HEDIS results are available upon request. Contact the Health Plan’s Quality Improvement Department, at 1-888-280-5367, to request information regarding those results.

If you would like to provide Cigna-HealthSpring with medical records for the current year, please fax them to our Stars Department at 877-440-9344 or email

HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).

Cigna-HealthSpring has implemented the Health Level Seven (HL7) standard messaging format for the transmission of lab results data, versions 2.3 and 2.5.1. This data is essential for HEDIS® reporting, in support of early detection and quality improvement for our customers. HL7 provides a robust and standardized approach to data exchange that is widely recognized and used in the health care industry. Where not explicitly stated otherwise, the HL7 standards are the required format for the transmission of lab results data to Cigna-HealthSpring. The companion guide, contains additional details and instructions for submitting lab results data in this format.

Cigna-HealthSpring CarePlan of Illinois provides disease management as a part of our care coordination program. The disease management program assists in providing the member with education on how to manage their chronic disease. Members are encouraged to take responsibility for understanding of the chronic disease state and how to improve their health and identify risk triggers.

All members participating in a disease management program will receive an assessment and participate in the development of a care plan. The member will be encouraged to set short and long term goals and develop interventions.

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The credentialing process is essential to ensuring that the care delivered to Cigna-HealthSpring members is of optimal quality. All practitioner and organizational applicants to Cigna-HealthSpring must meet basic eligibility requirements and complete the credentialing process prior to becoming a participating provider. Once an application has been submitted, the provider is subject to a rigorous verification process that includes primary and secondary source verifications of all applicable information for the contracted specialty(s). Upon completion of the verification process, providers are subject to a peer review process whereby they are approved or denied participation. No provider can be assigned a health plan effective date or be included in a provider directory without undergoing the credentialing verification and peer review process. All providers who have been initially approved for participation are required to re-credential at least once every three years in order to maintain their participating status.

Cigna-HealthSpring utilizes specific selection criteria to ensure that practitioners who apply to participate meet basic credentialing and contracting standards. At minimum these include, but are not limited to:

  • Holds appropriate, current and unencumbered licensure in the state of practice as required by state and federal entities
  • Holds a current, valid, and unrestricted federal DEA and state controlled substance certificate
  • Is board certified or has completed appropriate and verifiable training in the requested practice specialty
  • Maintains current malpractice coverage of $1 million per occurrence and $3 million aggregate
  • Participates in Medicare and has a Medicare number and/or a National Provider Identification number
  • If provider participates exclusively in Medicare-Medicaid, has a Medicare-Medicaid number or can provide proof of Medicare-Medicaid participation
  • Has not been excluded, suspended and/or disqualified from participating in any Medicare, Medicaid, or other government health related program
  • Is not currently opted out of Medicare
  • Has admitting privileges at a participating facility as applicable
  1. Submit a completed Illinois Uniform Health Care Credentials Form or CAQH ID number. (If utilizing CAQH, must confirm that all demographic and supplemental information is current before submitting).
  2. Application must contain a signed and dated Attestation and Consent and Release form that is less than 90 days old.
  3. All Professional Disclosure questions must be answered. If any of the questions are marked yes on the application, supply sufficient additional information and explanations for each yes response.
  4. Provide sufficient clinical detail for all malpractice cases that are pending, or resulted in a settlement or other financial payment.
  5. Submit copies of the following:
    1. All current and active state medical licenses,
    2. DEA certificate(s) and state controlled substance certificate
    3. Proof of current malpractice insurance that includes the effective and expiration dates of the policy and term limits
    4. Five years of work history documented in a month/year format either on the application or on a current curriculum vitae. Explanations are required for any gaps exceeding six (6) months
    5. If a physician, current and complete hospital affiliation information on the application. If no hospital privileges and the specialty warrants hospital privileges, a letter detailing the alternate coverage arrangement(s) or the name of the alternate admitting physician should be provided
    6. If provider participates in the Medicare-Medicaid program, proof of Medicare-Medicaid participation


Once a Practitioner has submitted an application for initial consideration, Cigna-HealthSpring’s Credentialing Department will conduct primary and secondary source verification of the applicant’s licensure, education and/or board certification, privileges, lack of sanctions or other disciplinary action, and malpractice history by querying the National Practitioner Data Bank. The credentialing process may take up to sixty (60) days to complete once all application information and verifications are received.

Once credentialing has been completed and the applicant has been approved, the Practitioner will be notified by Network Operations of their participation effective date.

To maintain participating status, all practitioners will be re-credentialed at least every three (3) years, in accordance with the state mandated Single Credentialing Cycle. Information obtained during the initial credentialing process will be updated and re-verified as required. Practitioners will be notified of the need to submit re-credentialing information in accordance with the appropriate Single Credentialing Cycle as determined by the last digit of their social security number. Three (3) separate attempts will be made to obtain the required information via mail, fax, email or telephonic request during the data collection period. Practitioners who fail to return re-credentialing information prior to their re-credentialing due date will be notified in writing of their termination from the network.

Office site surveys and medical record keeping practice reviews may be required when it is deemed necessary as a result of a patient complaint, quality of care issue and/or as otherwise mandated by state regulations. Practitioner offices will be evaluated in the following categories:

  • Physical Appearance and Accessibility
  • Patient Safety and Risk Management
  • Medical Record Management and
  • Security of Information
  • Appointment Availability

Providers who fail to pass the area of the site visit specific to the complaint or who score less than 90% on the site evaluation overall will be required to submit a corrective action plan and make corrections to meet the minimum compliance score. A follow up site evaluation will be done within sixty (60) days of the initial site visit if necessary to ensure that the correction action has been implemented.

Right to review information obtained from any outside source to evaluate their credentialing application with the exception of references, recommendations or other peer-review protected information. The provider may submit a written request to review his/her file information at least thirty days in advance at which time the Plan will establish a time for the provider to view the information at the Plan’s offices.

  • Right to correct erroneous information when information obtained during the credentialing process varies substantially from that submitted by the practitioner. In instances where there is a substantial discrepancy in the information, Credentialing will notify the provider in writing of the discrepancy within thirty (30) days of receipt of the information. The provider must submit a written response and any supporting documentation to the Credentialing Department to either correct or dispute the alleged variation in their application information within thirty (30) days of notification.
  • Right to be informed of the status of their application upon request. A provider may request the status of the application either telephonically or in writing.
  • The Plan will respond within two business days and may provide information on any of the following:
    • Application receipt date
    • Any outstanding information or verifications needed to complete
    • The credentialing process anticipated review
    • Date approval status

When assessing organizational or LTSS providers, Cigna-HealthSpring utilizes the following criteria:

  • Must be in good standing with all state and federal regulatory bodies
  • Has been reviewed and approved by an accrediting body If not accredited, can provide appropriate evidence of successfully passing a recent state or Medicare site review, or meets other Plan criteria
  • Maintains current professional and/or general liability insurance as applicable
  • Has not been excluded, suspended and/ or disqualified from participating in any Medicare, Medicaid, or any other government health related program
  • LTSS providers must participate in the IL Medicare-Medicaid program

A completed Ancillary/Facility Credentialing Application with a signed and dated attestation

  • If responded Yes to any disclosure question in the application, an appropriate explanation with sufficient details/information is required
  • Copies of all applicable state and federal licenses (i.e. facility license, DEA, Pharmacy license, CCP certification, etc.)
  • Proof of current professional and general liability insurance as applicable
  • LTSS providers will be required to provide proof of general liability insurance of at least $25,000/$50,000. Services provided in the home must show evidence of coverage specific to the business. LTSS applicants who also provide professional medical services must show proof of liability insurance of a minimum of $100,000/$300,000
  • Proof of Medicare-Medicaid contract
  • Proof of Medicare-Medicaid participation if supplying Medicare-Medicaid services. LTSS providers must provide evidence of current IDOA or other proof of Medicare-Medicaid contract for each type of service for which they are applying
  • If accredited, proof of current accreditation. Note: Current accreditation is required for DME, Prosthetic/Orthotics, and non-hospital based high tech radiology providers who perform MRIs, CTs and/or Nuclear/PET studies.
  • If not accredited, a copy of any state or CMS site survey that has occurred within the last three years, including evidence that the organization successfully remediated any deficiencies identified during the survey.

As part of the initial assessment, an on-site review will be required on all hospitals, skilled nursing facilities, free-standing surgical centers, home health agencies and in-patient, residential or ambulatory mental health or substance abuse centers that do not hold acceptable accreditation status or cannot provide evidence of successful completion of a recent state or CMS site survey. Any organizational provider may also be subject to a site survey as warranted, subsequent to the receipt of a complaint. Organizational providers who are required to undergo a site visit must score a minimum of 85% on the site survey tool. Providers who fall below acceptable limits will be required to submit a written Corrective Action Plan (CAP) within thirty (30) days and may be re-audited at minimum within sixty (60) days to verify specific corrective action items as needed. Providers who fail to provide an appropriate CAP or who are unable to meet minimum standards even after re-auditing will not be eligible for participation.

All initial applicants and re-credentialed providers are subject to a peer review process prior to approval or re-approval as a participating provider. Providers who meet all of the acceptance criteria may be approved by the Medical Director. providers who do not meet established thresholds are presented to the Credentialing Committee for consideration. The Credentialing Committee is comprised of contracted primary care, specialty providers and LTSS representatives, and has the authority to approve, deny or terminate an appointment status to a provider. All information considered in the credentialing and re-credentialing process must be obtained and verified within one hundred eighty (180) days prior to presentation to the Medical Director or the Credentialing Committee. All providers must be credentialed and approved before being assigned a participating effective date.

Cigna-HealthSpring’s Credentialing program is compliant with all guidelines from the National Committee for Quality Assurance (NCQA), Centers for Medicare-Medicaid Services (CMS) and Illinois State regulations. Through the universal application of specific assessment criteria, Cigna-HealthSpring ensures fair and impartial decision-making in the credentialing process and does not make credentialing decision based on an applicant’s race, gender, age,, ethnic origin, sexual orientation, or type of patients or procedures in which the provider specializes.

All initial applicants who successfully complete the credentialing process are notified in writing of their plan effective date. Providers are advised to not see Cigna-HealthSpring members until the notification from Network Operations of their contract participation effective date.

In the event that a provider’s participation is denied, limited, suspended or terminated by the Credentialing Committee, the provider is notified in writing within sixty (60) days of the decision. Notification will a) include the reasons for the action b) outline the appeals process or options available to the provider, and c) provide the time limits for submitting an appeal. All appeals will be reviewed by a panel of peers. When termination or suspension is the result of quality deficiencies, the appropriate state and federal authorities, including the National Practitioner Data Bank (NPDB) are notified of the action. Cigna-HealthSpring does not offer appeal rights to any initial applicant who was denied due to quality of care issues or failure to meet Medicare-Medicaid participation requirements.

All information obtained during the credentialing and re-credentialing process is considered confidential and is handled and stored in a confidential and secure manner as required by law and regulatory agencies. Confidential practitioner credentialing and re-credentialing information will not be disclosed to any person or entity except with the written permission of the practitioner or as otherwise permitted or required by law.

Cigna-HealthSpring conducts routine, ongoing monitoring of license sanctions, Medicare-Medicaid sanctions and the CMS Opt Out list between credentialing cycles. Participating providers who are identified as having been sanctioned, are the subject of a complaint review, or are under investigation for or have been convicted of fraud, waste, or abuse are subject to review by the Medical Director or the Credentialing Committee who may elect to limit, restrict or terminate participation. Any provider whose license has been revoked or suspended or has been excluded, suspended and/or disqualified from participating in any Medicare, Medicaid or any other government health related program or who has opted out of Medicare will be automatically terminated from the Plan.

Cigna-HealthSpring CarePlan of Illinois’ care coordination program includes Interdisciplinary Care Team meetings (ICTs). All members are encouraged to participate in an ICT discussion. The objective of the ICT is to provide a forum for members to express their goals and wishes, discuss obstacles/barriers that may be preventing the member to reach their goals, and/or new events that place the member’s independence at risk. Primary care providers, formal and informal support people are invited and encouraged to participate along with the member and/or their caregivers in these meetings. The meeting is led by a Cigna-HealthSpring CarePlan of Illinois care coordinator who is actively involved in working with the member. The team discussion can occur at the physician’s office, at the member’s home, during an inpatient admission, and/or out in the community.

Sub-populations such as community transition members, Nursing Facility residents and HCBS waiver members have a designated team with specific additional training related to the membership needs. These designated care coordinators facilitate and lead ICT and ensure all pertinent support people are provided the opportunity to participate in the meetings.

The ICTs will have experience with:

  • The member population
  • The barriers and obstacles they face
  • Socioeconomic impacts on their ability to access services
  • Substance use
  • Family systems and dynamics


Cigna-HealthSpring CarePlan of Illinois will use a holistic approach by integrating referral and access to:

  • Community resources
  • Transportation
  • Follow-up care
  • Medication review
  • Specialty care
  • Education
  • LTSS

To be included in Provider Directories or any other member information, providers must be fully credentialed and approved. Directory specialty designations must be commensurate with the education, training, board certification and specialty(s) verified and approved via the credentialing process. Any requests for changes or updates to the specialty information in the directory may only be approved by Credentialing.

Special Need Plan ± Model Of Care

The model of care described in this manual for the IL MMAI was built on Cigna-HealthSpring’s Dual Eligible Special Needs Plan Model of Care platform. Medicare-Medicaid Special Needs Plans (SNPs) are designed for specific groups of members with special healthcare needs. The three specific groups are:

  • Dual eligible beneficiaries (individuals who are eligible for both Medicaid and Medicare)
  • Individuals with Chronic conditions
  • Individuals who are residents of long-term care facilities or require that level of care and reside in the community.

In 2008, CMS issued the final regulation “Medicare Improvements for Patients and Providers Act of 2008”, known as MIPPA.” This regulation mandated that all Special Needs Plans have a filed and approved Model of Care by January 1, 2010.

The Model of Care is an evidenced-based process by which we integrate benefits and coordinate care for members enrolled in Cigna-HealthSpring’s Special Needs Plans. The Model of Care facilitates the early assessment and identification of health risks and major changes in the health status of members with complex care needs, coordinating care to improve their overall health. Cigna-HealthSpring’s Special Needs Plan

Model of Care has the following goals:

  • Improve access to medical, mental health, and social services
  • Improve access to affordable care
  • Improve coordination of care through an identified point of contact
  • Improve transitions of care across healthcare settings and providers
  • Improve access to preventive health services
  • Assure appropriate utilization of services
  • Improve beneficiary health outcomes

Importantly, the Model of Care focuses on the individual SNP member. SNP members receive a health risk assessment within 90 days of enrollment and annually thereafter. Based on the results of this assessment, an individualized care plan is developed, based on evidenced-based clinical protocols. An interdisciplinary care team, which includes practitioners of various disciplines and specialties based on the needs of the member, is responsible for care management. The member may participate in this process, as may all healthcare providers. The individualized care plan is recorded centrally so that it can be shared with all members of the interdisciplinary care team, as indicated. All providers are encouraged to participate in the SNP Model of Care and interdisciplinary care teams (referred to as Integrated Care Teams for IL MMAI).

Cigna-HealthSpring uses a data-driven process for identifying the frail/disabled, multiple chronic illnesses and those at the end of life. Risk stratification and protocols for intervention around care coordination, barriers to care, primary care givers, education, early detection, and symptom management are also components of the Model of Care. Based on the needs of plan members, a specialized provider network is available to assure appropriate access to care, complementing each member’s primary care provider. Execution of the model of care is supported by systems and processes to share information between the health plan, healthcare providers and the member. The SNP Model of Care includes periodic analysis of effectiveness, and all activities are supported by the Quality Improvement program.

Member Services

Cigna-HealthSpring provides services to people of all cultures, races, ethnic backgrounds, and religions as well as those with disabilities. Cigna-HealthSpring serves these members in a manner that recognizes, values, affirms, and respects their worth and protects and preserves the dignity of each. As such, Cigna-HealthSpring has implemented several key initiatives that are specifically designed to meet the special access needs of the MMAI population. These initiatives include a comprehensive cultural competency program, interpreter and translation services, and customized member materials that take into consideration variances in the population’s reading levels.

Cigna-HealthSpring ensures that all member communication is sensitive to the vast cultural differences spanning the MMAI population. Cigna-HealthSpring makes it a priority to employ and develop associates who can communicate effectively with members of various ages and cultural backgrounds. Cigna-HealthSpring supports the belief that providing quality health care means treating the whole patient and not just the medical condition. Cultural sensitivity plays a key role in accomplishing this goal successfully. As such, Cigna-HealthSpring encourages and advocates for providers to provide culturally competent care for its members. Cultural Competency training will also be included in as part of the provider trainings. Following is a list of cultural competency principles for health care providers to consider in the health care delivery process:

  • Knowledge: Knowledge and understanding of differences are essential components of cultural competency. To be culturally competent a provider must have an understanding of:
    • Race, ethnicity and influence
    • The historical factors which impact the health of minority populations, such as racism and immigration patterns
    • The particular psycho-social stressors relevant to minority patients including war trauma, migration, acculturation stress, and socioeconomic status
    • The cultural differences within minority groups
    • The minority patient within a family life cycle and intergenerational conceptual framework in addition to a personal developmental network
    • The differences between “culturally acceptable” behavior of psychopathological characteristics of different minority groups
    • Indigenous healing practices and the role of religion in the treatment of minority patients
    • The cultural beliefs of health and help-seeking patterns of minority patients
    • The health service resources for minority patients
    • Public health policies and their impact on minority patients and communities
  • Skills: To treat culturally-diverse populations successfully, health care providers must develop an ability to:
    • Interview and assess minority patients based on a psychological/social/biological/cultural/ political/spiritual model
    • Communicate effectively with the use of cross cultural interpreters
    • Diagnose minority patients with an understanding of cultural differences in pathology
    • Avoid under-diagnosis or over-diagnosis
    • Formulate treatment plans that are culturally sensitive to the member’s and family’s concept of health and illness
    • Utilize community resources such as church, community-based organizations (CBOs), and self-help groups
    • Provide therapeutic and pharmacological interventions, with an understanding of the cultural differences in treatment expectations and biological response to medication
    • Request for consultation
  • Attitudes: Aside from having the knowledge and skill set to treat culturally-diverse populations, health care providers must adopt positive attitudes and foster respect for their patients. This includes respecting and appreciating the:
    • “Survival merits” of immigrants and refugees
    • Importance of cultural forces
    • Holistic view of health and illness
    • Importance of spiritual beliefs
    • Skills and contributions of other professional and paraprofessional disciplines; and/or
    • Transference and counter-transference issues

Cigna-HealthSpring ensures its staff and subcontractors are educated about, remain aware of, and are sensitive to the linguistic needs and cultural differences of its members. Cigna-HealthSpring arranges for language interpretation services for over 170 languages through the Language Line. The Language Line can be accessed by calling the Cigna-HealthSpring provider Services Department at 1(866)486-6065. For telephone-interpreting service for the deaf, hard of hearing, deaf-blind, or speech impaired Cigna-HealthSpring can be reached using the State Relay Service (711).

Trained interpreters must be used when technical, medical, or treatment information is discussed. Family members, especially children, should not be used as interpreters in assessments, therapy and other situations where impartiality or confidentiality is critical unless specifically requested by the member.

All Cigna-HealthSpring member materials and website content are specially designed to take into consideration the MMAI population’s needs. Materials are intended to be user-friendly and concise, and they are written at a reading level that is at or below 6th grade as measured by the Flesch Reading Ease Test.

Specialty Care providers can act as PCPs under specific circumstances. A Specialty Care provider may be designated by Cigna-HealthSpring as a PCP for members who require a specialized physician to manage their specific health care needs such as those living with HIV or AIDS. Members with Special Health Care Needs also may designate a Specialty Care provider as a PCP to coordinate their care. A Specialty Care provider acting in the PCP role must agree to adhere to Cigna-HealthSpring’s PCP standards. To request to be a PCP, Specialty Care providers should call the Cigna-HealthSpring Provider Services Department at 1(866)486-6065.

Cigna-HealthSpring does not prohibit providers, acting within the scope of their practice, from advising, acting, or advocating on behalf of members about their conditions, risks, and treatment options. Cigna-HealthSpring is committed to promoting dignity, quality of life and quality care for our members. Cigna-HealthSpring believes that members and their families deserve the best and that they can have improved quality of life if given the opportunity to understand and access their rights.Cigna-HealthSpring members receive a complete list of the following member Rights and Responsibilities in their member Handbook. The member Handbook is included in the Welcome Kit.

Members’ Rights:
Members have the right to respect, dignity, privacy, confidentiality and nondiscrimination. That includes the right to:

  • Be treated fairly and with respect
  • Know that medical records and discussions with providers will be kept private and confidential

At Cigna-HealthSpring, we know our members’ privacy is extremely important to them, and we respect their right to privacy when it comes to their personal information and health care. We are committed to protecting our members’ personal information. Cigna-HealthSpring does not disclose member information to anyone without obtaining consent from an authorized person(s), unless we are permitted to do so by law. Because you are a valued provider to Cigna-HealthSpring, we want you to know the steps we have taken to protect the privacy of our members. This includes how we gather and use their personal information. Cigna-HealthSpring’s privacy practices apply to all of Cigna-HealthSpring’s past, present, and future members. When a member joins a Cigna-HealthSpring plan, the member agrees to give Cigna-HealthSpring access to Protected Health Information. Protected Health Information (“PHI”), as defined by the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), is information created or received by a health care provider, health plan, employer or health care clearinghouse, that: (i) relates to the past, present, or future physical or mental health or condition of an individual, the provision of health care to the individual, or the past, present or future payment for provision of health care to the individual; (ii) identifies the individual, or with respect to which there is a reasonable basis to believe the information can be used to identify the individual; and (iii) is transmitted or maintained in an electronic medium, or in any form or medium. Access to PHI allows Cigna-HealthSpring to work with providers, like yourself, to decide whether a service is a Covered Service and pay your clean claims for Covered Services using the members’ medical records. Medical records and claims are generally used to review treatment and to do quality assurance activities. It also allows Cigna-HealthSpring to look at how care is delivered and carry out programs to improve the quality of care Cigna-HealthSpring’s members receive. This information also helps Cigna-HealthSpring manage the treatment of diseases to improve our members’ quality of life.

Cigna-HealthSpring’s members have additional rights over their health information. They have the right to:

  • Send Cigna-HealthSpring a written request to see or get a copy of information about them, or amend their personal information that they believe is incomplete or inaccurate. If we did not create the information, we will refer Cigna-HealthSpring’s member to the source of the information.
  • Request that we communicate with them about medical matters using reasonable alternative means or at an alternative address, if communications to the home address could endanger them.
  • Receive an accounting of Cigna-HealthSpring’s disclosures of their medical information, except when those disclosures are for treatment, payment or health care operations, or the law otherwise restricts the accounting.

As a Covered Entity under HIPAA, providers are required to comply with the HIPAA Privacy Rule and other applicable laws in order to protect member PHI.

Members have the right to a reasonable opportunity to choose a health care plan and primary care provider. This is the doctor or health care provider seen most of the time and who will coordinates the members’ care. Member’s have the right to change to another plan or provider in a reasonably easy manner. That includes the right to:

  • Be told how to choose and change your health plan and a primary care provider
  • Choose any health plan they want that is available in your area and choose a primary care provider from that plan
  • Change their primary care provider
  • Change their health plan without penalty
  • Be told how to change their health plan or their primary care provider
  • Ask questions and get answers about anything they don’t understand. That includes the right to:
    • Explain to the member their health needs and talk about the different ways health care problems can be treated
    • Be told why care or services were denied and not given
  • Agree to or refuse treatment and actively participate in treatment decisions. That includes the right to:
    • Work as part of a team with a provider in deciding what health care is best for the member
    • Say yes or no to the care recommended by a provider

Members influence the composition and development of the ICT in two important ways: selection of their PCPs and completion of their HRAs, both of which promote member direction and involvement in the care management process. Furthermore, the Plan makes every effort to include the member and/or his or her caretaker in ICT meetings and the development of the Individualized Care Plan. ICT meeting attendance is open to members, families or caregivers when available and willing to participate in meaningful discussion concerning the member. All member discussions are kept confidential and follow HIPAA compliant guidelines.

Members enrolled in HCBS Waiver programs are also empowered by the option of Consumer Directed Healthcare services in which Cigna-HealthSpring supports the member in directing his or her own care, including selecting providers and services to receive, and as a co-employer over Personal Assistants.

Members have the right to use each available complaint and appeal process through the managed care organization and through Medicare-Medicaid, and get a timely response to complaints, appeals and fair hearings. That includes the right to:

  • Make a complaint to the members’ health plan or to the State Medicare-Medicaid program about their health care, your provider or your health plan
  • Get a timely answer to a complaint
  • Use the plan’s appeal process and be told how to use it
  • Ask for a fair hearing from the State Medicare-Medicaid program and get information about how that process works
  • Timely access to care that does not have any communication or physical access barriers. That includes the right to:
    • Have telephone access to a medical professional 24 hours a day, 7 days a week to get any emergency or urgent care needed
    • Get medical care in a timely manner
    • Be able to get in and out of a health care provider’s office. This includes barrier-free access for people with disabilities or other conditions that limit mobility, in accordance with the Americans with Disabilities Act
    • Have interpreters, if needed, during appointments with providers and when talking about health plans. Interpreters include people who can speak in the native language of the member, help someone with a disability, or help members understand the information
    • Be given information that the member can understand about health plan rules, including the health care services offered and how to get them
  • Not be restrained or secluded when it is for someone else’s convenience, or is meant to force the member to do something they don’t want to do, or to be punished
  • Know that providers, hospitals, and others who care for members can advise him or her on their health status, medical care, and treatment. The health plan cannot prevent health care professionals from giving members this information, even if the care or treatment is not a covered service. There are federal and state laws that protect the privacy of member medical records and personal health information. Cigna-HealthSpring keeps members’ personal health information private as required under these laws. Any personal information that a member gives Cigna-HealthSpring is protected. Cigna-HealthSpring staff will make sure that unauthorized people do not see or change member records. Generally, we will get written permission from the member (or from someone the member has given legal authority to make decisions on their behalf) before we can give member health information to anyone who is not providing the member’s medical care. There are exceptions allowed or required by law, such as release of health information to government agencies that are checking on quality of care
  • Not be responsible for paying for covered services. Doctors, hospitals, and others cannot require a copayments or any other amounts for covered services

Member Responsibilities:
Members must learn and understand each right they have under the MMAI program. That includes the responsibility to:

  • Learn and understand their rights under the MMAI program
  • Ask questions if they don’t understand his or her rights
  • Learn what choices of health plans are available in their area

Members must abide by the health plan and Medicare-Medicaid policies and procedures.
That includes the responsibility to:

  • Learn and follow health plan rules andMedicare-Medicaid rules
  • Choose a health plan and a primary care provider quickly
  • Make any changes in their health plan and primary care provider in the ways established by Medicare-Medicaid and by the health plan
  • Keep his or her scheduled appointments
  • Cancel appointments in advance when they can’t keep them
  • Contact a primary care provider first for non-emergency medical needs
  • Get approval from a primary care provider before going to a specialty care provider
  • Understand whether they shouldn’t go to the emergency room
  • Advise Cigna-HealthSpring if they have other insurance coverage

Members must share information about their health with their primary care provider and learn about service and treatment options. That includes the responsibility to:

  • Tell a primary care provider about their health;
  • Talk to providers about their health care needs and ask questions about the different ways health care problems can be treated
  • Help providers get medical records

Members must be involved in decisions relating to service and treatment options, make personal choices, and take action to maintain their health. That includes the responsibility to:

  • Work as a team with a provider in decidingwhat health care is best for them
  • Understand how the things they do can affect their health
  • Do the best they can to stay healthy
  • Treat providers and staff with respect


Member's Right to Designate an Ob/Gyn

Cigna-HealthSpring members have the right to pick an OB/GYN without a referral from their PCP. An OB/GYN can provide the following services:

  • One well-woman check-up each year
  • Care related to pregnancy
  • Care for any female medical condition
  • Referral to Specialty Care provider within the network

Cigna-HealthSpring CarePlan of Illinois provides care coordination for expectant members. Care coordination finds it crucial to identify expectant members as early as possible in their pregnancy. Cigna-HealthSpring CarePlan of Illinois care coordinators will work with the caring provider and requests the caring provider complete notification of pregnancy within five (5) business days of the initial pre-natal visit. As part of pre-natal care the provider is to identify date of confinement, facility to deliver and provider order for prenatal vitamins.

Member Complaint and  Appeal Process

Cigna-HealthSpring’s member complaint and appeal process is designed to facilitate prompt resolution to member issues and promote member satisfaction. Cigna-HealthSpring’s member Handbook contains a written description of Cigna-HealthSpring’s complaint process in a format that is easy to understand. Additionally, Cigna-HealthSpring has member advocates who are available to help members file complaints, if necessary.

A complaint means an expression of dissatisfaction expressed by a Complainant, orally or in writing to the HMO, about any matter related to the HMO other than an Action. As provided by 42 C.F.R. 438.400, possible subjects for complaints include, but are not limited to, the quality of care of services provided, and aspects of interpersonal relationships such as rudeness of a provider or employee, or failure to respect the Medicare-Medicaid member’s rights.

Action means:

  • The denial or limited authorization of a requested Medicare-Medicaid service, including the type orlevel of service
  • The reduction, suspension, or termination of a previously authorized service
  • The denial in whole or in part of payment for service;
  • The failure to provide services in a timely manner
  • The failure of an HMO to act within the timeframes set forth in the Contract and 42 C.F.R 438.408(b)
  • For a resident of a rural area with one HMO, the denial of a Medicare-Medicaid member’s request to obtain services outside of the Network

An Adverse Determination is one type of Action.

An Appeal is a formal process by which a member or his or her representative requests a review of the HMO’s Action, as defined above.
An Authorized Representative is any person or entity acting on behalf of the member, for whom Cigna-HealthSpring has received the member’s written consent. A provider may be an Authorized Representative.

Expedited appeal means an appeal to the HMO in which the decision is required quickly, based on the member’s health status, and the amount of time necessary to participate in a standard appeal could jeopardize the member’s life or health or ability to attain, maintain, or regain maximum function.

Member complaints can be filed verbally or in writing by contacting Cigna-HealthSpring as follows:

– By mail:

Appeals & Grievances Department
175 W. Jackson Street, Suite 1750
Chicago, IL 60604

– Fax:


– Or by Calling:

Member Services Department
8 a.m. - 8 p.m. CST, Monday – Friday

A Member Advocate is available to help file a complaint if necessary.

If a complaint is received verbally by telephone, Cigna-HealthSpring’s member Services representatives collect detailed information about the complaint and route the complaint electronically to the Appeals and Grievances Department for handling. Within five (5) business days of receipt of a complaint, Cigna-HealthSpring sends the member or the member’s Authorized Representative a letter acknowledging receipt of the complaint. The acknowledgement letter will include the date the complaint was received, a description of the complaint process, and the timeline for resolution. Cigna-HealthSpring will investigate the complaint and take corrective action if necessary. Cigna-HealthSpring will issue a response letter to the member or the member’s Authorized Representative within thirty (30) calendar days from the date the complaint was received. The response letter will include a description of the resolution and the process to appeal the complaint if the member or the member’s Authorized Representative is not satisfied with Cigna-HealthSpring’s decision.

Cigna-HealthSpring will ensure that every complaint, whether received by telephone or in writing, will be recorded with the following details:

  1. Date
  2. Identification of the individual filing the complaint
  3. Identification of the individual recording the complaint
  4. Nature of the complaint
  5. Disposition of the complaint (i.e., how the complaint was resolved)
  6. Corrective action required
  7. Date resolved

Members must exhaust the HMO’s complaint Process prior to contacting HHSC.

IL MMAI members have certain appeal rights for internal and external review. If a covered service is denied, delayed, limited, or stopped, Cigna-HealthSpring will notify the member in writing and provide an appeal form with instructions on how to file an appeal. Members have the option to request an appeal for denial of payment of services in whole or in part. Members may request an appeal verbally or in writing by contacting Cigna-HealthSpring as follows:

– By mail:

Cigna-HealthSpring Appeals Department
Attn: Appeals
PO Box 24087
Nashville, TN 37202-4087

– Phone:


– Fax:


– Or by Calling:

Member Services Department
8 a.m. - 8 p.m. CST, Monday – Friday
A Member Advocate is available to help file
an appeal if necessary.

All initial appeal requests must be filed with Cigna-HealthSpring. This is a Level One appeal. Appeals must be filed within 60 calendar days of receiving the notice of Adverse Action. The member, the members’ representative or the members provider, with the member’s consent may appeal a denial, terminations or reduction in services. The List below includes actions that may result in an appeal (as it appears in the member handbook):

  • Not approving or paying for a service or item for which a member’s provider asks
  • Stopping a service that was previously approved
  • Not giving a member the service or items in a timely manner
  • Not advising a member of his/her rights to freedom of choice of providers
  • Not approving a service for a member because it was not in our network

Expedited appeals may be filed orally or in writing. If the member requests an expedited appeal, Cigna-HealthSpring will notify the member within 24 hours of all information that is needed to evaluate the expedited appeal. The appeal decision will be made within 24 hours after receipt of the required information. Cigna-HealthSpring may extend this timeframe for up to 14 calendar days if the member requests an extension, or if Cigna-HealthSpring demonstrates the extension is in the best interest of the member. If Cigna-HealthSpring determines the member’s health or life is not in serious jeopardy and denies the request for an expedited reconsideration, the member or the member’s Authorized Representative is informed orally within 24 hours and a written notice follows within two (2) calendar days. The appeal becomes subject to standard appeal timeframes.

The standard appeal request must be submitted in writing, unless there is documentation of the appellant’s inability to write, read or other infirmity. An acknowledgment letter will be sent within two (2) days of receipt. The appeal decision will be made within fifteen (15) business days. Cigna-HealthSpring may extend this timeframe for up to 14 calendar days if the member requests an extension, or if Cigna-HealthSpring demonstrates the extension is in the best interest of the member.

If the appeal is denied, the appeal decision letter includes a clear statement of the basis for the denial, the specialty of the physician or other health care provider making the denial and the appealing party’s right to seek review of the denial through the next level of appeal process. Further processing of appeals depends on the type of service.

Medicare Part A & B Only
Medicare-Medicaid Overlap ServicesMedicaid Only Services
Continuation of Care during appeal All benefits will continue to be provided pending completion of appeal All benefits will continue to be provided pending completion of appeal through IRE. If State Fair Hearing requested within 10 days of decision, benefits will be continued

If appeal received within 10 days of original denial,and the member requests continuation, except the continuation may cease if the authorization expires or authorized limits are met. If the final resolution is adverse the member may be held liable for the cost of the services.

Next level appeal if plan upholds original decision
Automatically sent to the IRE for review Automatically sent to the
IRE for review.
Member may request a State Fair Hearing within 30 days
of receipt of appeal decision AND/OR the member may request a review by the Independent external review (except for
HCBS Waiver Services)
Next level of appeal
Member may request
an Administrative Law Judge Review
Member may request
a State Fair Hearing &/or Administrative Law Judge Review within 30 days of notice



The member must receive a written notice of explanation called an Important Message from Medicare About your Rights. The member has the right to request a review by a Quality Improvement Organization (QIO) of any hospital discharge notice. The notice will include information on filing the QIO appeals. The member must contact the QIO before he/she leaves the hospital but no later than the planned discharge date.

Medicare Advantage Program Requirements

The terms and conditions herein are included to meet federal statutory and regulatory requirements of the federal Medicare-Medicaid program under Part C of Title XVIII of the Social Security Act (“Medicare-Medicaid program”). Provider understands that the specific terms as set forth herein are subject to amendment in accordance with federal statutory and regulatory changes to the federal statutory and state regulatory changes to the Medicare-Medicaid Program. Such amendment shall not require the consent of provider or Cigna-HealthSpring and will be effective immediately on the effective date thereof.

  • Books and Records; Governmental Audits and Inspections. Provider shall permit the Department of Health and Human Services (“HHS”), the Comptroller General, or their designees to inspect, evaluate and audit all books, records, contracts, documents, papers and accounts relating to provider’s performance of the Agreement and transactions related to the CMS Contract (collectively, “Records”). The right of HHS, the comptroller General or their designees to inspect, evaluate and audit provider’s Records for any particular contract period under the CMS Contract shall exist for a period of ten (10) years from the later to occur of (i) the final date of the contract period for the CMS Contract or (ii) the date of completion of the immediately preceding audit (if any) (the “Audit Period”). Provider shall keep and maintain accurate and complete Records throughout the term of the Agreement and the Audit Period.
  • Privacy and Confidentiality Safeguards. Provider shall safeguard the privacy and confidentiality of members and shall ensure the accuracy of the health records of members. Provider shall comply with all state and federal laws and regulations and administrative guidelines issued by CMS pertaining to the confidentiality, privacy, data security, data accuracy and/or transmission of personal, health, enrollment, financial and consumer information and/or medical records (including prescription records) of members, including, but not limited to, the Standards for Privacy of Individually Identifiable Information promulgated pursuant to the Health Insurance Portability and Accountability Act.
  • Member Hold Harmless. Provider shall not, in any event (including, without limitation, non-payment by Cigna-HealthSpring or breach of the Agreement), bill, charge, collect a deposit from, seek compensation or remuneration or reimbursement from or hold responsible, in any respect, any member for any amount(s) that Cigna-HealthSpring may owe to provider for services performed by provider under the Agreement. This provision shall not prohibit provider from collecting supplemental charges, co-payments or deductibles specified in the Benefit Plans. Provider agrees that this provision shall be construed for the benefit of the member and shall survive expiration, non-renewal or termination of the Agreement regardless of the cause for termination.
  • Delegation of Activities or Responsibilities. To the extent activities or responsibilities under a CMS Contract are delegated to provider pursuant to the Agreement (“Delegated Activities”), provider agrees that (i) the performance of the Delegated Activities and responsibilities thereof shall be subject to monitoring on an ongoing basis by Cigna-HealthSpring; and (ii) in the event that Cigna-HealthSpring or CMS determine that provider has not satisfactorily performed any Delegated Activity or responsibility thereof in accordance with the CMS Contract, applicable State and/or Federal laws and regulations and CMS instructions, then Cigna-HealthSpring shall have the right, at any time, to revoke the Delegated Activities by terminating the Agreement in whole or in part, and shall have the right to institute corrective action plans or seek other remedies or curative measures as contemplated by the Agreement. Provider shall not further delegate any activities or requirements without the prior written consent of Cigna-HealthSpring. To the extent that the Delegated Activities include professional credentialing services, provider agrees that the credentials of medical professionals affiliated or contracted with provider will either be:
    • Directly reviewed by Cigna-HealthSpring, or
    • Provider’s credentialing process will be reviewed and approved by Cigna-HealthSpring and Cigna-HealthSpring shall audit provider’s credentialing process on an ongoing basis. Provider acknowledges that Cigna-HealthSpring retains the right to approve, suspend or terminate any medical professionals, as well as any arrangement regarding the credentialing of medical professionals. In addition, provider understands and agrees that Cigna-HealthSpring maintains ultimate accountability under its MMAI contract with CMS. Nothing in this Agreement shall be construed to in any way limit Cigna-HealthSpring’s authority or responsibility to comply with applicable regulatory requirements.
  • Prompt Payment. Cigna-HealthSpring agrees to pay provider in compliance with applicable state or federal law following its receipt of a “clean claim” for services provided to Cigna-HealthSpring members. For purposes of this provision, a clean claim shall mean a claim for provider services that has no defect or impropriety requiring special treatment that prevents timely payment by Cigna-HealthSpring.
  • Compliance with Cigna-HealthSpring’s Obligations, Provider Manual, Policies and Procedures. Provider shall perform all services under the Agreement in a manner that is consistent and compliant with Cigna-HealthSpring’s contract(s) with CMS (the “CMS Contract”) and the State of Illinois. Additionally, provider agrees to comply with the Cigna-HealthSpring provider Manual and all policies and procedures relating to the Benefit Plans.
  • Subcontracting. Cigna-HealthSpring maintains ultimate accountability for adhering to and otherwise fully complying with all terms and conditions of its contract with CMS and the state. Provider shall not subcontract for the performance of Covered Services under this Agreement without the prior written consent of Cigna-HealthSpring. Every subcontract between provider and a subcontractor shall (i) be in writing and comply with all applicable local, State and federal laws and regulations; (ii) be consistent with the terms and conditions of this Agreement; (iii) contain Cigna-HealthSpring and member hold harmless language as set forth in Section 3 hereof; (iv) contain a provision allowing Cigna-HealthSpring and/ or its designee access to such subcontractor’s books and records as necessary to verify the nature and extent of the Covered Services furnished and the payment provided by provider to subcontractor under such subcontract; and(v) be terminable with respect to members or Benefit Plans upon request of Cigna-HealthSpring.
  • Compliance with Laws. Provider shall comply with all State and Federal laws, regulations and instructions applicable to provider’s performance of services under the Agreement. Provider shall maintain all licenses, permits and qualifications required under applicable laws and regulations for provider to perform the services under the Agreement. Without limiting the above, provider shall comply with Federal laws designed to prevent or ameliorate fraud, waste and abuse, including but not limited to applicable provisions of Federal criminal law, the False Claims Act (31U.S.C. 3729 et. seq.) and the anti-kickback statute (section 1128B(b) of the Social Security Act).
  • Program Integrity. Provider represents and warrants that provider (or any of its staff) is not and has not been (i) sanctioned under or listed as debarred, excluded or otherwise ineligible for participation in state or federal programs involving the provision of health care or prescription drug services, or (ii) criminally convicted or has a civil judgment entered against it for fraudulent activities. Provider shall notify Cigna-HealthSpring immediately if, at any time during the term of the Agreement, provider (or any of its staff) is (i) sanctioned under or listed as debarred, excluded or otherwise ineligible for participation in the Medicare program or any Federal program involving the provision of health care or prescription drug services, or (ii) criminally convicted or has a civil judgment entered against it for fraudulent activities. Provider acknowledges that provider’s participation in Cigna-HealthSpring shall be terminated if provider (or any of its staff) is debarred, excluded or otherwise ineligible for participation in the Medicare program or any Federal program involving the provision of health care or prescription drug services.
  • Continuation of Benefits. Provider shall continue to provide services under the Agreement to members in the event of (i) Cigna-HealthSpring’s insolvency, (ii) Cigna-HealthSpring’s discontinuation of operations or (iii) termination of the CMS or State contract, throughout the period for which CMS payments have been made to Cigna-HealthSpring, and, to the extent applicable, for members who are hospitalized, until such time as the member is appropriately discharged.
  • Incorporation of Other Legal Requirements. Any provisions now or hereafter required to be included in the Agreement by applicable Federal and/or State laws and regulations or by CMS shall be binding upon and enforceable against the parties to the Agreement and be deemed incorporated herein, irrespective of whether or not such provisions are expressly set forth in this Manual or elsewhere in your Agreement.
  • Conflicts. In the event of a conflict between any specific provision of your Agreement and any specific provision of the Manual, the specific provisions of this Manual shall control.