2018 Provider Manual

Customer Information

All Participating Providers are responsible for verifying a customer’s eligibility at each and every visit. Please note that customer data is subject to change. The Centers for Medicare and Medicaid Services (CMS) retroactively terminates customers for various reasons. When this occurs, Cigna-HealthSpring’s claim recovery unit will request a refund from the provider. The provider must then contact CMS Eligibility to determine the customer’s actual benefit coverage for the date of service in question.

How to Verify Customer Eligibility

You can verify customer eligibility the following ways:

    You must call the Health Plan to verify eligibility when the customer cannot present identification or does not appear on your monthly eligibility list. Please note: the Health Plan should have the most updated information; therefore, call the Health Plan for accuracy.
  • Provider Services: 1-800-230-6138, Hours Monday-Friday: 8 am - 5 pm CST
  • Use HSConnect. The Cigna-HealthSpring web portal, HSConnect, allows our providers to verify customer eligibility online by visiting https://healthspring.hsconnectonline.com/HSConnect.
  • Ask to see the customer’s Identification Card. Each customer is provided with an individual customer identification card. Noted on the ID card is the customer’s identification number, plan code, name of PCP, copayment, and effective date. Since changes do occur with eligibility, the card alone does not guarantee the customer is eligible.
  • Pursue additional proof of identification. Each PCP and Specialist office is provided with a monthly Eligibility Report upon request, which lists new and current Cigna-HealthSpring customers with their effective dates. Please be sure to refer to the most current month’s Eligibility Report.

Medicare Advantage and Prescription Drug (MAPD)

2018 Medicare Advantage and Prescription Drug Plan Identification Card

Medicare Advantage (MA Only)

2018 Medicare Advantage Plan Identification Card

Medicare Advantage and Prescription Drug (MAPD) - Kansas City

2018 Medicare Advantage and Prescription Drug Plan Identification Card - Kansas City

Medicare Advantage (MA ONLY) - Kansas City

2018 Medicare Advantage Plan Identification Card - Kansas City

The Maximum Out-of-Pocket (MOOP) benefit is now a part of all Cigna-HealthSpring benefit plans. Customers have a limit on the amount they will be required to pay out-of-pocket each year for medical services which are covered under Medicare Part A and Part B. Once the MOOP expense has been reached, the customer is no longer responsible for any out-of- pocket expenses, including any cost shares, for the remainder of the year for covered Part A and Part B services (excluding the customer’s Medicare Part B premium and Cigna-HealthSpring plan premium).

Participating Providers are prohibited from balance billing Cigna-HealthSpring customers 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 customers or persons, other than Cigna-HealthSpring, acting on behalf of customers for Covered Services provided pursuant to the Participating Provider’s Agreement. The provider is not, however, prohibited from collecting copayments, coinsurances or deductibles for covered services in accordance with the terms of the applicable customer’s Benefit Plan.

At Cigna-HealthSpring, we know our customers’ 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 customers’ personal information. Cigna-HealthSpring does not disclose customer 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 customers. This includes how we gather and use their personal information. Cigna-HealthSpring’s privacy practices apply to all of our past, present, and future customers.

When a customer joins a Cigna-HealthSpring Medicare Advantage plan, the customer 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: relates to the past, present, or future physical or behavioral 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 customers’ medical records. Medical records and claims are generally used to review treatment and to conduct quality assurance activities but they also allow Cigna-HealthSpring to look at how care is delivered and carry out programs to improve the quality of care Cigna-HealthSpring’s customers receive. This information also helps Cigna -HealthSpring manage the treatment of diseases to improve our customers’ quality of life.

Cigna-HealthSpring’s customers 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 customer 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 their 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 customer PHI. To discuss any breaches of the privacy of our customers, please contact our HIPAA Privacy Officer at 1-860-787-6801.

Cigna-HealthSpring customers have the following rights:

The right to be treated with dignity and respect

Customers have the right to be treated with dignity, respect, and fairness at all times. Cigna-HealthSpring must obey laws against discrimination that protect customers from unfair treatment. These laws state that Cigna-HealthSpring cannot discriminate against customers (treat customers unfairly) because of a person’s race, disability, religion, gender, sexual orientation, health, ethnicity, creed, age, or national origin. If customers need help with communication, such as help from a language interpreter, they should be directed to call Customer Service. Customer Service can also help customers file complaints about access to facilities (such as wheel chair access). Customers can also call the Office for Civil Rights at 1-800-368-1019 or TTY/TDD 1-800-537-7697, or theOffice for Civil Rights in their area for assistance.

The right to the privacy of medical records and personal health information

There are federal and state laws that protect the privacy of customer medical records and personal health information. Cigna-HealthSpring keeps customers’ personal health information private as required under these laws. Any personal information that a customer gives Cigna-HealthSpring is protected. Cigna-HealthSpring staff will make sure that unauthorized people do not see or change customer records. Generally, we will get written permission from the customer (or from someone the customer has given legal authority to make decisions on their behalf) before we can give customer health information to anyone who is not providing the customer’s medical care. There are exceptions allowed or required by law, such as releasing health information to government agencies that are checking on quality of care.

The laws that protect customer privacy give them rights related to accessing information and controlling how their health information is used. Cigna-HealthSpring is required to provide customers with a notice that informs them of these rights and explains how Cigna-HealthSpring protects the privacy of their health information. For example, customers have the right to look at their medical records, and obtain copies of the records (there may be a fee charged for making copies). Customers also have the right to ask plan providers to make additions or corrections to their medical records (if customers ask plan providers to do this, they will review customer requests and figure out whether the changes are appropriate). Customers have the right to know how their health information has been given out and used for routine and non-routine purposes. If customers have questions or concerns about privacy of their personal information and medical records, they should be directed to call Customer Service. Cigna-HealthSpring will release a customer’s information, including prescription drug event data, to Medicare, which may release it for research and other purposes that follow all applicable federal statutes and regulations.

The right to see Participating Providers, get covered services, and get prescriptions filled within a reasonable period of time

Customers will get most or all of their health care from Participating Providers, that is, from doctors and other health providers who are part of Cigna-HealthSpring's provider network. Customers have the right to choose a participating provider (Cigna-HealthSpring will work with customers to ensure they find physicians who are accepting new patients).

Customers have the right to go to a women’s health Specialist (such as a gynecologist) without a referral. Customers have the right to timely access to their providers and to see Specialists when care from a Specialist is needed. Customers also have the right to timely access to their prescriptions at any network pharmacy. “Timely access” means that customers can get appointments and services within a reasonable amount of time. The Evidence of Coverage explains how customers access Participating Providers to get the care and services they need, and their rights to receive care for a medical emergency and urgently needed care.

The right to know treatment choices and participate in decisions about their health care

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.

Customers have the right to receive a detailed explanation from Cigna-HealthSpring if they believe that a plan provider has denied care that they believe they are entitled to receive or care they believe they should continue to receive. In these cases, customers must request an initial decision. “Initial decisions” are discussed in the customers’ Evidence of Coverage.

Customers have the right to refuse treatment. This includes the right to leave a hospital or other medical facility, even if their doctor advises them not to leave. This also includes the right to stop taking their medication. If customers refuse treatment, they accept responsibility for what happens as a result of refusing treatment.

The right to use Advance Directives (such as a Living Will or a Power of Attorney)

Customers have the right to ask someone such as a family customer or friend to help them with decisions about their health care. Sometimes, people become unable to make health care decisions for themselves due to accidents or serious illness. A customer may use a special form to give someone they trust the legal authority to make decisions for them if they ever become unable to make decisions for themselves. Customers also have the right to give their doctors written instructions mandating how to handle their medical care if they become unable to make decisions for themselves. The legal documents that customers can use to give their directions in advance of these situations are called “advance directives,” and they include “living wills” and “powers of attorney for health care.

Customers may obtain advance directives from their lawyer, from a social worker, from Cigna-HealthSpring, from some office supply stores, or potentially from organizations that give people information about Medicare. Since advance directives are legal documents, customers should consider having a lawyer help them prepare them. It is important to sign this form and keep a copy at home. Customers should give a copy of the form to their doctor and to the person they name as the ultimate decision maker. Customers may want to give copies to close friends or family customers as well.

If customers know in advance that they are going to be hospitalized and they have signed an advance directive, they should take a copy with them to the hospital. If customers are admitted to the hospital, the hospital will ask them whether they have signed an advance directive and whether they have it with them. If customers have not signed an advance directive or do not have a copy available during admission, the hospital has forms available and will ask if the customer wants to sign one.

Remember, it is a customer’s choice whether he/ she wants to fill out an advance directive (including whether they want to sign one if they are in the hospital). According to law, no one can deny them care or discriminate against them based on whether or not they have signed an advance directive. If customers have signed an advance directive and they believe that a doctor or hospital has not followed the instructions in it, customers may file a complaint with their State Board of Medicine or appropriate state agency (this information can be found in the customer’s Evidence of Coverage).

The right to make complaints

Customers have the right to make a complaint if they have concerns or problems related to their coverage or care. Customers or an appointed/authorized representative may file appeals, grievances, concerns and Coverage Determinations. If customers make a complaint or file an appeal or Coverage Determination, Cigna-HealthSpring must treat them fairly and is prohibited from discriminating against them because they made a complaint or filed an appeal or Coverage Determination. To obtain information relative to appeals, grievances, concerns and/or Coverage Determinations, customers should call Customer Service.

The right to obtain information about their health care coverage and cost

The Evidence of Coverage tells customers what medical services are covered and what they have to pay. If they need more information, they should be directed to call Customer Service. Customers have the right to an explanation from Cigna-HealthSpring about any bills they receive for services not covered by Cigna-HealthSpring. Cigna-HealthSpring must tell customers in writing why Cigna-HealthSpring will not pay for or allow them to get a service, and how they can file an appeal to ask Cigna-HealthSpring to change this decision. Provider’s staff should inform customers on how to file an appeal, if asked, and should direct customers to review their Evidence of Coverage for more information about filing an appeal.

The right to obtain information about Cigna-HealthSpring, plan providers, drug coverage, and costs

Customers have the right to obtain information about the Cigna-HealthSpring plans and operations. This includes information about our financial condition, about the services we provide, and about our health care providers and their qualifications. Customers have the right to know how we pay our doctors. To obtain any of this information, customers should be directed to call Customer Service. Customers have the right to obtain information from us about their Part D prescription coverage. This includes information about our financial condition and about our network pharmacies. To obtain any of this information, staff should direct customers to call Customer Service.

The right to receive more information about customers’ rights

Customers have the right to receive information about their rights and responsibilities. If customers have questions or concerns about their rights and protections, they should be directed to call Customer Service. Customers can also get free help and information from their State Health Insurance Assistance Program (SHIP). Additionally, customers can obtain a free copy of the Customer Medicare Rights and Protections booklet by calling 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. Customers can call 24 hours a day, 7 days a week, or customers can visit www.medicare.gov to order this booklet or print it directly from their computer.

The right to take action if a customer thinks they have been treated unfairly or their rights are not being respected

If customers think they have been treated unfairly or their rights have not been respected, there are options for what they can do.

  • If customers think they have been treated unfairly due to their race, color, national origin, disability, age, or religion, we must encourage them to inform us immediately. They can also call the Office for Civil Rights in their area
  • For any other kind of concern or problem related to their Medicare rights and protections described in this section, customers should call Customer Service. Customers can also get help from their State Health Insurance Assistance Program (SHIP).

Along with certain rights, there are also responsibilities associated with being a customer of Cigna-HealthSpring.

Customers are responsible for the following:

  • Becoming familiar with their Cigna-HealthSpring coverage and the rules they must follow to get care as a customer. Customers can use their Cigna-HealthSpring Evidence of Coverage and other information that we provide them to learn about their coverage, what we have to pay, and the rules they need to follow. Customers should call Customer Service if they have any questions or complaints.
  • Advising Cigna-HealthSpring if they have other insurance coverage.
  • Notifying providers when seeking care (unless it is an emergency) that they are enrolled with Cigna-HealthSpring and present their plan enrollment card to the provider.
  • Giving their doctors and other providers the information they need to provide care for them and to follow agreed upon treatment plans and instructions. Customers must be encouraged to ask questions of their doctors and other providers whenever the customer has them.
  • Acting in a way that supports the care given to other patients and helps the smooth running of their doctor’s office, hospitals, and other offices.
  • Paying their plan premiums and any copayments or coinsurances they may have for the Covered Services they receive. Customers must also meet their other financial responsibilities that are described in their Evidence of Coverage.
  • Informing Cigna-HealthSpring if they have any questions, concerns, problems, or suggestions regarding their rights, responsibilities, coverage, and/or Cigna-HealthSpring operations.
  • Notifying Cigna-HealthSpring Customer Service and their providers of any address and/or phone number changes as soon as possible.
  • Using their Cigna-HealthSpring plan only to access services, medications and other benefits for themselves.

The Federal Patient Self-Determination Act grants patients the 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), and our own policies and procedures, Cigna-HealthSpring requires all participating providers to have a process in place pursuant to the intent of the Patient Self Determination Act.

All providers contracted directly or indirectly with Cigna-HealthSpring may be informed by the customer that the customer has executed, changed, or revoked an advance directive. At the time a service is provided, the provider should ask the customer to provide a copy of the advance directive to be included in his/her medical record.

If the Primary Care Physician (PCP) and/or treating provider cannot as a matter of conscience fulfill the customer’s written advance directive, he/she must inform the customer and Cigna-HealthSpring. Cigna-HealthSpring and the PCP and/or treating provider will arrange for a transfer of care. Participating Providers may not condition the provision of care or otherwise discriminate against an individual based on whether the individual has 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.

To ensure providers maintain the required processes to advance directives, Cigna-HealthSpring conducts periodic patient medical record reviews to confirm that required documentation exists.

All Cigna-HealthSpring customers receive benefits and services as defined in their Evidence of Coverage (EOC). Each month, Cigna-HealthSpring makes available to each participating Primary Care Physician a list of their active customers. Along with the customer’s demographic information, the list includes the name of the plan in which the customer enrolled. Please be aware that recently terminated customers may appear on the list. (See “Eligibility Verification” section of this manual).

Cigna-HealthSpring encourages its customers to call their Primary Care Physician to schedule appointments. However, if a Cigna-HealthSpring customer calls or comes to your office for an unscheduled non-emergent appointment, please attempt to accommodate the customer and explain to them your office policy regarding appointments. If this problem persists, please contact Cigna-HealthSpring.

Emergency Services
An emergency is defined by Cigna-HealthSpring as the sudden onset of a medical condition with acute symptoms (the full definition of Emergency Services is located in your Agreement). A customer may reasonably believe that the lack of immediate medical attention could result in:

  • Permanently placing the customer’s health in jeopardy;
  • Causing serious impairments to body functions; or
  • Causing serious or permanent dysfunction of any body organ or part

In the event of a perceived emergency, customers have been instructed to first contact their Primary Care Physician for medical advice. However, if the situation is of such a nature that it is life threatening, customers have been instructed to go immediately to the nearest emergency room facility. Customers who are unable to contact their PCP prior to treatment have been instructed to contact their PCP as soon as is medically possible or within forty-eight (48) hours after receiving care. The PCP will be responsible for providing and arranging any necessary follow-up services.

For emergency services within the service area, the PCP is responsible for providing, directing, or authorizing a customer’s emergency care. The PCP or his/her designee must be available twenty-four (24) hours a day, seven days a week to assist customers needing emergency services. The hospital may attempt to contact the PCP for direction. Customers have a copayment responsibility for outpatient emergency visits unless an admission results.

For emergency services outside the service area, Cigna-HealthSpring will pay reasonable charges for emergency services received from Non-Participating Providers if a customer is injured or becomes ill while temporarily outside the service area. Customers may be responsible for a copayment for each incident of outpatient emergency services at a hospital’s emergency room or urgent care facility.

Urgent care services

Urgent Care services are for the treatment of symptoms that are non-life threatening but that require immediate attention. The customer must first attempt to receive care from his/her PCP. Treatment at a participating Urgent Care Center will be covered by Cigna-HealthSpring without a referral.

Continuing or follow-up treatment

Continuing or follow-up treatment, except by the PCP, whether in or out of the service area, is not covered by Cigna-HealthSpring unless specifically authorized or approved by Cigna-HealthSpring. Payment for covered benefits outside the service area is limited to medically necessary treatment required before the customer can reasonably be transported to a participating hospital or returned to the care of the PCP.

In addition to any exclusion or limitations described in the customer’s EOC, the following items and services are not covered under the Original Medicare Plan or by Cigna-HealthSpring:

  • Services which are not reasonable and necessary, according to the standards of the Original Medicare Plan, unless these services are otherwise listed by our plan as a covered service.
  • Experimental or investigational medical and surgical procedures, equipment, and medications, unless covered by the Original Medicare Plan or unless, for certain services, the procedures are covered under an approved clinical trial. The Centers for Medicare and Medicaid Services (CMS) will continue to pay through Original Medicare for clinical trial items and services covered under the September 2000 National Coverage Determination that is provided to plan customers. Experimental procedures and items are those items and procedures determined by our plan and the Original Medicare Plan to not be generally accepted by the medical community.
  • Surgical treatment of morbid obesity unless medically necessary or covered under the Original Medicare Plan.
  • Private room in a hospital, unless medically necessary.
  • Private duty nurses.
  • Personal convenience items, such as a telephone or television in a customer’s room at a hospital or skilled nursing facility.
  • Nursing care on a full-time basis in a customer’s home.
  • Custodial care unless it is provided in conjunction with covered skilled nursing care and/or skilled rehabilitation services. This includes care that helps people with activities of daily living like walking, getting in and out of bed, bathing, dressing, eating, using the bathroom, preparation of special diets, and supervision of medication that is usually self-administered.
  • Homemaker services.
  • Charges imposed by immediate relatives or customers of the customer’s household.
  • Meals delivered to the customer’s home.
  • Elective or voluntary enhancement procedures, services, supplies, and medications including but not limited to: weight loss, hair growth, sexual performance, athletic performance, cosmetic purposes, anti-aging, and mental performance unless medically necessary.
  • Cosmetic surgery or procedures, unless needed because of accidental injury or to improve the function of a malformed part of the body. All stages of reconstruction are covered for a breast after a mastectomy, as well as for the unaffected breast to produce a symmetrical appearance.
  • Routine dental care (i.e. cleanings, fillings, or dentures) or other dental services unless otherwise specified in the EOC. However, non-routine dental services received at a hospital may be covered.
  • Chiropractic care is generally not covered under the plan with the exception of manual manipulation of the spine and is limited according to Medicare guidelines.
  • Routine foot care is generally not covered under the plan and is limited according to Medicare guidelines.
  • Supportive devices for the feet; orthopedic shoes unless they are part of a leg brace and included in the cost of the brace.

Exception: Orthopedic or therapeutic shoes are covered for people with diabetic foot disease.

  • Hearing aids and routine hearing examinations unless otherwise specified in the E
  • Eyeglasses, with the exception of after cataract surgery, routine eye examinations, radical keratotomy, LASIK surgery, vision therapy, and other low vision aids and services unless otherwise specified in the E
  • Self-administered prescription medication for the treatment of sexual dysfunction, including erectile dysfunction, impotence, and anorgasmy or hyporgasmy unless otherwise included in the customer’s Part D ben Please see the formulary for details.
  • Reversal of sterilization measures, sex change operations, and non-prescription contraceptives
  • Acupuncture
  • Naturopath service
  • Services provided to veterans in Veterans Affairs (VA) fa However, in the case of emergency situations received at a VA hospital, if the VA cost-sharing is more than the cost-sharing required under the plan, the plan will reimburse veterans for the difference. Customers are still responsible for our plan cost-sharing amount.

Any of the services listed above that are not covered will remain not covered even if received at an emergency facility. For example, non-authorized, routine conditions that do not appear to a reasonable person to be based on a medical emergency are not covered if received at an emergency facility.

All telephonic inquiries received by Cigna- HealthSpring’s Medicare Advantage Customer Service Department will be resolved on an informal basis, except for inquiries that involve “Appealable” issues. Appealable issues will be routed through either the standard or expedited appeal process. An expedited appeal is processed within 72 hours of receipt for situations where waiting longer for a response could result in serious health consequences. Standard appeals are resolved within 30 days of receipt for services not yet received and within 60 days for services that have been provided prior to submitting the appeal. In situations where a customer is not in agreement with the informal resolution, the customer must submit a written request for reconsideration. Written requests for reconsideration should be sent to:
Cigna-HealthSpring
Attn: Reconsiderations
PO Box 20002
Nashville, TN 37202

All other written correspondence received by Cigna-HealthSpring will be documented and routed through the appropriate Appeal or grievance channels.

Cigna-HealthSpring customers have the right to file a complaint, also referred to as a grievance, regarding any 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.
  • Dissatisfaction with the office experience such as excessive wait times, physician behavior or demeanor, or inadequacy of facilities.
  • Involuntary disenrollment situations.
  • Poor quality of care or services received.

Cigna-HealthSpring customers 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 of the service area or Emergency Services worldwide.
  • A denied claim for any health services furnished by a non-participating provider or supplier they believe should have been provided, arranged for, or reimbursed by Cigna-HealthSpring.
  • Services not received, but believed to be the responsibility of Cigna-HealthSpring.
  • A reduction or termination of a service a customer feels is medically necessary.

In addition, a customer may Appeal any decision related to a hospital discharge. In this case, a notice will be given to the customer with instructions for filing an Appeal. The customer will remain in the hospital while the Appeal documentation is reviewed. The customer will not be held liable for charges incurred during this period, regardless of the outcome of the review. Please refer to the Cigna-HealthSpring Evidence of Coverage (EOC) for additional benefit information.

Many of your patients may have Cigna-HealthSpring as their primary insurance payer and Medicaid as their secondary payer. You must coordinate the benefits of these “dual eligible” Cigna-HealthSpring customers by determining whether the customer should be billed for the deductibles, copayments, or coinsurances associated with their benefit plan. Providers may not assess a QMB (Qualified Medicare Beneficiary) or QMB-Plus for Cigna-HealthSpring copayments, coinsurances, and/or deductibles.

Providers will accept as payment in full Cigna-HealthSpring’s payment and will not seek additional payment from the state or dual eligible customers. Additional information concerning Medicaid provider participation is available at: www.cignahealthspring.com.

For Alabama and Florida: Providers are prohibited from billing, charging, collecting a deposit, seeking compensation or remuneration from, or having any recourse against any Cigna-HealthSpring customer for fees that are the responsibility of Cigna-HealthSpring.

For Alabama: Providers must accept payment from Cigna-HealthSpring as payment in full. A customer’s level of Medicaid eligibility can change due to their medical and financial needs. Cigna-HealthSpring encourages you to verify customers’ Medicaid eligibility when rendering services which will help you determine if the customer owes a deductible or copay.

Medicaid eligibility can be obtained by using the Medicaid telephonic Eligibility Verification System. If you do not have access to the system, please contact your State Medicaid provider for additional information.

Please note: Each state varies in their decision to cover the cost-share for populations beyond QMB and QMB+.

Patient’s Medicaid plan Patient’s liability Patient owes deductibles and copayments associated with benefit plan Medicaid provides benefits patient not liable for deductibles and copayments associated with benefit plan
Medicaid (FBDE) No Yes
QMB Only No Yes
QMB+ No Yes
SLMB Yes No
SLMB+ Yes No
QI-1 Yes No
QDWI Yes No

Full Benefit Dual Eligibles (FBDE)

An “FBDE” is an individual who is eligible for Medicaid either categorically or through optional coverage groups such as Medically-Needy or special income levels for institutionalized or home and community- based waivers, but who does not meet the income or resource criteria for QMB or SLMB. Obligations may effectively be covered by the state Medicaid benefit, but certain conditions must be met including:

  1. The service is also covered by Medicaid;
  2. The provider is a Medicaid provider; and
  3. The Medicaid fee schedule amount is greater than the Medicare amount paid.

 

Qualified Medicare Beneficiary (QMB Only)

A “QMB” is an individual who is entitled to Medicare Part A, has income that does not exceed 100% of the Federal Poverty Level (FPL), and whose resources do not exceed twice the Supplemental Security Income (SSI) limit. A QMB is eligible for Medicaid payment of Medicare premiums, deductibles, coinsurance, and copayments (except for Part D). QMBs who do not qualify for any additional Medicaid benefits are called “QMB Only”. Providers may not assess a QMB for Cigna-HealthSpring deductibles, copayments, or coinsurances.

Qualified Medicare Beneficiary Plus (QMB+)

A “QMB+” is an individual who meets standards for QMB eligibility and also meets criteria for full Medicaid benefits in the state. These individuals often qualify for full Medicaid benefits by meeting Medically Needy standards, or through spending down excess income to the Medically Needy level.

Specified Low-Income Medicare Beneficiary (SLMB Only)

An “SLMB” is an individual who is entitled to Medicare Part A, has income that exceeds 100% FPL but is less than 120% FPL, and whose resources do not exceed twice the SSI limit. The only Medicaid benefit for which a SLMB is eligible is payment of Medicare Part B premiums. SLMBs who do not qualify for any additional Medicaid benefits are called “SLMB Only.”

Specified Low-Income Medicare Beneficiary Plus (SLMB+)

A “SLMB+” is an individual who meets the standards for SLMB eligibility, but who also meets the criteria for full state Medicaid benefits. Such individuals are entitled to payment of the Medicare Part B premium, as well as full state Medicaid benefits. These individuals often qualify for Medicaid by meeting the Medically Needy standards, or through spending down excess income to the Medically Needy level.

Qualifying Individual (QI)

A “QI” is an individual who is entitled to Part A, has income that is at least 120% FPL but less than 135% FPL, resources that do not exceed twice the SSI limit, and who is not otherwise eligible for Medicaid. A QI is similar to an SLMB in that the only benefit available is Medicaid payment of the Medicare Part B premium; however, expenditures for QIs are 100% federally funded and the total expenditures are limited by statute.

Other Full Benefit Dual Eligibles (FBDE)

An “FBDE” is an individual who is eligible for Medicaid either categorically or through optional coverage groups such as Medically-Needy or special income levels for institutionalized or home and community-based waivers, but who does not meet the income or resource criteria for QMB or SLMB.

Qualified Disabled and Working Individual (QDWI)

A “QDWI” is an individual who lost Medicare Part A benefits due to returning to work, but who is eligible to enroll in and purchase Medicare Part A. The individual’s income may not exceed 200% FPL and resources may not exceed twice the SSI limit. The individual may not be otherwise eligible for Medicaid. QDWIs are eligible only for Medicaid payment of Part A premium.

COORDINATION OF CARE WITH STAR+PLUS MEDICAID

The state of Texas’ goal for managed Medicaid services is to integrate acute care and Long Term Services and Supports, including services provided through Medicare Advantage Dual Special Needs Plans (MA-

Dual SNP); provide continuity of care; and ensure timely access to quality care through an adequate provider network that includes behavioral health services and disease management services.

The term “dual eligible” refers to someone who is enrolled in both Medicaid and Medicare. Some dual eligible clients are eligible for STAR+PLUS. Dual eligible clients must choose a STAR+PLUS MCO, but do not choose a PCP because they receive acute care services from their Medicare providers. The STAR+PLUS MCO covers only Long-Term Services and Supports (LTSS) for dual eligible customers.

Certain Medicaid clients are excluded from enrolling in STAR+PLUS. This includes:

  • Clients of Medicaid 1915(c) waiver services other than Community-Based Alternatives services.
  • Clients not eligible for full Medicaid benefits, such as Frail Elderly program customers, Qualified Medicare Beneficiaries, Specified Low-IncomeMedicare Beneficiaries, Qualified Disabled Working Individuals and undocumented aliens.
  • Children in state foster care.
  • People not eligible for Medicaid.
  • Undocumented immigrants.

In service areas where STAR+PLUS is available, customers are eligible for Community-Based Long-Term Care Services and Supportsthrough their STAR+PLUS MCO.

Long-term Care Services available to all STAR+PLUS customers include:

  • Providers offering Personal Attendant Services (PAS) assist customers with the performance of activities of daily living and household chores necessary to maintain the home in a clean, sanitary, and safe environment. The level of assistance provided is determined by the customer’s needs and plan of care. Services may also include the provision of nursing tasks delegated by a registered nurse in accordance with state rules promulgated by the Texas Board of Nursing, and protective supervision provided solely to ensure the health and welfare of a customer with cognitive/ memory impairment and/or physical weakness.
  • Day Activity and Health Services (DAHS) include nursing and personal care services, physical rehabilitation services, nutrition services, transportation services, and other supportive services.

These services are offered by facilities licensed by the Texas Department of Human Services and certified by Texas Department of Aging and Disability Services. Except for holidays, these facilities must have services available at least 10 hours a day, Monday through Friday.

Long-term Care Services Available to STAR+PLUS customers who qualify under the HCBS STAR+PLUS Waiver (SPW) (previously known as 1915 (c) Nursing Facility Waiver program):

Adaptive Aids

Adaptive aids and medical equipment include devices, controls, or medically necessary supplies that enable customers with functional impairments to perform activities of daily living or to perceive, control, or communicate with the environment in which they live. A complete listing of covered adaptive aids and medical equipment is available in the STAR+PLUS Handbook which is available at www.dads.state.tx.us/handbooks/sph.

Adult Foster Care

Adult foster care is a 24-hour living arrangement in a Department of Human Services (DHS) foster home for people who, because of physical or mental limitations, are unable to continue residing in their own homes. Services may include meal preparation, housekeeping, personal care, help with activities of daily living, supervision, and the provision or arrangement of transportation.

Assisted Living

Assisted living (AL) is a twenty-four (24) hour living arrangement in a licensed personal care facility in which personal care, home management, escort, social and recreational activities, twenty-four (24) hour supervision, supervision of, assistance with, and direct administration of medications, and the provision or arrangement of transportation are provided. Under the HCBS STAR+PLUS Waiver (SPW), personal care facilities may contract to provide services in two distinct types of living arrangements: (1) assisted living apartments, and (2) assisted living non-apartment settings.

Dental Services

The services provided by a dentist to preserve teeth and meet the medical need of the customer. Allowable services include emergency dental treatment necessary to control bleeding, relieve pain and eliminate acute infection; preventive procedures required to prevent the imminent loss of teeth; the treatment of injuries to teeth or supporting structures; dentures and the cost of preparation and fitting; and routine procedures necessary to maintain good oral health.

Emergency Response Services

Emergency Response Services (ERS) are electronic monitoring systems for use by functionally impaired individuals who live alone or are isolated in the community. In an emergency, the customer can press a call button to signal for help. The electronic monitoring system, which has a twenty-four (24) hour, seven (7) day per week capability, helps ensure that the appropriate persons or service agency responds to an alarm call from the customer.

Financial Management Services

Assistance to customers with managing funds associated with services elected for self-direction and is provided by the consumer directed services agency. This service includes initial orientation and ongoing training related to the responsibilities of being an employer and adhering to legal requirements for employers.

Home Delivered Meals

Home delivered meals are provided to people who are unable to prepare their own meals and for whom there are no other persons available to do so or where the provision of a home delivered meal is the most cost effective method of delivering a nutritionally adequate meal. Modified diets, where appropriate, will be provided to meet the customer’s individual requirements.

Home Modifications

Minor home modifications are services that assess the need for, arrange for, and provide modifications and/or improvements to an individual’s residence to enable them to reside in the community and to ensure safety, security and accessibility.

Medical Supplies

Medical supplies are not available under the 1915(b) Waiver program.

Nursing Services

In-home Nursing Services include, but are not limited to, assessing and evaluating health problems and the direct delivery of nursing tasks, providing treatments and health care procedures ordered by a physician and/ or required by standards of professional practice or state law, delegating nursing tasks to unlicensed persons according to state rules promulgated by the Texas Board of Nursing, developing the health care plan and teaching customers about proper health maintenance.

Respite Services

Respite Services offer temporary relief to persons caring for functionally impaired adults in community settings other than Adult Foster Care (AFC) homes or Assisted Living /Residential Care (AL/RC) facilities. Respite services are provided on an in-home basis and out-of-home basis and are limited to thirty (30) days per year. Room and board is included in the Waiver program payment for out-of-home settings.

Support Consultation

Support Consultation is an optional service component that offers practical skills training and assistance to enable an individual to successfully direct those services the individual elects for participantdirection. This service is provided by a certified support advisor, and includes skills training related to recruiting, screening, and hiring workers, preparing job descriptions, verifying employment eligibility and qualifications, completion of documents required to employ an individual, management of workers, and development of effective back-up plans for services considered critical to the individual’s health and welfare in the absence of the regular provider or an emergency situation. Support consultation is provided only by a certified support advisor certified by the Department of Aging and Disability.

Therapy Services

  • Physical therapy includes specialized techniques for the evaluation and treatment of chronic conditions related to functions of the neuromusculoskeletal systems. Services include the full range of activities provided by a physical therapist or a licensed physical therapy assistant under the direction of a licensed physical therapist, within the scope of the therapist’s state licensure.
  • Occupational therapy includes interventions and procedures for chronic conditions to promote or enhance safety and performance in instrumental activities of daily living, education, work, play, leisure and social participation. Services include the full range of activities provided by an occupational therapist or a licensed occupational therapy assistant under the direction of a licensed occupational therapist, within the scope of the therapist’s state licensure.
  • Speech therapy includes evaluation and treatment of impairments, disorders or deficiencies related to a customer’s speech and language which are chronic conditions. Services include the full range of activities provided by speech and language pathologists under the scope of their state licensure.

Transition Assistance Services (TAS)

Offers a maximum of $2,500 to enhance the ability of nursing facility residents to transition and receive services in the community. TAS helps defray the costs associated with setting up a household for those customers establishing an independent residence. TAS include, but are not limited to, payment of security deposits to lease an apartment, purchase of essential furnishings (table, eating utensils), payment of moving expenses, etc.

Employment Assistance

Employment Assistance Services is a service that assists individuals to obtain competitive integrate employment and includes, but are not limited to the following: Identifying a member’s employment preferences, job skills, and requirements for a work setting and work conditions; locating prospective employers offering employment compatible with a member’s identified preferences, skills, and requirements; and contacting a prospective employer on behalf of a member and negotiating employment.

Supported Employment

Supported Employment Services are assistive services provided in order to sustain paid employment, to a member who, because of a disability, requires intensive, ongoing support to be self-employed, work from home, or perform in a work setting at which members without disabilities are employed. Supported Employment includes employment adaptations, supervision, and training related to a member’s diagnosis.

Cognitive Rehabilitation Therapy

Cognitive rehabilitation therapy is a service that assists an individual in learning or relearning cognitive skills that have been lost or altered as a result of damage to brain cells/chemistry in order to enable the individual to compensate for the lost cognitive functions. Cognitive rehabilitation therapy is provided when determined to be medically necessary through an assessment an appropriate professional. Cognitive rehabilitation therapy is provided in accordance with the plan of care developed by the assessor, and includes reinforcing, strengthening, or reestablishing previously learned patterns of behavior, or establishing new patterns of cognitive activity or compensatory mechanisms for impaired neurological systems conducted by an appropriate professional. Cognitive rehabilitation therapy is provided in accordance with the plan of care developed by the assessor, and includes reinforcing, strengthening, or reestablishing previously learned patterns of behavior, or establishing new patterns of cognitive activity or compensatory mechanisms for impaired neurological systems.

Targeted Case Management

Targeted Case Management (TCM) consists of services designed to assist Members who are diagnosed with Severe and Persistent Mental Illness (SPMI) and Severe Emotional Disturbance (SED) with gaining access to needed medical, social, educational and other services and supports.

Mental Health Rehabilitative Service

Mental Health Rehabilitative Services are those age appropriate services determined by HHSC and Federally approved protocol as medically necessary to reduce a Member’s disability resulting from severe mental illness or serious emotional or behavioral disorders that help to increase the Member’s level of functioning and maintain independence in the home and the community. These services include the following: medication training and support, psychosocial rehabilitative services, skills training and development, crisis intervention, and day programming for acute episodes.

Community First Choice (CFC)

Community First Choice (CFC) allows provider to provide home and community-based attendant services and supports to Medicaid recipients with disabilities. All CFC services will be provided in a home or community based setting, which does not include a nursing facility, hospital providing long-term services, institution for mental disease, a condition, or a setting with the characteristics of an institution. Community First Choice Services include: help with activities of daily living and health-related tasks through hands-on assistance, supervision or cueing; services to help the individual learn how to care for themselves; backup systems or ways to ensure continuity of services and supports; training on how to select, manage and dismiss attendants.

Provider Information

Cigna-HealthSpring recognizes Family Medicine, General Practice, Geriatric Medicine, and Internal Medicine physicians as Primary Care Physicians (PCPs).

Cigna-HealthSpring may recognize Infectious Disease Physicians as PCPs for customers who may require a specialized physician to manage their specific health care needs.

All contracted, credentialed providers participating with Cigna-HealthSpring are listed in the region-appropriate Provider Directory, which is provided to customers and made available to the public.

Each Cigna-HealthSpring customer must select a Cigna-HealthSpring participating Primary Care Physician (PCP) at the time of enrollment. The PCP is responsible for managing all the health care needs of a Cigna-HealthSpring customer as follows:

  • Manage the health care needs of Cigna-HealthSpring customers who have chosen the physician as their PCP.
  • Ensure that each customer receives treatment as frequently as is necessary based on the customer’s condition.
  • Develop an individual treatment plan for each customer.
  • Submit accurate and timely claims and encounter information for clinical care coordination.
  • Comply with Cigna-HealthSpring’s pre-authorization and referral  procedures.
  • Refer customers to appropriate Cigna-HealthSpring Participating Providers.
  • Comply with Cigna-HealthSpring’s Quality Management and Utilization Management programs.
  • Participate in Cigna-HealthSpring’s 360 Assessment Program.
  • Use appropriate designated ancillary services.
  • Comply with emergency care procedures.
  • Comply with Cigna-HealthSpring access and availability standards as outlined in this manual,  including after-hours care.
  • Bill Cigna-HealthSpring on the current CMS 1500 claim form or electronically in accordance with Cigna-HealthSpring billing procedures.
  • Ensure that, when billing for services provided, coding is specific enough to accurately capture the acuity and complexity of a customer’s condition and ensure that the codes submitted are supported by proper documentation in the medical record.
  • Comply with Preventive Screening and Clinical Guidelines.
  • Adhere to Cigna-HealthSpring’s medical record standards as outlined in this manual.

Each Cigna-HealthSpring customer is entitled to see a Specialist Physician for certain services required for treatment of a given health condition. The Specialist Physician is responsible for managing all the health care needs of a Cigna-HealthSpring customer as follows:

  • Provide specialty health care services to customers as needed.
  • Collaborate with the customer's Cigna-HealthSpring Primary Care Physician to enhance continuity of health care and appropriate treatment.
  • Provide consultative and follow-up reports to the referring physician in a timely manner.
  • Comply with access and availability standards as outlined in this manual including after-hours care.
  • Comply with Cigna-HealthSpring's pre-authorization and referral process.
  • Comply with Cigna-HealthSpring's Quality Management and Utilization Management programs.
  • Bill Cigna-HealthSpring on the CMS 1500 claim form in accordance with Cigna-HealthSpring's billing procedures.
  • Ensure that, when billing for services provided, coding is specific enough to capture the acuity and complexity
  • of a customer's condition and ensure that the codes submitted are supported by proper documentation in the medical record.
  • Refer customers to appropriate Cigna-HealthSpring participating providers.
  • Submit encounter information to Cigna-HealthSpring accurately and timely.
  • Adhere to Cigna-HealthSpring's medical record standards as outlined in this manual.

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 1-800-230-6138.

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.

  • The PCP should provide the Specialist Physician with relevant clinical information regarding the customer's care.
  • The Specialist Physician must provide the PCP with information about his/her visit with the customer in a timely manner.
  • The PCP must document in the customer's medical record his/her review of any reports, labs, or diagnostic tests received from a Specialist Physician.

The information below is a general guideline to assist Cigna-HealthSpring providers who have contracted with multiple Medicare Advantage plans and accept Medicare FFS patients determine what marketing and patient outreach activities are permissible under the CMS guidelines. CMS has advised Medicare Advantage 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.

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 Advantage 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 Advantage 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 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 Program (SHIP), Cigna-HealthSpring marketing representatives, state Medicaid, or 1-800-Medicare to assist the patient in learning about the plan and making a health care enrollment decision.
  • Display and distribute in provider offices Cigna-HealthSpring MA and MAPD marketing materials, excluding application forms. The officemust 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 Advantage or to close panel to original Medicare FFS if appropriate.
  • Record messages on our auto dialer to existing Cigna-HealthSpring customers 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.
  • 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.

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, as health screening is prohibited.
  • Expect compensation directly or indirectly from the plan for beneficiary enrollment activity.
  • Call customers who are disenrolling 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 a health plan.
  • Advertise using Cigna-HealthSpring's name without Cigna-HealthSpring's prior consent and potentially
  • Issue advertisements without CMS approval depending upon the content of the advertisement.

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

  • Fraudulent use of services or benefits.
  • The customer is disruptive, unruly, threatening, or uncooperative to the extent that customer seriously impairs Cigna-HealthSpring's or the provider's ability to provide services to the customer or to obtain new customers and the aforementioned behavior is not caused by a physical or behavioral health condition.
  • Threats of physical harm to a provider and/or office staff.
  • Non-payment of required copayment for services rendered.
  • 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 customer steadfastly refuses 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 customer'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 the customer's behavior cannot be remedied through reasonable efforts, and the PCP feels the relationship has been irreparably harmed, the PCP must complete the customer transfer request form and submit it to Cigna-HealthSpring.

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

Procedure

  • Once the provider has submitted the Physician Notice to Discharge a Customer from Panel form to Cigna-HealthSpring with supporting documentation, Cigna-HealthSpring will review the form and determine whether the provider can immediately proceed to send written notice to the customer about the upcoming change or if further investigation is required.
  • Once Cigna-HealthSpring approves the provider’s request to discharge the customer from the member’s panel, the physician will send written notice to the customer informing them of their decision to terminate the physician/customer relationship at least 30 (calendar) days before terminating the relationship. The physician will continue to provide care to the customer during the thirty (30) day period or until the customer selects or is assigned to another physician. Cigna-HealthSpring will assist the customer in establishing a relationship with another physician.
  • The physician will transfer, at no cost, a copy of the medical records of the customer to the new PCP and will cooperate with the customer's new PCP in regard to transitioning care and providing information regarding the customer's care needs.

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

Providers must be contracted with and credentialed by Cigna-HealthSpring according to the following guidelines:

Provider: New to plan and not previously credentialed
Status   Action
Practicing in a solo practice Requires a signed contract and initial credentialing
Joining a participating group practice Requires initial credentialing

 

Provider: Already participating and credentialed
Status   Action
Leaving a group practice to begin a solo practice Does not require credentialing; however a new contract is required and the previous group practice affiliation is terminated
Leaving a participating group practice to join another participating group practice Does not require credentialing yet the group practice affiliation will be amended
Leaving a participating group practice to join a non-participating group practice The provider's participation is terminated unless the non-participating group signs a contract with Bravo Health/Cigna-HealthSpring. Credentialing is still valid until recredentialing due date

Participating providers must provide written notice to Cigna-HealthSpring no less than 90 days in advance of any changes to their practice or, if advance notice is not possible, as soon as possible thereafter.

The following is a list of changes that must be reported to Cigna-HealthSpring by contacting your Network Operations Representative or Customer Service:

  • Practice address.
  • Billing address.
  • Fax or telephone number.
  • Hospital affiliations.
  • Practice name.
  • Providers joining or leaving the practice (including retirement or death).
  • Provider taking a leave of absence.
  • Practice mergers and/or acquisitions.
  • Adding or closing a practice location.
  • Tax Identification Number (please include W-9 form).
  • NPI number changes and additions.
  • Changes in practice office hours, practice limitations, or gender limitations.

By providing this information in a timely manner, you will ensure that your practice is listed correctly in the Provider Directory.

Please note: Failure to provide up to date and correct information regarding demographic information regarding your practice and the physicians that participate may result in the denial of claims for you and your physicians.

When a participating Primary Care Physician elects to stop accepting new patients, the provider’s patient panel is considered closed. If a participating Primary Care Physician closes his or her patient panel, the decision to stop accepting new patients must apply to all patients regardless of insurance coverage. Providers may not discriminate against Cigna-HealthSpring customers by closing their patient panels for Cigna-HealthSpring customers only, nor may they discriminate among Cigna-HealthSpring customers by closing their panel to certain product lines. Providers who decide that they will no longer accept any new patients must notify Cigna-HealthSpring’s Network Management Department, in writing, at least 30 days before the date on which the patient panel will be closed or the time frame specified in your contract.

Cigna-HealthSpring requires the following items in customer medical records:

  • Identifying information of the customer.
  • Identification of all providers participating in the customer's care and information on services furnished by these providers.
  • A problem list, including significant illnesses and medical and psychological conditions.
  • Presenting complaints, diagnoses, and treatment plans.
  • Prescribed medications, including dosages and dates of initial or refill prescriptions.
  • Information on allergies and adverse reactions (or a notation that the patient has no known allergies or history of adverse reactions).
  • Information on advanced directives.
  • Past medical history, physical examinations, necessary treatments, and possible risk factors for the customer relevant to the particular treatment.

Note: Unless otherwise specifically stated in your provider services agreement, medical records shall be provided at no cost to Cigna-HealthSpring and CIgna-HealthSprIng customers.

 

  • A Primary Care Physician (PCP) must have their primary office open to receive Cigna-HealthSpring customers five (5) days and for at least 20 hours per week.
  • The PCP must ensure that coverage is available 24 hours a day, seven days a week.
  • PCP offices must be able to schedule appointments for Cigna-HealthSpring customers at least two (2) months in advance of the appointment.
  • A PCP must arrange for coverage during absences with another Cigna-HealthSpring Participating Provider in an appropriate specialty which is documented on the Provider Application and agreed upon in the Provider Agreement.

 

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
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

 

Behavioral 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 10 business days of the referral*

 

After-hours Access Standards

All Participating Providers must return telephone calls related to medical issues. Emergency calls must be returned within 30 minutes of the receipt of the telephone call. Non-emergency calls should be returned within a 24-hour time period. A reliable 24 hours a day/7 days a week answering service with a beeper or paging system and on-call coverage arranged with another Participating Provider of the same specialty is preferred.

Physician Rights

  • 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 customer who has selected you as his/her Primary Care Physician, you may request that Cigna-HealthSpring have that customer removed from your care.
  • You may request a claims reconsideration on any claims submissions in which you feel are not paid according to payment policy.
  • You may request an Appeal on any claims submission in which you feel are not paid in keeping with the level of care rendered or Clinical Practice Guidelines.
  • You may request to discuss any referral request with the Medical Director or Chief Medical Officer after various times in the review process, before a decision is rendered or after a decision is rendered.

Physician Responsibilities

  • You must treat Cigna-HealthSpring customers the same as all other patients in your practice, regardless of the type or amount of reimbursement.
  • Primary Care Physicians shall use best efforts to provide patient care to new customers within four (4) months of enrollment with Cigna-HealthSpring.
  • Primary Care Physicians shall use best efforts to provide follow-up patient care to customers that have been in the hospital setting within ten (10) days of hospital discharge.
  • Primary Care Physicians are responsible for the coordination of routine preventive care along with any ancillary services that need to be rendered with authorization.
  • All providers are required to code to the highest level of specificity necessary to accurately and fully describe a customer’s acuity level. All coding should be conducted in accordance with CMS guidelines and all applicable state and federal laws.
  • Specialists must provide specialty services upon referral from the Primary Care Physician and work closely with the referring physician regarding the treatment the customer is to receive. Specialists
    must also provide continuous 24 hour, 7 days a week access to care for Cigna-HealthSpring customers.
  • Specialists must coordinate the referral process (i.e. obtain authorizations) for further care that they recommend. This responsibility does not revert back to the Primary Care Physician while the care of
    the customer is under the direction of the Specialist.
  • In the event you are temporarily unavailable or unable to provide patient care or referral services to a Cigna-HealthSpring customer, you must arrange for another physician to provide such services on your
    behalf. This coverage cannot be provided by an Emergency Room.
  • You must provide continuing care to participating customers.
  • You must utilize Cigna-HealthSpring’s participating physicians/facilities when services are available and can meet your patient’s needs. Approval prior to referring outside of the contracted network of providers may be required.
  • You must participate in Cigna-HealthSpring’s peer review activities as they relate to the Quality Management/ Utilization Review program.
  • 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 services under the customer’s benefit plan. This includes all treatment options available to them, including medication treatment options, regardless
    of benefit limitations.
  • You may not balance bill a customer for providing services that are covered by Cigna-HealthSpring. This excludes the collection of standard copays. You may bill a customer for a procedure that is not a covered benefit if you have followed the appropriate procedures outlined in the Claims section of this manual.
  • All claims must be received within the timeframe specified in your contract.

Participating providers shall provide health care services to all customers, consistent with the benefits covered in their policy, without regard to race, ethnicity, national origin, religion, sex, age, mental or physical disability or medical condition, sexual orientation, claims experience, medical history, evidence of insurability (including conditions arising out of acts of domestic violence), genetic information, source of payment, or any other bases deemed unlawful under federal, state, or local law.

Participating providers shall provide covered services in a culturally competent manner to all customers by making a particular effort to ensure those with limited English proficiency or reading skills, diverse cultural and ethnic backgrounds, and physical or mental disabilities receive the health care to which they are entitled. Examples of how a provider can meet these requirements include but are not limited to: translator services, interpreter services, teletypewriters or TTY (text telephone or teletypewriter phone) connection.

Cigna-HealthSpring offers interpreter services and other accommodations for the hearing-impaired. Translator services are made available for non-English speaking or Limited English Proficient (LEP) customers. Providers can call Cigna-HealthSpring customer service at 1-800-230-6138 to assist with translator and TTY services if these services are not available in their office location.

Delegation is a formal process by which Cigna-HealthSpring enters into a written contract with an entity to provide administrative or health care services on behalf of a Medicare eligible customer. A function may be fully or partially delegated. Full delegation allows all activities of a function to be delegated. Partial delegation allows some of the activities to be delegated. The decision of what function may be considered for delegation is determined by the type of participation agreement a provider group has with Cigna-HealthSpring, as well as the ability of the provider group to perform the function. Contact the local Cigna-HealthSpring provider representative for detailed information on delegation.

  • Although Cigna-HealthSpring can delegate the authority to perform a function, it cannot delegate the responsibility.
  • Delegated providers must comply with the responsibilities outlined in the Delegated Services Agreement and Cigna-HealthSpring policies and procedures.

Contract Exclusions

Cigna-HealthSpring retains the right to deliver certain services through a vendor or contractor. Should Cigna-HealthSpring elect to deliver certain services for which you are currently contracted to provide through a vendor or contractor, you will be provided a minimum of thirty (30) day’s advance notice and your contract terms will be honored during that notice period. After such time and notification, Cigna-HealthSpring retains the right to discontinue reimbursement for services provided by the vendor or contractor.

 

Transmission of Lab Results



Cigna-HealthSpring has implemented the Health Level Seven (HL7) standard messaging format for the transmission of lab results data, version 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. A companion guide, containing additional details and instructions for submitting lab results data in this format, can be found by clicking here.

Exchange of Electronic Data

Cigna-HealthSpring follows all applicable laws, rules, and regulations regarding the electronic transmittal and reception of Customer and Provider information. As such, if an electronic connection is made to facilitate such data transfer, all applicable laws must be followed. At all times, a provider must be able to track disclosures, provide details of data protections, and respond to requests made by Cigna-HealthSpring regarding information protection.

When an electronic connection is needed, relevant connection details will be provided to a customer by Cigna-HealthSpring

Cigna-HealthSpring's IT Operations team, will engage with a provider’s staff to appropriately implement the connection. Any files placed for receipt by provider staff must be downloaded in 24 hours, as all data is deleted on a fixed schedule. If the files are unable to be downloaded, then alternate arrangements for retransmission must be made. The provider and provider’s staff will work collaboratively with Cigna-HealthSpring to ensure information is adequately protected and secure during transmission.

  • View customer eligibility.
  • Create referrals and precertifications.
  • Search authorizations.
  • Search claims.

Contact the HSConnect Help Line: 1-866-952-7596 or e-mail HSConnectHelp@HSConnectOnline.com

Credentialing and Recredentialing Program

All practitioner and organizational applicants to Cigna-HealthSpring must meet basic eligibility requirements and complete the credentialing process prior to becoming a participating provider. When Network Operations notifies Credentialing to start the credentialing process, every provider undergoes 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 with the plan. No provider can be assigned a health plan effective date or be included in a provider directory or have members assigned without completing the credentialing and peer review process. All providers who have been initially approved for participation are required to recredential at least once every three years in order to maintain participation status. Physicians and practitioners must have and maintain malpractice insurance of at least $1,000,000 per incident and $3,000,000 aggregate.

 

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 as applicable.
  • Is board-certified or has completed appropriate and verifiable training in the requested practice specialty.
  • Maintains current malpractice coverage with limits commensurate with the community standard in which practitioner practices.
  • Has a National Provider Identification number and is actively enrolled with Medicare.
  • Has not been excluded, suspended, and/or disqualified from participating in any Medicare, Medicaid, or any other government health related program.
  • Is not currently opted out of Medicare.
  • Has admitting privileges at a participating facility as applicable.
  1. Complete and submit a Network Interest Form to Network Operations.   Network Operations will review each practitioner for eligibility, current contract status and network need.   If approved for a contract, Network Operations will send a credentialing packet that will include a contract (unless a current group agreement already exists) and a W-9 form that must be completed and signed.   If the provider utilizes the Council for Affordable Quality HealthCare (CAQH) Proview system, practitioner must ensure that all information contained in their CAQH profile is current, including the attestation signature date, and that they have given Cigna / Cigna-HealthSpring permission to access the CAQH information.   If the provider does not utilize CAQH, then an application form will be included in the credentialing/contract packet and must be completed and returned by the practitioner with the contract.  

  2. All credentialing applications must contain the following information to be considered ‘complete’:
    • All current and active state medical licenses, DEA certificate(s), and state controlled substance certificate as applicable.
    • Evidence of current malpractice insurance that includes the effective and expiration dates of the policy and term limits.
    • 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.
    • If any of the Professional Disclosure questions are answered ‘yes’ on the application, supply sufficient additional information and explanations.
    • Provide appropriate clinical detail for all malpractice cases that are pending, or resulted in a settlement or other financial payment within the last 5 years.
    • If a physician, include current and complete hospital affiliation information on the application. If no hospital admitting privileges and the specialty warrants hospital privileges, a letter detailing the alternate coverage arrangement(s) or the name of the alternate admitting physician must be provided. 
    • Application must be signed and dated.

  3. Once a completed and signed contract/credentialing packet has been received, Network Operations will submit a request to Credentialing to start the credentialing verification process and forward any application information that was received.   

  4. Credentialing logs all received applications and begins the verification process.   Applications are processed by the date that they are received unless Network Operations indicates that there is a specific member or network need that requires more expedited processing.  

  5. Once the credentialing process is complete, Network Operations assigns a contract effective date and sends out a welcome letter that contains the participating effective date.

Cigna-HealthSpring’s Credentialing Department conducts primary and secondary source verification of the applicant’s licensure, education and/ or board certification, privileges, lack of sanctions or other disciplinary action, Medicare status and malpractice history by querying the National Practitioner Data Bank. The credentialing process generally takes up to ninety days to complete, but can in some instances take longer. Once credentialing has been completed and the applicant has been approved, Network Operations will notify the practitioner in
writing of their participation effective date.

To maintain participating status, all practitioners are required to recredential at least every three (3) years. Information obtained during the initial credentialing process will be updated and re-verified as required.  Practitioners who do not have a current CAQH profile or do not utilize CAQH will be notified of the need to submit recredentialing information in advance of their three-year credentialing anniversary date. Three (3) separate attempts will be made to obtain the required information via mail, fax, email, or telephonic request. Practitioners who fail to return recredentialing information at least 45 days prior to their recredentialing  anniversary 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:

  1. Physical appearance and accessibility.
  2. Patient safety and risk management.
  3. Medical record management and security of information.
  4. Appointment availability.

Providers who fail to pass the area of the site visit specific to the complaint or who score less than 80% 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 corrective action plan 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 committee review date, and approval status.

When assessing organizational providers for participation, 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 deemed by Medicare or recognized by Cigna-HealthSpring.
  • If not accredited, must provide a copy of a survey conducted by a state of federal agency within the 36 months prior to app submission which contains the corrective action plan for any identified deficiencies and proof of state/federal acceptance of the corrective action and/or current compliance with Medicare/Medicaid program requirements.     
  • Organizations that are not accredited or have not been surveyed by a state or federal regulatory body within the last 36 months may be subject to a health plan conducted site audit. 
  • Maintains current professional and 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.
  • Is currently enrolled in an active status with Medicare, including any sub-entities and/or additional National Provider Identifier (NPI) numbers the organization may utilize.
  1. A completed Ancillary/Facility Credentialing Application with a signed and dated attestation.
  2. If responding, "Yes" to any disclosure question in the application, an appropriate explanation with sufficient details/information is required.
  3. Copies of all applicable state and federal licenses (i.e. facility license, DEA, CLIA  certificate , Pharmacy license, etc.).
  4. Proof of current professional and general liability insurance as applicable.
  5. Proof of Medicare enrollment per site if submitting multiple locations
  6. If accredited, proof of current accreditation.
    • Note: Current accreditation status is required for DME, Prosthetic/Orthotics, and non-hospital based high tech radiology providers who perform MRIs, CTs and/or Nuclear/PET studies.
  7. If not accredited, a copy of any state or CMS site surveys that 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 inpatient, residential or ambulatory mental health or substance abuse centers that do not hold an 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.

All Durable Medical Equipment (DME) and Orthotics and Prosthetic providers are required by Medicare to be accredited by one of the 10 national accreditation organizations. The most current listing of these organizations can be found at:
http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/Downloads/.


Pharmacies that provide Durable Medical Equipment but are exempt from the accreditation requirement under Public Law #111-148 which amended title XVII of the Social Security Act, must provide the following information with their initial application:

  1. Evidence the pharmacy has been enrolled with Medicare as a supplier of Durable Medical Equipment, prosthetics, orthotics, and suppliers and has been issued a provider number for at least 5 years.
  2. An attestation that the pharmacy has met all criteria under the above referenced amendment.

All initial applicants and recredentialed 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 and specialty providers, and has the authority to approve or deny an appointment status to a provider. All required credentialing information and verifications must be completed and less than one hundred eighty (180) days old at the time of presentation to the Medical Director or the Credentialing Committee for approval.

Cigna-HealthSpring’s credentialing program is compliant with all guidelines from the National Committee for Quality Assurance (NCQA), Centers for Medicare and Medicaid Services (CMS), and state regulations as applicable. 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 decisions based on an applicant’s race, gender, age, ethnic origin, nationality, sexual orientation, gender identity or due to the 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 customers until they receive notification of their plan
participation and effective date. Applicants who are denied by the Credentialing Committee will be notified via a certified letter within sixty (60) days of the decision detailing the reasons for the denial.

If a  provider’s participation is limited, suspended, or terminated, the provider is notified in writing within sixty (60) days of the decision. Notification will include: a) the reasons for the action, b) outline of the Appeals process or options available to the provider, and c) the time limits for submitting an Appeal. All Appeals will be reviewed by a panel of the provider’s 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.

All information obtained during the credentialing and recredentialing 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 recredentialing 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 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.

To be included in Provider Directories or any other customer communications, 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.

Claims

While Cigna-HealthSpring prefers electronic submission of claims, both electronic and paper claims are accepted. If you are interested in submitting claims electronically, contact Cigna-HealthSpring Provider Services for assistance at 1-800-230-6138.

All completed claims forms should be forwarded to the following address:
Cigna-HealthSpring
PO Box 981706
El Paso, TX 79998
Electronic claims may be submitted through:

  • Change Healthcare (Payer ID: 52192)
  • SSIGroup (Payer ID: 63092)
  • Availity (Payer ID: 63092 or 52192)
  • Capario/Proxymed (Payer ID: 63092)
  • Medassets (Payer ID: 63092)
  • Zirmed (Payer ID: 63092)
  • Office Ally (Payer ID: 63092)
  • TriZetto/GatewayEDI GatewayEDI (Payer ID: 63092)
  • Relay Health (Professional claims CPID: 2795 or 3839 Institutional claims CPID: 1556 or 1978)

 

Timely Filing
As a Cigna-HealthSpring Participating Provider, you have agreed to submit all claims within the timeframes outlined in your provider agreement.

Claim Format Standards
Standard CMS required data elements can be found in the CMS claims processing manual located at https://www.cms.gov/manuals/downloads/clm104c12.pdf and must be present for a claim to be considered a clean claim.

Cigna-HealthSpring can only pay claims which are submitted accurately. The provider is always responsible for accurate claims submissions. While Cigna-HealthSpring will make its best effort to inform the provider of claims errors, the claim accuracy rests solely with the provider.

Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. If more than one service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, they must bill and be paid as though they were a single physician. For example, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems. Instead of billing separately, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that level.

Physicians in the same group practice, but who are in different specialties may bill and be paid without regard to their customer in the same group.

Claim Format Standards
Cigna-HealthSpring pays clean claims according to contractual requirements and the Centers for Medicare and Medicaid Services (CMS) guidelines. A clean claim is defined as a claim for a Covered Service that has no defect or impropriety. A defect or impropriety includes, without limitation, lack of data fields required by Cigna-HealthSpring or substantiating documentation, or a particular circumstance requiring special handling or treatment, which prevents timely payment from being made on the claim. The term shall be consistent with the Clean Claim definition set forth in your Agreement and applicable federal or state law, including lack of required substantiating documentation for Non-Participating Providers and suppliers, or particular circumstances requiring special treatment that prevents timely payment from being made on the claim. If additional substantiating documentation involves a source outside of Cigna-HealthSpring, the claim is not considered clean

Offsetting
As a contracted Cigna-HealthSpring provider, you will be informed of any overpayments or other payments you may owe us. You will have thirty (30) days from receipt of notification seeking recovery to refund us. We will provide you with the customer’s name, customer’s identification number, Cigna-HealthSpring’s claim number, your patient account number, date of service, a brief explanation of the recovery request, and the amount or the requested recovery. If you have not refunded us within the thirty (30) days recovery notice period, we will offset the recovery amounts identified in the initial notification, or in accordance with the terms of your agreement unless an appeal or refund is received.

Pricing
Original Medicare typically has market-adjusted prices by code (i.e. CPT or HCPCS) for services that Original Medicare covers. However, there are occasions where Cigna-HealthSpring offers a covered benefit for which Medicare has no pricing. In order to expedite claims processing and payment in these situations, Cigna-HealthSpring will work to arrive at a fair market price by researching other external, publicly available pricing sources, such as other carriers, fiscal intermediaries, or state published schedules for Medicaid. Cigna-HealthSpring requests that you make every effort to submit claims with standard coding, failure to do so could delay processing. As described in this Manual and/or your agreement, you retain your rights to submit a Request for Reconsideration if you feel the reimbursement was incorrect. In the instance of an inpatient admission downgrade to observation, please submit an itemized bill including CPT and or HCPCS codes in order to expedite processing.

Claims Encounter Data
Providers who are being paid under capitation must submit claims in order to capture encounter data as required per your Cigna-HealthSpring Provider Agreement.

Explanation of Payment (EOP)/Remittance Advice (RA)
The EOP/RA statement is sent to the provider after coverage and payment have been determined by Cigna-HealthSpring. The statement provides a detailed description of how the claim was processed.

Non-Payment/Claim Denial
Any denials of coverage or non-payment for services by Cigna-HealthSpring will be addressed on the Explanation of Payment (EOP) or Remittance Advice (RA). An adjustment/denial code will be listed per each billed line if applicable. An explanation of all applicable adjustment codes per claim will be listed below that claim on the EOP/RA. Per your contract, the customer may or may not be billed for services denied by Cigna-HealthSpring. The customer may not be billed for a covered service when the provider has not followed the Cigna-HealthSpring procedures. In some instances, providing the needed information may reverse the denial (i.e. referral form with a copy of the EOP/RA, authorization number, etc.). When no benefits are available for the customer, or the services are not covered, the EOP/RA will alert you to this and you may bill the customer.

Pricing of Inpatient Claims
Unless the contract states otherwise, all outpatient services, including observation and emergency room services, furnished to a customer by a hospital during an uninterrupted encounter (no discharge home) on the date of a customer's inpatient admission or immediately preceding the date of a customer’s inpatient hospital admission, regardless of the number of uninterrupted days prior to the inpatient admission, will be paid under the applicable inpatient MS-DRG.

SNF Consolidated Billing
Consolidated Billing Payment for the majority of services to beneficiaries in a Medicare-covered Part A SNF stay, including most services provided by entities other than the SNF, are included in a bundled prospective payment to the SNF. The SNF must bill these bundled services in a consolidated bill. For services subject to consolidated billing (CB) and provided by entities other than the SNF, the entity looks to the SNF for payment and must not bill separately for those services.

CB RESOURCES:  For more information, take the SNF CB web-based training course on the Medicare Learning Network® (MLN) Learning Management and Product Ordering System. To help determine how CB applies to specific services, refer to the flow charts in the Skilled Nursing Facility Prospective Payment System educational product.

Processing of Hospice Claims
When a Medicare Advantage (MA) customer elects hospice care, but chooses not to dis-enroll from the plan, the customer is entitled to continue to receive any MA benefits which are not responsibility of the hospice through Cigna-HealthSpring. Under such circumstances the premium Cigna-HealthSpring receives from the Centers for Medicare and Medicaid Services (CMS) is adjusted to hospice status. As of the day the customer is certified as hospice, the financial responsibility for that customer shifts from Cigna-HealthSpring to Original Medicare. During a hospice election, Original Medicare covers all Medicare–covered services rendered with cost-sharing of Original Medicare. Cigna-HealthSpring will remain financially responsible for any benefits above Original Medicare benefits that are non-hospice related. Non-Medicare covered services, such as vision eyewear allowable, prescription drug claims, and medical visit transportation will remain the responsibility of Cigna-HealthSpring. Plan cost-sharing will apply to Cigna-HealthSpring covered services. If the customer chooses original Medicare for coverage of covered, non-hospice-care, original Medicare services and also follows MA plan requirements, then, the customer pays plan cost-sharing and original Medicare pays the provider. Cigna-HealthSpring will pay the provider the difference between original Medicare cost-sharing and plan cost-sharing, if applicable. Plan rules must still be followed and apply for both professional and facility charges. An HMO customer who chooses to receive services out of network has not followed plan rules and therefore is responsible to pay FFS cost-sharing; A PPO customer who receives services out of network has followed plan rules and is only responsible for plan cost-sharing. The customer need not communicate to the plan in advance his/her choice of where services are obtained. When a customer revokes hospice care, financial responsibility for Medicare-covered services will return to the plan on the first of the month following the revocation.

The following are the submission guidelines for Medicare Advantage customers enrolled in Hospice:

Hospice-Related Services

  • Submit the claim directly to CMS.

Medicare hospices bill the Medicare fee-for-service contractor for customers who have coverage through Medicare Advantage just as they do for customers, or beneficiaries, with fee-for-service coverage. Billing begins with a notice of election for an initial hospice benefit period, and followed by claims with types of bill 81X or 82X. If the customer later revokes election of the hospice benefit, a final claim indicating revocation, through use of occurrence code 42 should be submitted as soon as possible so the customer’s medical care and payment is not disrupted.

Medicare physicians may also bill the Medicare fee-for-service contractor for customers who have coverage through Medicare Advantage as long as all current requirements for billing for hospice beneficiaries are met. These claims should be submitted with a GV or GW modifier as applicable. Medicare contractors process these claims in accordance with regular claims processing rules. When these modifiers are used, contractors are instructed to use an override code to assure such claims have been reviewed and should be approved for payment by the Common Working File in Medicare claims processing systems.

As specified above, by regulation, the duration of payment responsibility by fee-for-service contractors extends through the remainder of the month in which hospice is revoked. MA plan customers that have elected hospice may revoke hospice election at any time, but claims will continue to be paid by fee-for-service contractors as if the beneficiary were a fee-for-service beneficiary until the first day of the month following the month in which hospice was revoked.

Non-Hospice Services

  • For Part A services not related to the customer’s terminal condition, submit the claim to the fiscal intermediary using the condition code 07.
  • For Part B services not related to the customer’s terminal condition, submit the claim to the Medicare carrier with a “GW” modifier.
  • For services rendered for the treatment and management of the terminal illness by a non-hospice employed attending physician, submit the claim to the fiscal Intermediary/ Medicare carrier with a “GV” modifier.

Additional & Supplemental Benefits

  • Submit the claim to Cigna-HealthSpring.

For additional detail on hospice coverage and payment guidelines, please refer to 42 CFR 422.320-Special Rules for Hospice Care. Section (C) outlines the Medicare payment rules for customers who have elected hospice coverage. The Medicare Managed Care Manual, Chapter 11, Sections 40.2 and 50, and the CMS Program Memorandum AB-03-049 also outline payment responsibility and billing requirements for hospice services. This documentation is also available online at the CMS website: www.cms.gov.

In January 2009, the U.S. Department of Health and Human Services (HHS) published a final rule requiring the use of International Classification of Diseases version 10 (ICD-10) for diagnosis and hospital inpatient procedure coding. The rule impacts the health care industry – including health plans, hospitals, doctors, and other health care professionals, as well as vendors and trading partners.

The implementation of ICD-10 has been delayed a few times. The U.S. Department of Health and Human Services released a rule on July 31, 2014 finalizing October 1, 2015 as the new compliance date for health care providers, health plans, and health care clearing houses to transition to ICD-10, the tenth revision of the International Classification of Diseases.

ICD-10 (International Classification of Diseases, 10th Edition, Clinical Modification /Procedure Coding System) consists of two parts:

  • ICD-10-CM for Diagnosis coding is for use in all U.S. health care settings. Diagnosis coding under ICD-10-CM uses 3 to 7 characters instead of the 3 to 5 characters used with ICD-9-CM, adding more specificity.

ICD-10 Code Example: Displaced fracture of neck

  • ICD-10-PCS for Inpatient Procedure coding is for use in U.S. inpatient hospital settings only. ICD- 10-PCS uses 7 alphanumeric characters instead of the 3 or 4 numeric characters used under ICD-9-CM procedure coding. Coding under ICD- 10-PCS is much more specific and substantially different from ICD-9-CM procedure coding.

ICD-10 Code Example: Resection of Appendix

Note: Procedure codes are only applicable to inpatient claims and not prior authorizations.

The transition to ICD-10 is occurring because ICD-9 codes have limited data about patients’ medical conditions and hospital inpatient procedures. ICD-9 is 30 years old, has outdated terms, and is inconsistent with current medical practice. Also, the structure of ICD-9 limits the number of new codes that can be created, and many ICD-9 categories are full.

ICD-10 will affect diagnosis and inpatient procedure coding for everyone covered by the Health Insurance Portability Accountability Act (HIPAA), not just those who submit Medicare or Medicaid claims. The change to ICD-10 does not affect CPT or HCPCS coding for outpatient procedures.

ICD-9 vs. ICD-10 Claim Submission Guidelines

Health care professionals must be prepared to comply with the transition to ICD-10 by October 1, 2015 Cigna-HealthSpring will strictly adhere to the following guidelines:

  • All electronic transactions must use Version 5010 standards, which have been required since January 1, 2012. Unlike the older Version 4010/4010A standards, Version 5010 accommodates ICD-10 codes.
  • We currently accept the revised CMS 1500 Health Insurance Claim form (version 02/12). As of October 1, 2014, Cigna-HealthSpring will only accept the CMS 1500 form (02/12). Although the revised CMS 1500 claim form has the functionality for accepting ICD-10 codes, we will not accept ICD-10 codes on claims until the new compliance date.
  • Professional and outpatient claims submitted with a date of service or inpatient claims submitted with a discharge date prior to the new compliance date must be processed using ICD-9 codes.
  • Professional and outpatient claims submitted with a date-of-service or inpatient claims submitted with a discharge date on or after the new compliance date must be processed using ICD-10 codes.
  • Claims with ICD-9 codes for date of service or discharge provided on or after the new compliance date will be rejected.
  • Claims with ICD-10 codes for date of service or discharge provided prior to the new compliance date will be rejected.
  • Claims submitted with a mix of ICD-9 and ICD-10 codes will be rejected. Claims should be coded based on date of service (outpatient) or discharge date (inpatient).
  • Some institutional claims, such as those for long-term or on-going care should be processed as split claims during the transition period. With such a split claim, all services rendered during a particular cycle before the new compliance date would be accounted for on one claim with ICD-9 codes. The other remaining services rendered on or after the new compliance date during that same cycle would be accounted for on a separate claim using ICD-10 codes.
  • We will only process claims after the compliance date with ICD-9 codes with dates of service or discharge dates prior to the new compliance date for a period of time to allow for claim run-off, including the following issues:
    • Appeals with dates of service or discharge dates before the new compliance date should be submitted
      with the appropriate ICD-9 codes
    • Corrected or resubmitted claims with dates of service or discharge dates before the new compliance date should be submitted with the correct ICD-9 codes to the claim office for adjustment or correction.

Billable vs. Non-Billable Codes

  • A billable ICD-9 or ICD-10 code is defined as a code that has been coded to its highest level of specificity.
  • A non-billable ICD-9 or ICD-10 code is defined as a code that has not been coded to its highest level of specificity. If a claim is submitted with a non-billable code, the claim will be rejected.
  • The following are examples of billable ICD-9 codes with corresponding non-billable codes:
    Billable ICD-9 codes Non-billable ICD-9 codes
    473.0 - Chronic maxillary sinusitis 473 - Chronic sinusitis
    474.00 - Chronic tonsillitis 474 - Chronic disease of tonsils and adenoids
  • The following is an example of a billable ICD-10 code with corresponding non-billable codes.
    Billable ICD-10 codes Non-billable ICD-10 codes
    M1A.3110 - Chronic gout due to renal impairment, right shoulder, without tophus M1A.3 - Chronic gout due to renal impairment
      M1A.311 - Chronic gout due to renal impairment, right shoulder
  • It is acceptable to submit a claim using an unspecified code when sufficient clinical information is not known or available about a particular health condition to assign a more specific code.
    Billable unspecified ICD-9 codes Billable unspecified ICD-10 codes
    428.0 - Congestive heart failure, unspecified I50.9 - Heart failure, unspecified
    486 - Pneumonia, organism unspecified J18.9 - Pneumonia, unspecified organism
  • Questions Concerning ICD-10

    If you have a question as it pertains to ICD-10, please consult with your Network Operations Representative.

General Definitions

Coordination of Benefits (COB)

Benefits that a person is entitled to under multiple plan coverage. Coordinating payment of these plans will provide benefit coverage up to but not exceeding one hundred percent of the allowable amount. The respective primary and secondary payment obligations of the two coverages are determined by the Order of Benefits Determination Rule contained in the National Association of Insurance Commissioners (NAIC) COB Model Regulations Guidelines.

Order of benefit determination rule

Rules which, when applied to a particular customer covered by at least two plans, determine the order of responsibility each plan has with respect to the other plan in providing benefits for that customer. A plan will be determine to have Primary or Secondary responsibility for a person’s coverage with respect to other plans by applying the NAIC rules.

Primary

This carrier is responsible for costs of services provided up to the benefit limit for the coverage or as if no other coverage exists.

Secondary

This carrier is responsible for the total allowable charges, up to the benefit limit for the coverage less the primary payment not to exceed the total amount billed (maintenance of benefits).

Allowable Expense

Any expense customary or necessary, for health care services provided as well as covered by the customer’s health care plan.

Conclusion

COB is applying the NAIC rules to determine which plan is primarily responsible and secondarily responsible when alternate coverage exists. If COB is to accomplish its purpose, all plans must adhere to the structure set forth in the Model COB regulations.

Basic NAIC Rules for COB

Birthday Rule

The primary coverage is determined by the birthday that falls earliest in the year, understanding both spouses are employed and have coverage. Only the day and month are taken into consideration. If both customers have the same date of birth, the plan which covered the customer the longest is considered primary.

General Rules

The following table contains general rules to follow to determine a primary carrier:

If the customer/beneficiary The below conditions exists Then the below program pays first The below program pays secondary
Is age 65 or older, and is covered by a Group Health Plan (GHP) through current employment or a family customer's current employment The employer has more than 20 employees, or at least one employer is a multi-employer group that employs 20 or more employees The Group Health Plan (GHP) pays primary CignaHealthSpring/Medicare pays secondary
Is age 65 or older and is covered a Group Health Plan (GHP) through current employment or a family customers current employment The employer has less than 20 employees CignaHealthSpring/ Medicare pays primary Group Health Plan (GHP) pays secondary
Is entitled based on disability and is covered by a Large Group Health Plan (LGHP) through his/her current employment or through a family customers current employment The employer has 100 or more employees or at least one employer is a multi-employer group that employs 100 or more employees The Large Group Health Plan (LGHP) pays primary CignaHealthSpring/ Medicare pays secondary
Is entitled based on disability and is covered by a Large Group Health Plan (LGHP) through his/her current employment or through a family customers current employment The employer employs less than 100 employees CignaHealthSpring/ Medicare pays primary Large Group Health Plan (LGHP) pays secondary
Is age 65 or older or entitled based on disability and has retirement insurance only Does not matter the number of employees CignaHealthSpring/ Medicare pays primary Retirement Insurance pays secondary
Is age 65 or older or is entitled based on disability and has COBRA coverage Does not matter the number of employees Cigna-HealthSpring/ Medicare pays primary COBRA pays secondary
Becomes dually entitled based on age/ESRD Had insurance prior to becoming dually entitled with ESRD as in block one above The Group Health Plan (GHP) pays primary for the first 30 months CignaHealthSpring/ Medicare pays secondary (after 30 months Cigna-HealthSpring pays primary)
Becomes dually entitled based on age/ESRD but then retires and keeps retirement insurance Had insurance prior to becoming dually entitled with ESRD as in block one above and then retired The Retirement Insurance pays primary for the first 30 months Cigna-HealthSpring /Medicare pays secondary (after 30 months Cigna-HealthSpring pays primary)
Becomes dually entitled based on age/ESRD but then obtains COBRA insurance through employer Had insurance prior to becoming dually entitled with ESRD as in block one above and picks up COBRA coverage COBRA insurance would pay primary for the first 30 months (or until the customer drops the COBRA coverage Cigna-HealthSpring/ Medicare pays secondary (after 30 months Cigna-HealthSpring pays primary)
Becomes dually entitled based on disability/ESRD Had insurance prior to becoming dually entitled with ESRD as in block three above The Large Group Health Plan (LGHP) pays primary CignaHealthSpring/ Medicare pays secondary (after 30 months Cigna-HealthSpring pays primary)
Becomes dually entitled based on disability/ESRD but then obtains COBRA insurance through employer Had insurance prior to becoming dually entitled with ESRD as in block three above and picks up the COBRA coverage COBRA insurance would pay primary for the first 30 months or until the customer drops the COBRA coverage CignaHealthSpring/ Medicare pays secondary (after 30 months Cigna-HealthSpring pays primary)

Basic Processing Guidelines for COB

For Cigna-HealthSpring to be responsible as either the primary or secondary carrier, the customer must follow all HMO rules (i.e. pay copays and follow appropriate referral process).

When Cigna-HealthSpring is the secondary insurance carrier:

  • All Cigna-HealthSpring guidelines must be met in order to reimburse the provider (i.e. pre-certification, referral forms, etc.).
  • The provider collects only the copayments required.
  • Be sure to have the customer sign the “assignment of benefits” sections of the claim form. Once payment and/or EOB are received from the other carriers, submit another copy of the claim with the EOB of Cigna-HealthSpring for reimbursement. Be sure to note all authorization numbers on the claims and attach a copy of the referral form if applicable.

When Cigna-HealthSpring is the primary insurance carrier:

  • The provider collects the copayment required under the customer’s Cigna-HealthSpring plan.
  • Submit the claim to Cigna-HealthSpring first
  • Be sure to have the customer sign the “assignment of benefits” sections of the claim form.
  • Once payment and/or Remittance Advise (RA) has been received from Cigna-HealthSpring, submit a copy of the claim with the RA to the secondary carrier for adjudication. Please note: Cigna-HealthSpring is a total replacement for Medicare.
  • Medicare cannot be secondary when customers have Cigna-HealthSpring.
  • Medicaid will not pay the copay for Cigna-HealthSpring customers.

Cigna-HealthSpring does not cover worker’s compensation claims. When a provider identifies medical treatment as related to an on-the-job illness or injury, Cigna-HealthSpring must be notified. The provider will bill the worker’s compensation carrier for all services rendered, not Cigna-HealthSpring.

Subrogation is the substitution of one party in place of another with respect to a legal claim. In the case of a health plan which has paid benefits for its insured, the health plan is substituted in place of its insured and can make legal claims against the party which should be responsible for paying those bills such as the person who caused the insured’s injuries and their third party insurer (i.e. property and casualty insurer, automobile insurer, or worker’s compensation carrier).

COB protocol, as mentioned above, would still apply in the filing of the claim.

Customers who may be covered by third party liability insurance should only be charged the required copayment. The bill can be submitted to the liability insurer. The provider should submit the claim to Cigna-HealthSpring with any information regarding the third party carrier (i.e. auto insurance name, lawyers name, etc.). All claims will be processed per the usual claims procedures.

Cigna-HealthSpring uses a contracted vendor for review and investigation of all possible subrogation cases. This vendor coordinates all requests for information from the customer, provider and attorney name(s)/office(s) and assists with settlements. For questions related to a subrogated case, please contact Customer Service at 1-855-744-0223. An experienced subrogation representative from our vendor, The Rawlings Group, will gladly provide assistance.

An appeal is a request for Cigna-HealthSpring to review a previously made decision related to medical necessity, clinical guidelines, or prior authorization and referral requirements. You must receive a notice of denial, or remittance advice before you can submit an appeal. Please do not submit your initial claim in the form of an appeal. Appeals can take up to 60 days for review and determination. Timely filing requirements are not affected or changed by the appeal process or by the appeal outcome. If an appeal decision results in approval of payment contingent upon the filing of a corrected claim, the time frame is not automatically extended and will remain consistent with the timely filing provision in the Cigna-HealthSpring agreement.

You may appeal a previous decision not to pay for a service. For example, claims denied for no authorization or no referral, including a decision to pay for a different level of care; this includes both complete and partial denials. Examples of partial denials include: denials of certain levels of care, isolated claim line items not related to claims reconsideration issues, or a decreased quantity of office or therapy visits not related to claims reconsideration issues. Total and partial denials of payment may be appealed using the same appeal process. Your appeal will receive an independent review by a Cigna-HealthSpring representative not involved with the initial decision. Requesting an appeal does not guarantee that your request will be approved or that the initial decision will be overturned. The appeal determination may fully or partially uphold the original decision. You may appeal a health services or Utilization Management denial of a service not yet provided, on behalf of a customer. The customer must be aware that you are appealing on his or her behalf. Customer Appeals are processed according to Medicare guidelines.

An Appeal must be submitted within 60 days of the original decision unless otherwise stated in your provider agreement. With your appeal request, you must include: an explanation of what you are appealing along with the rationale for appealing, a copy of your denial, any medical records that would support the medical necessity for the service, hospital stay, or office visit, and a copy of the insurance verification completed on the date of service. If necessary medical records are not submitted, the request will be returned and action pended until the medical records are submitted.

You must submit your appeal using the “Request for Appeal or Reconsideration” form and medical records. There are several ways to submit your appeal to Cigna-HealthSpring.

You may send your request via secure e-mail to: FAX-SOL@healthspring.com or fax the appeal request to our secure fax line at 1-800-931-0149.

Alternatively, for large medical record files, you may mail the appeal request form attached to a CD containing medical records to:
Cigna-HealthSpring
Attn: Appeals Unit PO Box 24087
Nashville, TN 37202-4087

Phone: 1-800-511-6943

Fax: 1-800-931-0149

You have up to 180 days to request reconsideration of a claim. You may request claim reconsideration if you feel your claim was not processed appropriately according to the Cigna-HealthSpring claim payment policy or in accordance with your provider agreement. A claim reconsideration request is appropriate for disputing denials such as coordination of benefits, timely filing, or missing information. Payment retractions, underpayments/ overpayments, as well as coding disputes should also be addressed through the claim reconsideration process. Cigna-HealthSpring will review your request, as well as your provider record, to determine whether your claim was paid correctly.

You must request reconsideration by submitting the completed request form to:

Cigna-HealthSpring
Attn: Reconsiderations
PO Box 20002
Nashville, TN 37202

Fax: 1-615-401-4642

Request for Appeal or Reconsideration



ERA/EFT Enrollment Process



New electronic payment options help save time and reduce error.  Through our partnership with Change Healthcare, we are pleased to continue offering simpler, more efficient ePayment Solutions to help you maximize revenue and profit, reduce costs and errors and increase payment efficiency.

For ERA Provider Setup form:

  1. Go to: https://www.changehealthcare.com/support/customer-resources/enrollment-services/medical-hospital-era-enrollment-forms

  2. Under ‘Commonly Used ERA Enrollment forms, open the form named: ERA Provider Setup Form. This form will be used to add the Cigna-HealthSpring payer ID (52192)to a provider’s 835 enrollment.

  3. Complete the form per the instructions and return to CHC.

 

For EFT setup (NEW Provider):

  1. Go to: https://www.changehealthcare.com/support/customer-resources/enrollment-services/medical-hospital-eft-enrollment-forms

  2. Under ‘New Provider’, open the form named: EPayment Enrollment Authorization.

  3. Complete form using the instructions provided. *Note: CHC recommends a New provider check the box below on this form so they get enrolled for EFT for all payers who participate. This will help them avoid having to complete a new form each time they want to add a new Payer ID for EFT.*

    1. From the form:

      1. Please check this box if you would like to enroll for all TIN & NPI (if provided) EFT Payers included on page 5 & 6.

  4. Return the form to CHC.

 

For EFT setup (EXISTING Provider):

  1. Go to: https://www.changehealthcare.com/support/customer-resources/enrollment-services/medical-hospital-eft-enrollment-forms

  2. Under ‘Existing Provider’, open the form named: EFT Payer Add/Change/Delete Authorization Form.

  3. Complete the form to Add payer ID 52192 to the existing EFT enrollment.

  4. Return the form to CHC.

 

**Any issues locating the forms or assistance in completing please call 1-866-506-2830, option 1.**

Health Care Plan 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 include measures such as Comprehensive Diabetes Care, Adult Access to Ambulatory and Preventive Care, Controlling High Blood Pressure, Breast Cancer Screening, Medication Reconciliation Post Discharge, 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. 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's HEDIS results are available upon request. Contact the Health Plan’s Quality Improvement Department by email at StarQualityPartners@healthspring.com to request information regarding those results.

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

Stars Guidance



The Centers for Medicare and Medicaid Services (CMS) uses the Five-Star Quality Rating System to determine compensation for Medicare Advantage plans and educate consumers on health plan quality. The Star Ratings system consists of over 50 measures from six different rating systems. The cumulative results of these measures make up the Star rating assigned to each health plan.

Star Ratings have a significant impact on the financial outcome of Medicare Advantage health plans by directly influencing the bonus payments and rebate percentages received. CMS will award quality-based bonus payments to high performing health plans based on their Star Ratings performance. For health plans with a four star or more rating, a bonus payment is paid in the form of a percentage (maximum of five percent) added to the county benchmark. (A county benchmark is the amount CMS expects health care to cost to provide hospital and medical insurance in the state and county.) After 2015, any health plans with Star Ratings below four will no longer receive bonus payments.

The Star Rating is comprised of over 50 different measures from six different rating systems

 

Five Main Components of the Star Ratings System:

  1. HEDIS (Health Effectiveness Data and Information Set) is a set of performance measures developed for the managed care industry. All claims are processed regularly to extract the NCQA (National Committee for Quality Assurance) defined measures. For example, this allows the health plan and CMS to determine how many enrollees have been screened for high blood pressure.
  2. CAHPS (Consumer Assessment of Health Care Providers and Systems) is a series of patient surveys rating health care experiences performed on behalf of CMS by an approved vendor.
  3. Administrative measures evaluate a health plan’s ability to address customer complaints, appeals, various enrollment items, and also calls to its customer service line.
  4. PDE (Prescription Drug Event) is data collected on various medications related events, such as high-risk medications, adherence for chronic conditions, and pricing.
  5. HOS (Health Outcomes Survey) is a survey that addresses customers’ perceptions of their health plan and recollection of specific provider care delivered over a 2.5 year time period.

These Systems Rate the Plans Based on Six Domains:

  1. Staying healthy: screenings, tests and vaccines.
  2. Managing chronic (long term) conditions.
  3. Customer experience with health plan.
  4. Customer complaints, problems getting services, and improvement in the health plan's performance.
  5. Health plan customer service.
  6. Data used to calculate the ratings comes from surveys, observation, claims data, and medical records. 

CMS continues to evolve the Star Ratings system by adding, removing and adjusting various measures on a yearly basis to ensure continuous quality improvement by Medicare Advantage health plans.

Behavioral Health

Cigna-HealthSpring provides comprehensive mental health and substance abuse services to its customers. Its goal is to treat the customer in the most appropriate, least restrictive level of care possible, and to maintain and/or increase functionality.

Cigna-HealthSpring’s network is comprised of mental health and substance abuse services and providers who identify and treat customers with behavioral health care needs. Integration and communication among behavioral health and physical health providers is most important. Cigna-HealthSpring encourages and facilitates the exchange of information between and among physical and behavioral health providers. Customer follow-up is essential. High risk customers are evaluated and encouraged to participate in Cigna-HealthSpring’s behavioral health focused case management program where education, care coordination, and support is provided to increase customer’s knowledge and encourage compliance with treatment and medications. Cigna-HealthSpring works with its providers to become part of the strategy and the solution to provide quality behavioral health services.

Behavioral Health Services

Behavioral Health services are available and provided for the early detection, prevention, treatment, and maintenance of the customer’s behavioral health care needs. Behavioral health services are interdisciplinary and multidisciplinary: a customer 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:

  • Access to Cigna-HealthSpring's Customer Service for orientation and guidance
  • Routine outpatient services to Psychiatrists, Psychologists, Licensed Clinical Social Workers, and Psychiatric Nurse Practitioners. PCPs may provide behavioral health services within their scope of practice
  • Initial evaluation and assessment
  • Individual and group therapy
  • Psychological testing according to established guidelines and needs
  • Inpatient hospitalization
  • Detoxification treatment
  • Medication management
  • Partial hospitalization programs

Cigna-HealthSpring's behavioral health providers 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 customer
  • Direct customers to community resources as needed to maintain or increase customer’s functionality and ability to remain in the community

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

  • Screening and early identification of mental health and substance abuse issues
  • Treating customers with behavioral health care needs within the scope of his/her practice and according to established Clinical Practice Guidelines. These can be customers with co-morbid physical and minor behavioral health problems or those customers 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

Customers may access behavioral health services as needed:

  • Customers may self-refer to any in-network behavioral health provider for initial assessment and evaluation,
    and ongoing outpatient treatment
  • Customers 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
  • Customers and providers can call Cigna-HealthSpring Behavioral Health Customer Service to receive orientation on how to access behavioral health services, provider information, and Prior Authorizations at 1-866-780-8546.

When requesting Prior Authorization for specific services or billing for services provided, behavioral health providers must use the current DSM multi-axial classification system and document a complete diagnosis. The provision of behavioral health services requires progress note documentation that corresponds with day of treatment, the development of a treatment plan, outcome of treatment and the discharge plan as applicable for each customer in treatment.

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

  • Evaluate customer if he/she was hospitalized for a behavioral health condition within 7 days post-discharge.
  • Provide customers receiving care with contact information for any emergency or urgent matter arising that necessitates communication between the customer and the provider.
  • Evaluate customer needs when the customer is in acute distress.
  • Communicate with the customer’s other health care providers.
  • Identify those customers 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 customer 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 customers.

Cigna-HealthSpring’s Utilization Management staff base their utilization-related decisions on the clinical needs of customers, the customer’s Benefit Plan, well-established clinical decision-making support tools, the appropriateness of care, Medicare National Coverage Guidelines, health care objectives, scientifically-based clinical criteria and treatment guidelines in the context of provider and/or customer-supplied clinical information and other relevant information. For requests for behavioral health services that require authorization, Cigna-HealthSpring will approve the request or issue a notice of denial if the request is not medically necessary.

Behavioral Health Quick Reference Guide



Health Services

Cigna-HealthSpring's Health Services Department coordinates health care services to ensure appropriate utilization of health care resources. This coordination assures promotion of the delivery of services in a quality-oriented, timely, clinically appropriate, and cost-effective manner for the customers.

Cigna-HealthSpring Utilization Management staff base their utilization-related decisions on the clinical needs of customers, the customer's Benefit Plan, well-established clinical decision making support tools, 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 customer-supplied clinical information and other such relevant information.

Cigna-HealthSpring in no way rewards or incentivizes, either financially or otherwise, practitioners, Utilization Reviewers, clinical care managers, physician advisers or other individuals involved in conducting Utilization Review, for issuing denials of coverage or service, or inappropriately restricting care.

  • To ensure that services are authorized at the appropriate level of care and are covered under the customer's health plan benefits.
  • To monitor utilization practice patterns of Cigna-HealthSpring's contracting physicians, contracting hospitals, contracting ancillary services, and contracting specialty providers.
  • To provide a system to identify high-risk customers and ensuring that appropriate care is accessed.
  • To provide Utilization Management data for use in the process of re-credentialing providers.
  • To educate customers, physicians, contracted hospitals, ancillary services, and specialty providers about Cigna-HealthSpring's goals for providing quality, value-enhanced managed health care.
  • To improve utilization of Cigna-HealthSpring's resources by identifying patterns of over- and under- utilization that have opportunities for improvement.
  • Prior Authorization
  • Referral Management
  • Concurrent Review
  • Discharge Planning
  • Case Management and Disease Management
  • Continuity of Care

The Primary Care Physician (PCP) or Specialist is responsible for requesting Prior Authorization of all scheduled admissions or services/procedures, for referring a customer for an elective admission, outpatient service, and for requesting services in the home. Prior Authorization should be received at least seven (7) days in advance of the admission, procedure, or service. Requests for Prior Authorization are prioritized according to level of medical necessity. As part of the prior authorization process, Cigna-HealthSpring reserves the right to determine the place of service for any requested service.

  • Please refer to the state specific prior authorization grid for your specific service for authorization guidelines and/or requirements.
  • The requesting provider has the responsibility of notifying the customer that services are approved and documenting the communication in the medical record.


Cigna-HealthSpring accepts Prior Authorization requests via our confidential fax lines and portal 24 hours per day, 7 days per week. Requests must include all pertinent clinical information.

The contact numbers listed below include options for: Customer Service, Benefits, Prior Authorization, Case Management, Skilled Nursing, Part B and D pharmacy, Behavioral Health, etc. Please listen carefully to the prompts to make the appropriate selection.

Alabama, Southern Mississippi, and Northwest Florida

Providers can submit most requests
via our online portal 24 hours per day,
7 days per week at: HSConnect

Providers can fax:

  • 1-205-444-4263 or
  • 1-800-872-8685 (Southern Mississppi and
    Northwest Florida only)

Providers can call:

Fax and Portal are available 24 hours per day, 7 days per week.

Phone lines are staffed Monday through Friday between the hours of 8:00 a.m. and 5:00 p.m. CST.

 

Maryland, Delaware, Washington DC, and Pennsylvania

Providers can submit most requests
via our online portal 24 hours per day,
7 days per week at: HSConnect

Providers can fax: 1-866-464-0707

Providers can call: 1-888-454-0013

Fax and Portal are available 24 hours per day, 7 days per week.

Phone lines are staffed Monday through Friday between the hours of 8:30 a.m. and 5:00 p.m. EST.

 

Texas, Southwestern Arkansas

Providers can submit most requests
via our online portal 24 hours per day,
7 days per week at: HSConnect

Providers can fax: 1-888-856-3969

Providers can call: 1-800-511-6932

Fax and Portal are available 24 hours per day, 7 days per week.

Phone lines are staffed Monday through Friday between the hours of 8:00 a.m. and 5:00 p.m. CST.

 

Illinois, and Indiana

Providers can submit most requests
via our online portal 24 hours per day,
7 days per week at: HSConnect

Providers can fax:

  • 1-866-287-5834 or
  • 1-855-544-0625 (Illinois only)

Providers can call: 1-800-230-7298

Fax and Portal are available 24 hours per day, 7 days per week.

Phone lines are staffed Monday through Friday between the hours of 8:00 a.m. and 5:00 p.m. CST.

 

Kansas City

Providers can submit most requests
via our online portal 24 hours per day,
7 days per week at: HSConnect

Providers can fax:

  • 1-866-464-0707 or
  • 1-888-545-0024 (Inpatient Admission
    Fax Line)

Providers can call: 1-888-454-0013

Fax and Portal are available 24 hours per day, 7 days per week.

Phone lines are staffed Monday through Friday between the hours of 8:30 a.m. and 5:00 p.m. EST.

 

Tennessee, Northern Georgia, and Eastern Arkansas

Providers can submit most requests
via our online portal 24 hours per day,
7 days per week at: HSConnect

Providers can fax:

  • 1-866-287-5834 or
  • 1-615-291-7545 (Tennessee)

Providers can call: 1-800-453-4464

Fax and Portal are available 24 hours per day, 7 days per week.

Phone lines are staffed Monday through Friday between the hours of 8:00 a.m. and 5:00 p.m. CST.

 

Georgia (All counties excluding Catoosa, Dade, and Walker)

Providers can submit most requests
via our online portal 24 hours per day,
7 days per week at: HSConnect

Providers can fax: 1-855-388-1452

Providers can call: 1-866-949-7103

Fax and Portal are available 24 hours per day, 7 days per week.

Phone lines are staffed Monday through Friday between the hours of 8:30 a.m. and 5:00 p.m. EST.

 

North Carolina

Providers can submit most requests
via our online portal 24 hours per day,
7 days per week at: HSConnect

Providers can fax: 1-855-500-2774

Providers can call: 1-866-949-7099

Fax and Portal are available 24 hours per day, 7 days per week.

Phone lines are staffed Monday through Friday between the hours of 8:30 a.m. and 5:00 p.m. EST.

 

South Carolina

Providers can submit most requests
via our online portal 24 hours per day,
7 days per week at: HSConnect

Providers can fax: 1-855-420-4717

Providers can call: 1-866-949-7101

Fax and Portal are available 24 hours per day, 7 days per week.

Phone lines are staffed Monday through Friday between the hours of 8:30 a.m. and 5:00 p.m. EST.

Services requiring Prior Authorization are listed in this manual as well as on Cigna-HealthSpring’s website. The presence or absence of a service or procedure on the list does not determine coverage or benefits. Log in to HSConnect or contact customer service to verify benefits, coverage, and customer eligibility.

The Prior Authorization Department, under the direction of licensed nurses, clinical pharmacists, and medical directors, documents and evaluates requests for authorization, including:

  • Verification that the customer is enrolled with Cigna-HealthSpring at the time of the request for authorization and on each date of service
  • Verification that the requested service is a covered benefit under the customer’s benefit package
  • Determination of the appropriateness of the services (medical necessity)
  • Verification that the service is being provided by the appropriate provider and in the appropriate setting
  • Verification of other insurance for coordination of benefits

The Prior Authorization Department documents and evaluates requests utilizing CMS guidelines as well as nationally accepted criteria, processes the authorization determination, and notifies the provider of the determination.

Examples of information required for a determination include, but are not limited to:

  • Customer name and identification number
  • Location of service (e.g., hospital or surgi-center setting)
  • Primary Care Physician name
  • Servicing/attending physician name
  • Date of service
  • Diagnosis
  • Service/procedure/surgery description and CPT or HCPCS code
  • Clinical information supporting the need for the service to be rendered

For customers who go to an emergency room for treatment, an attempt should be made in advance to contact the PCP unless it is not medically feasible due to a serious condition that warrants immediate treatment.

If a customer appears at an emergency room for care which is non-emergent, the PCP should be contacted for direction. The customer may be financially responsible for payment if the care rendered is non-emergent. Cigna-HealthSpring also utilizes urgent care facilities to treat conditions that are non-emergent but require immediate treatment. Notification of Emergency Admissions must also be pre-certified by Cigna-HealthSpring. Please be prepared to discuss the customer’s condition and treatment plan with our Nurse Case Manager.

Triage Unit:

  • Consists of non-clinical personnel
  • Receives all faxes and phone calls for services that require Prior Authorization
  • Handles issues that can be addressed from a non-clinical perspective:
  • Did you receive my fax?
  • Does this procedure/service require Prior Authorization?
  • Setting up "shells" for services that must be forwarded to clinical personnel for determination

Prior Authorization Unit:

  • Consists of RN's and LPN's.
  • Teams of nurses are organized based on customer’s PCP or provider specialty
  • Handles all issues that require a clinical determination, such as:
    • Home Health Services
    • Infusion
    • Outpatient surgical procedures
    • DME/ O and P
    • Ambulance transports
    • Outpatient diagnostic testing
    • Outpatient therapy

Emergency

An Emergency Medical Condition is a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, with an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:

  • Serious jeopardy to the health of the individual or, in the case of a pregnant woman, the health of the woman or her unborn child;
  • Serious impairment to bodily functions;
  • Or, serious dysfunction of any bodily organ or part.

Prior Authorization is not required for an Emergency Medical Condition.

Expedited

An expedited request can be requested when you as a physician believe that waiting for a decision under the routine time frame could place the customer's life, health, or ability to regain maximum function in serious jeopardy. Expedited requests will be determined within 72 hours or as soon as the customer's health requires.

Routine

If all information is submitted at the time of the request, CMS mandates a health plan determination within 14 calendar days.

Once the Precertification Department receives the request for authorization, we will review the request using nationally recognized industry standards or local Coverage Determination criteria. If the request for authorization is approved, Cigna-HealthSpring will assign an authorization number and enter the information in our medical management system. This authorization number can be used to reference the admission, service or procedure.

The requesting provider has the responsibility of notifying the customer that services are approved and documenting the communication in the medical record.

Retrospective Review is the process of determining coverage for clinical services by applying guidelines/ criteria to support the claim adjudication process after the opportunity for Precertification or Concurrent Review timeframe has passed. The only scenarios in which retrospective requests can be accepted are:

  • Authorizations for claims billed to an incorrect carrier.
    • As long as you have not billed the claim to Cigna-HealthSpring and received a denial, you can request a retro authorization from Health Services within 2 business days of receiving the RA from the incorrect carrier.
    • If the claim has already been submitted to Cigna-HealthSpring and you have received a denial, the request for retro authorization then becomes an Appeal and you must follow the guidelines for submitting an Appeal.
  • Cigna-HealthSpring will retrospectively review any medically necessary services provided to Cigna-HealthSpring customers after hours, holidays, or weekends. Cigna-HealthSpring does require the retro authorization request and applicable clinical information to be submitted to the Health Services department within 1 business day of the start of care.
  • In accordance with Cigna-HealthSpring policy, retrospective requests for authorizations not meeting the scenarios listed above will not be accepted and claims may be denied for payment.

Cigna-HealthSpring requires notification of home health services prior to commencement of such services. Timely receipt of clinical information supports the clinical review process. Failure to comply with notification timelines or failure to provide timely clinical documentation to support the need for home health services or continuation of home health services could result in an adverse determination. Cigna-HealthSpring's nurses, utilize CMS guidelines and nationally accepted, evidence-based review criteria to conduct medical necessity review of services.

A Cigna-HealthSpring Medical Director reviews all home health services that do not meet medical necessity criteria and issues a determination. If the Cigna-HealthSpring Medical Director deems that the services do not meet medical necessity criteria, the Medical Director will issue an adverse determination (a denial). The Prior Auth Nurse or designee will notify the provider and customer verbally and in writing of the adverse determination via notice of denial.

Cigna-HealthSpring issues written Notice of Medicare Non-Coverage (NOMNC) determinations in accordance with CMS guidelines. Cigna HealthSpring will issue a CMS approved NOMNC letter with each approved authorization. This notice will be sent by fax to the HHA. The agency is responsible for delivering the notice to the customer or their authorized representative/power of attorney (POA) 2 days prior to the end of the currently approved authorization. The agency is responsible for ensuring the customer, authorized representative or POA signs the notice within the specified time frame. If the agency believes continued home health care is required, a request for additional services must be submitted prior to the expiration of the existing authorization.

The agency is required and expected to fax a copy of the signed NOMNC back to Health Services at the number provided. The NOMNC includes information on customer's rights to file a fast track Appeal.

Concurrent Review is the process of initial assessment and continual reassessment of the medical necessity and appropriateness of inpatient care during an acute care hospital admission, rehabilitation admission or skilled nursing facility or other inpatient admission in order to ensure:

  • Covered services are being provided at the appropriate level of care
  • Services are being administered according to the individual facility contract

Cigna-HealthSpring requires admission notification for the following:

  • Elective admissions
  • ER and Urgent admissions
  • Transfers to Acute Rehabilitation, LTAC and SNF admissions
  • Admissions following outpatient procedures or observation status
  • Observation status
  • Newborns remaining in the hospital after the mother is discharged.

Emergent or urgent admission notification must be received within twenty-four (24) hours of admission or next business day, whichever is later, even when the admission was prescheduled. If the customer's condition is unstable and the facility is unable to determine coverage information, Cigna-HealthSpring requests notification as soon as it is determined, including an explanation of the extenuating circumstances. Timely receipt of clinical information supports the care coordination process to evaluate and communicate vital information to hospital professionals and discharge planners. Failure to comply with notification timelines or failure to provide timely clinical documentation to support admission or continued stay could result in an adverse determination.

Cigna-HealthSpring's Health Services department complies with individual facility contract requirements for Concurrent Review decisions and timeframes. Cigna-HealthSpring's nurses, utilizing CMS guidelines and nationally accepted, evidence-based review criteria, will conduct medical necessity review. Cigna-HealthSpring is responsible for final authorization.

Cigna-HealthSpring's preferred method for Concurrent Review is a live dialogue between our Concurrent Review nursing staff and the facility's UM staff within 24 hours of notification or on the last covered day. If clinical information is not received within 72 hours of admission or last covered day, the case will be reviewed for medical necessity with the information Cigna-HealthSpring has available. If it is not feasible for the facility to contact Cigna-HealthSpring via phone, facilities may fax the customer's clinical information within 24 hours of notification to:

 

Alabama, Northwest Florida, and Southern Mississippi

Concurrent: 1-205-444-4262
Skilled Nursing Facility (SNF) Reviews should be faxed to:
1-205-444-4264

Concurrent: 1-866-287-5834
Skilled Nursing Facility (SNF) Reviews should be faxed to:

  • MTN: 1-615-401-4589 or 1-855-694-2445
  • ETN: 1-888-766-6404>
  • WTN: 1-901-474-0193

Georgia (all counties excluding Catoosa, Dade, and Walker)

Concurrent and SNF/Rehab Request/Reviews:
1-866-785-8129

North Carolina

Concurrent and SNF/Rehab Request/Reviews:
1-855-693-2168

South Carolina

Concurrent and SNF/Rehab Request/Reviews:
1-855-792-2308

Illinois and Indiana

Concurrent Review Fax Numbers

Kansas City

Concurrent and SNF fax line: 1-855-784-7599

Southwestern Arkansas and Texas

Concurrent: 1-832-553-3426
Skilled Nursing Facility (SNF) Reviews should be faxed to:
1-832-553-3426

Delaware, Maryland, Pennsylvania, and Washington, DC

Concurrent: 1-866-234-7230

Cigna-HealthSpring has partnered with naviHealth to provide Skilled Nursing Facility (SNF) admission post-acute network management services to its members. NaviHealth will be working with members and their caregivers to arrange for the least restrictive, most appropriate site where a customer’s health can improve most effectively.

To obtain prior authorization, please contact naviHealth by faxing your request to 1-855-847-7240 or by calling 1-855-512-7005.

The following post-acute services remain the responsibility of Cigna-HealthSpring:

  • Long Term Acute Care (LTAC) admissions and concurrent review
  • In-patient Rehabilitation Facilities (IRF) admissions and concurrent review Home Health Services for all new admissions or resumptions of care
  • Durable Medical Equipment, Infusion Therapy, and/or Hospice

 

Following an initial determination, the Concurrent Review nurse will request additional updates from the facility on a case-by-case basis. The criteria used for the determination is available to the practitioner/facility upon request. Cigna-HealthSpring will render a determination within 24 hours of receipt of complete clinical information. Cigna-HealthSpring's nurse will make every attempt to collaborate with the facility's utilization or case management staff and request additional clinical information in order to provide a determination. Clinical update information should be received 24 hours prior to the next review date.

A Cigna-HealthSpring Medical Director reviews all acute, rehab, LTAC, and SNF confinements that do not meet medical necessity criteria and issues a determination. If the Cigna-HealthSpring Medical Director deems that the inpatient or SNF/Rehab confinement does not meet medical necessity criteria, the Medical Director will issue an adverse determination (a denial). The Concurrent Review nurse or designee will notify the provider(s) e.g. facility, attending/ ordering provider, and customer verbally and in writing of the adverse determination via notice of denial.

For all regions (excluding Delaware, Maryland, Pennsylvania, and Washington, DC):

For customers receiving hospital care and for those who transfer to a Skilled Nursing Facility or Acute Inpatient Rehabilitation Care, Cigna-HealthSpring will approve the request or issue a notice of denial if the request is not medically necessary. Cigna-HealthSpring will also issue a notice of denial if a customer who is already receiving care in an Acute Inpatient Rehabilitation Facility has been determined to no longer require further treatment at that level of care. This document will include information on the customer's or their representative's right to file an expedited appeal, as well as instructions on how to do so if the customer or customer's physician does not believe the denial is appropriate.

For Delaware, Maryland, Pennsylvania, and Washington, DC:

Cigna-HealthSpring will fax or send via designated secure email a Daily Determination Log (Monday-Friday, excluding holidays) or other facility generated list to the acute care facility regarding each customer’s confinement status. The log will indicate if the confinement is approved, denied or pended if additional clinical information is necessary. For pre-service requests, Cigna-HealthSpring will approve the request or issue a notice of denial if the request is not medically necessary. This document will include information on the customers’ or their Representatives’ right to file an expedited appeal, as well as instructions on how to submit.

Cigna-HealthSpring also issues written Notice of Medicare Non-Coverage (NOMNC) determinations in accordance with CMS guidelines. This notice will be sent by fax to the SNF or HHA. The facility/agency is responsible for delivering the notice to the customer or their authorized representative/power of attorney (POA) and for having the customer, authorized representative or POA sign the notice within the written time frame listed in the Adverse Determination section of the provider manual. The facility is requested and expected to fax a copy of the signed NOMNC back to Health Services at the number provided. The NOMNC includes information on customer's rights to file a fast track Appeal.

The Health Services Department will review all readmissions occurring within 31 days following discharge from the same facility, according to established processes, to assure services are medically reasonable and necessary, with the goal of high quality cost effective health care services for health plan customers. The Health Services Utilization Management (UM) staff will review acute Inpatient and Observation readmissions. If admissions are determined to be related; they may follow the established processes to combine the two confinements.

Cigna-HealthSpring Acute Care case managers (ACCMs) are registered nurses. All ACCMs are expected to perform at the height of their license. They understand Cigna-HealthSpring plan benefits and utilize good clinical judgment to ensure the best outcome for the customer.

The Cigna-HealthSpring Acute Care Case Manager has two major functions:

  • Ensure the customer is at the appropriate level of care, in the appropriate setting, at the appropriate time through Utilization Review
  • Effectively manage care transitions and length of stay (LOS).

Utilization Review is performed utilizing evidence- based guidelines, well-established clinical decision-making support tools and collaborating with Primary Care Physicians (PCP), attending physicians, and Cigna-HealthSpring Medical Directors.

The ACCM effectively manages all transitions of care through accurate discharge planning and collaboration with facility personnel to prevent unplanned transitions and readmissions via interventions such as:

  • Medication reconciliation
  • Referral of customers to Cigna-HealthSpring programs such as: CHF CCIP Program, Respiratory Care Program, and Fragile Fracture Program
  • Appropriate coordination of customer benefits
  • Obtaining needed authorizations for post-acute care services or medications
  • Collaborating with attending physician and PCP, as needed
  • Introducing and initiating CTI (Care Transition Intervention)
  • Addressing STAR measures, as applicable: Hgb A1C and foot care, LDL, colorectal cancer screening, osteoporosis management in women who had a fracture, falls, emotional health, flu and pneumonia vaccines and medication adherence
  • Facilitating communication of care level changes to all parties
  • The goals of the Cigna-HealthSpring ACCM are aligned with the goals of acute care facilities
  • Customers/patients receive the appropriate care, at the appropriate time, and in the most appropriate setting
  • Readmissions are reduced and LOS is managed effectively

At Cigna-HealthSpring, we strive for Primary Care Physicians (PCP), attending physicians, and acute care facility personnel to view the Cigna-HealthSpring ACCM as a trusted resource and partner in the care of our customers (your patients).

Discharge planning is a critical component of the process that begins with an early assessment of the customer's potential discharge care needs in order to facilitate transition from the acute setting to the next level of care. Such planning includes preparation of the customer and his/her family for any discharge needs along with initiation and coordination of arrangements for placement and/or services required after acute care discharge. Cigna-HealthSpring's ACCM staff will coordinate with the facility discharge planning team to assist in establishing a safe and effective discharge plan. Cigna-HealthSpring's ACCM staff will coordinate with the facility discharge planning team to assist in establishing a safe and effective discharge plan. The Cigna-HealthSpring ACCM nurse will facilitate the communication for all needed authorizations for services, equipment, and skilled services upon discharge.

In designated contracted facilities, Cigna-HealthSpring also employs ACCMs to assist with the process, review the inpatient medical record, and complete face-to-face customer interviews to identify customers at risk for readmission, in need of post-discharge complex care coordination and to aid the transition of care process. This process is completed in collaboration with the facility discharge planning and acute care management team customers and other Cigna-HealthSpring staff. When permissible by facility agreement, the ACCM also completes the Concurrent Review process onsite at assigned hospitals. The role of the ACCM onsite reviewer then also includes the day-to-day functions of the Concurrent Review process at the assigned hospital by conducting timely and consistent reviews and discussing with a Cigna-HealthSpring medical director as appropriate. The reviewer monitors the utilization of inpatient customer confinement at the assigned hospitals by gathering clinical information in accordance with hospital rules and contracting requirements including timelines for decision-making. All clinical information is evaluated utilizing nationally accepted review criteria.

The ACCM onsite reviewer will identify discharge-planning needs and be proactively involved by interacting with attending physicians and hospital case managers in an effort to facilitate appropriate and timely discharge. The onsite reviewer will follow the policies and procedures consistent with the guidelines set forth by Cigna-HealthSpring Health Services Department and the facility.

On-Call After Hours (For Delaware, Maryland, Pennsylvania, and Washington, DC only)

Cigna-HealthSpring has an on-call nurse available to providers who can be reached between the hours of 5p.m. to 8a.m. Monday through Friday, and 24 hours a day on weekends and holidays to assist with the authorization process for customers being discharged.

The on-call cellular telephone number is 1-800-931-0154.For the convenience of our providers and customers; Cigna-HealthSpring accepts requests via facsimile (fax) during and after normal business hours. Cigna-HealthSpring Utilization Management staff however does not monitor and retrieve faxed documentation routinely after normal business hours. In these circumstances, after business hours, the time of receipt for non-urgent requests is considered the next business day.

Rendering of Adverse Determinations (Denials)

The Utilization Management staff is authorized to render an administrative denial decision to participating providers based only on contractual terms, benefits, or eligibility.

Every effort is made to obtain all necessary information, including pertinent clinical information and original documentation from the treating provider to allow the Medical Director to make appropriate determinations.

Only a Cigna-HealthSpring Medical Director may render an adverse determination (denial) based on medical necessity but he/she may also make a decision based on administrative guidelines. The Medical Director, in making the initial decision, may suggest an alternative Covered Service to the requesting provider. If the Medical Director makes a determination to deny or limit an admission, procedure, service, or extension of stay, Cigna-HealthSpring notifies the facility or provider's office of the denial of service. Such notice is issued to the provider and the customer, when applicable, documenting the original request that was denied and the alternative approved service, along with the process for appeal.

Cigna-HealthSpring employees are not compensated for denial of services. The PCP or attending physician may contact the Medical Director by telephone to discuss adverse determinations.

Notification of Adverse Determinations (Denials)

The reason for each denial, including the specific Utilization Review criteria with pertinent subset/ information or benefits provision used in the determination of the denial, is included in the written notification and sent to the provider and customer as applicable. Written notifications are sent in accordance with CMS and NCQA requirements to the provider and/or customer as follows:

  • For non-urgent pre-service decisions - within 14 calendar days of the request.
  • For urgent pre-service decisions - *within 72 hours or three calendar days of the request.
  • For urgent concurrent decisions - *within 24 hours of the request.
  • For post-service decisions - within 30 calendar days of the request.

Cigna-HealthSpring complies with CMS requirements for written notifications to customers, including rights to appeal and grievances.

ICD-10 Diagnosis and Procedure Code Reporting

ICD-10 (International Classification of Diseases, 10th Edition, Clinical Modification /Procedure Coding System) consists of two parts:

  • ICD-10-CM for Diagnosis coding is for use in all U.S. health care settings. Diagnosis coding under ICD-10-CM uses 3 to 7 characters instead of the 3 to 5 characters used with ICD-9-CM, adding more specificity.
  • ICD-10-PCS for Inpatient Procedure coding is for use in U.S. inpatient hospital settings only. ICD- 10-PCS uses 7 alphanumeric characters instead of the 3 or 4 numeric characters used under ICD-9-CM procedure coding. Coding under ICD- 10-PCS is much more specific and substantially different from ICD-9-CM procedure coding.

Note: Procedure codes are only applicable to inpatient claims and not prior authorizations.

Billable vs. Non-billable Codes

  • A billable ICD-10 code is defined as a code that has been coded to its highest level of specificity.
  • A non-billable ICD-10 code is defined as a code that has not been coded to its highest level of specificity. If a claim is submitted with a non-billable code, the claim will be rejected.
  • The following is an example of a billable ICD-10 code with corresponding non-billable codes.

Billable ICD-10 codes

M1A.3110 - Chronic gout due to renal impairment, right shoulder, without tophus

Non-billable ICD-10 codes

M1A.3 - Chronic gout due to renal impairment

M1A.311 - Chronic gout due to renal impairment, right shoulder

  • It is acceptable to submit a claim using an unspecified code when sufficient clinical information is not known or available about a particular health condition to assign a more specific code.

Billable unspecified ICD-10 codes

I50.9 - Heart failure, unspecified

J18.9 - Pneumonia, unspecified organism

Clinical Practice Guidelines and Reference Material

Cigna-HealthSpring has adopted evidence-based Clinical Practice Guidelines as roadmaps for health care decision-making targeting specific clinical circumstances. Please refer to the section Cigna-HealthSpring’s Clinical Guidelines.

Clinical Guidelines



Case Management Services

Cigna-HealthSpring has published and actively maintains a detailed set of program objectives available upon request in our case management program description. These objectives are clearly stated, measurable, and have associated internal and external benchmarks against which progress is assessed and evaluated throughout the year. Plan demographic and epidemiologic data, and survey data are used to select program objectives, activities, and evaluations.

Cigna-HealthSpring has multiple programs in place to promote continuity and coordination of care, remove barriers to care, prevent complications and improve customer quality of life. It is important to note that Cigna-HealthSpring treats disease management as a component of the case management continuum, as opposed to a separate and distinct activity. In so doing, we are able to seamlessly manage cases across the care continuum using integrated staffing, content, data resources, risk identification algorithms, and computer applications.

Cigna-HealthSpring employs a segmented and individualized case management approach that focuses on identifying, prioritizing, and triaging cases effectively and efficiently. Our aim is to assess the needs of individual customers, to secure their agreement to participate, and to match the scope and intensity of our services to their needs. Results from health risk assessment surveys, eligibility data, retrospective claims data, and diagnostic values are combined using proprietary rules, and used to identify and stratify customers for case management intervention. The plan uses a streamlined operational approach to identify and prioritize customer outreach, and focuses on working closely with customers and family/caregivers to close key gaps in education, self-management, and available resources. Personalized case management is combined with medical necessity review, ongoing delivery of care monitoring, and continuous quality improvement activities to manage target customer groups.

Customers are discharged from active case management under specific circumstances which many include stabilization of symptoms or a plateau in disease processes, the completed course of therapy, customer specific goals obtained; or the customer has been referred to Hospice. A customer's case may be re-initiated based on the identification of a transition in care, a change in risk score, or through a referral to case management.

Customers that may benefit from case management are identified in multiplies ways, including but not limited to: Utilization Management activities, predictive modeling, and direct referrals from a provider. If you would like to refer a Cigna-HealthSpring customer for case management/care coordinator services, please call the numbers listed below and listen to the prompts carefully that will direct you to Case Management:

 

StateProviders Should Call:
Alabama, Southern Mississippi, and Northwest Florida 1 (800) 962-3016 Option 4
or
1 (205) 423-1222 Option 4
Monday - Friday 8:00 AM - 5:00 PM CST
Maryland, Delaware, Washington DC, and Pennsylvania 1-888-454-0013, Option 9
Monday - Friday 8:30 AM - 5:00 PM EST
Texas and Southwestern Arkansas 1-888-501-1116
Monday - Friday 8:00 AM - 5:00 PM CST
Illinois and Indiana 1-800-230-7298 Option 4
Monday - Friday 8:00 AM - 5:00 PM CST
Kansas City 1-888-454-0013, Option 9
Monday - Friday 8:30 AM - 5:00 PM EST
Tennessee, Northern Georgia, and Eastern Arkansas 1 (800) 453-4464 Option 4
or
1 (888) 615-2709
Monday - Friday 8:00 AM - 5:00 PM CST
North Carolina 1-866-949-7099, Option 4
Monday - Friday 8:30 AM - 5:00 PM EST
South Carolina 1-866-949-7101, Option 4
Monday - Friday 8:30 AM - 5:00 PM EST
Georgia (All counties excluding Catoosa, Dade, and Walker) 1-866-949-7103, Option 4
Monday - Friday 8:30 AM - 5:00 PM EST

 

In addition, our customers have access to information regarding the program via a brochure and website and may self-refer. Our case management staff contacts customers by telephone or in a face-to-face encounter. The customer has the right to opt out of the program. If the customer opts in, a letter will be sent to the customer and you as the provider. Once enrolled, an assessment is completed with the customer and a plan of care with goals, interventions, and needs is established.

Cigna-HealthSpring offers customers access to a contracted network of facilities, primary care and specialty care physicians, mental health, and alcohol and substance abuse specialists, as well an ancillary care network. Each customer receives a provider directory annually giving in-depth information about how to find network providers in their area (by zip code and by specialty), how to select a PCP, conditions under which out-of-area and out-of-network providers may be seen, and procedures for when the customer’s provider leaves the network. A toll-free Customer Service telephone number is provided, and customers with questions are asked to reach out to the plan. Customers also have access to a series of web-based provider materials. The website allows customers to search the provider directory for doctors, facilities, and pharmacies.

The provider is a key part of the Interdisciplinary care team. Our case management staff will work with you and your staff to meet the unique needs of each customer. Case managers work with customers and providers to schedule and prepare for customer visits, to make sure that identified care gaps are addressed and prescriptions are filled, and to mitigate any non-clinical barriers to care. In cases where provider referrals are necessitated, case managers work closely with customers to identify appropriate providers, schedule visits, and secure transportation. The plan also has a provider incentive program that supports case management objectives and which incentivizes providers to coordinate closely with the customer and plan on specified quality measures.

Customers of our Special Needs Plan have a defined Model of Care (See Model of Care Section) that includes Provider Training. Our case management program includes initiatives specific to this population and our case managers provide support to resolve the special needs of this population. As a provider, the need to coordinate benefits available from Medicare and Medicaid may occur with our Special Needs program customers. Our Summary of Benefits available on our website defines the benefits for your state and the case management staff can assist with identifying resources and providing support to assure coordination.

Cigna-HealthSpring provides multiple communication channels to customers. The plan maintains a full- service inbound call program that allows customers to inquire about all aspects of their relationship with the plan. Outbound customer services and care management calls are also made regularly to customers to encourage them to participate in clinical programs and assessment activities provided as part of their health care benefit. In addition to telephonic touch points, the plan regularly sends educational materials to customers in response to identified care gaps and changes in health status. Customers also have access to web-based materials, where they can learn more about their benefits, explore additional benefits, search the provider directory, find a pharmacy, query the formulary, and identify the time and location of sales sessions.

Cigna-HealthSpring continually monitors the program, and makes changes as needed to its structure, content, methods, and staffing. Changes to the program are made under two conditions: (1) changes must benefit customers; and (2) changes must be in compliance with applicable regulations and guidance. Changes to the program are accompanied by policy and procedure revisions and staff training as required. The program operates under the umbrella of the plan’s Quality Improvement Committee which reports to the Corporate Quality Improvement Committee. It is reviewed and updated annually in collaboration with the Quality Improvement Department. The plan’s Physician Advisory Committee made up of network providers, also reviews the program and its Clinical Practice Guidelines at certain intervals and provides improvement recommendations.

Cigna-HealthSpring is committed to preserving the confidentiality of its customers and practitioners. Written policies and procedures are in place to ensure the confidentiality of customer information. Patient data gathered during the case management process are available for the purposes of review only and are maintained in a confidential manner. Employees receive confidentiality training that includes appropriate storage and disposal of confidential information. Employees also sign a confidentiality agreement at the time of their initial company orientation.

Cigna-HealthSpring’s policy is to provide for continuity and coordination of care with medical practitioners treating the same patient, and coordination between medical and behavioral health services. When a practitioner leaves Cigna-HealthSpring’s network and a customer is in an active course of treatment, our Health Services staff will attempt to minimize any disruption in care by potentially offering continuity of care services with the current provider for a reasonable period of time.

In addition, customers undergoing active treatment for a chronic or acute medical condition will have access to the exiting provider through the current period of active treatment or a maximum of 90 calendar days, whichever is shorter. Customers in their second or third trimester of pregnancy have access to the exiting provider through the postpartum period.

If the plan terminates a participating provider, Cigna-HealthSpring will work to transition a customer into care with a participating physician or other provider within Cigna-HealthSpring’s network. Cigna-HealthSpring is not responsible for the health care services provided by the terminated provider following the date of termination under such circumstances.

Cigna-HealthSpring also recognizes that new customers join our health plan and may have already begun treatment with a provider who is not in Cigna-HealthSpring's network. Under these circumstances, Cigna-HealthSpring will work to coordinate care with the provider by identifying the course of treatment already ordered and offering the customer a transition period of up to 90 calendar days to complete the current course of treatment.

Cigna-HealthSpring will honor plans of care (including prescriptions, DME, medical supplies, prosthetic and orthotic appliances, Specialist referrals, and any other on-going services) initiated prior to a new customer’s enrollment for a period of up to 90 calendar days or until the Primary Care Physician evaluates the customer and establishes a new plan of care. For additional information about continuity of care or to request authorization for such services, please review our Health Services section of this manual for contact information for Case Management Services.

Quality Improvement Organization Program Changes



Recently, the Centers for Medicare and Medicaid Services announced restructuring of the Quality Improvement Organization (QIO) program allowing two Beneficiary and Family-Centered Care (BFCC) QIO contractors to support program activities. The BFCC-QIO contactors will focus on conducting quality of care reviews, discharge and termination of service appeals, and other areas of required review.

The two chosen BFCC-QIO contractors are:

 

Livanta

AreaAddressToll-free numberFax number
1 (CT, ME, MA, NH, NJ, NY, PA, PR, RI, VT, VI) Livanta
BFCC-QIO Program
9090 Junction Drive, Suite 10
Annapolis Junction,
MD 20701
1-866-815-5440
TTY: 1-866-868-2289
Appeals:
1-855-236-2423
All other reviews:
1-844-420-6671
5 (AK, AZ, CA, HI, ID, NV, OR, WA) Livanta
BFCC-QIO Program
9090 Junction Drive, Suite 10
Annapolis Junction,
MD 20701
1-877-588-1123
TTY: 1-855-887-6668
Appeals:
1-855-694-2929
All other reviews:
1-844-450-6672

KePRO

AreaAddressToll-free numberFax number
2 (DC, DE, GL, GA, MD, NC, SC, VA, WV) KePRO
5201 W. Kennedy Boulevard
Suite 900
Tampa, FL 33609
1-844-455-8708 1-844-834-7129
3 (AL, AR, CO, KY, LA, MS, MT, ND, NM, OK, SD, TN, TX, UT, WY) KePRO
5201 W. Kennedy Boulevard
Suite 900
Tampa, FL 33609
V with pops 1-844-430-9504 1-844-834-7129
4 (IA, IL, IN, KS, MI, MN, MO, NE, OH, WI) KePRO
5201 W. Kennedy Boulevard
Suite 900
Tampa, FL 33609
1-855-408-8557 1-844-834-7130

More Information about the QIO restructuring is detailed in the CMS press release at: http://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2014-Press-releases-items/2014-05-09.html

Special Needs Plan Model of Care

Medicare Advantage Special Needs Plans (SNPs) are designed for specific groups of customers with special health care needs.

The three specific groups are:

  • Dual eligible SNP (D-SNP): beneficiaries (individuals who are eligible for both Medicaid and Medicare)
  • Chronic condition SNP (C-SNP): beneficiaries with chronic conditions
  • Institutional SNP (I-SNP): beneficiaries who are residents of a long-term care facility

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 Patient Protection and Affordable Care Act reinforced the importance of the SNP Model of Care as a fundamental component by requiring NCQA review and approval.

The Model of Care is an evidenced-based process by which we integrate benefits and coordinate care for customers 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 SNP customers with complex care needs, as well as the coordination of care to improve their overall health.

The Model of Care focuses on the individual SNP customer.  The Cigna-HealthSpring SNP process includes HRA, ICP and ICT coordination.  All of this is necessary, to provide appropriate care management.   

SNP customers receive a Health Risk Assessment (HRA) within 90 days of enrollment and then, annually, within one year of completion of the last HRA. Based on the results of their assessment, an individualized care plan is developed using evidence-based clinical protocols. All SNP customers must have an HRA conducted and an individualized care plan.  The Interdisciplinary care teams are responsible for the care management and support of the individual care plan goals and care planning process.     Based on the needs of plan customers, a specialized provider network is available to assure appropriate access to care, complementing each customer’s PCP.

Cigna-HealthSpring Primary Care Providers (PCPs) who treat SNP customers are core participants of their Interdisciplinary Care Team (ICT) and oversee clinical care plan development and maintenance.  However, ICT participants can include practitioners of various disciplines and specialties, based on the customer’s individual needs. The customer may participate in the ICT meetings, as may health care providers. 

Cigna-HealthSpring will invite you to participate in ICT meetings. We encourage you to participate in the ICT and collaborate with health plan staff to coordinate the care of your SNP customer. Cigna-HealthSpring uses risk stratification to identify our most vulnerable SNP customers, including those who are frail/disabled, customers with multiple chronic illnesses and those at the end of life.  SNP customers are risk stratified to identify the appropriate care management level. The risk stratification process includes input from the provider, customer, and data analysis.  The goal is to identify interventions, care coordination and care transitions needs, barriers to care, education, early detection, and symptom management.

Cigna-HealthSpring SNP programs support customers through care planning, transitions of care, connect customers to the appropriate providers, and through this increased communication,  promote care management and customer goal self-management. Additionally, care transitions, whether planned or unplanned, are monitored, and PCPs are informed accordingly. PCP communication to promote continuity of care and ICT involvement is a critical aspect of Cigna-HealthSpring’s care transitions protocols.

Implementation of the SNP Model of Care is supported through feedback from you, as well as systems and information sharing between the health plan, health care providers and the customer. The SNP Model of Care includes periodic analysis of effectiveness, and all activities are supported by the Stars & Quality department.

When a SNP customer completes a Health Risk Assessment (HRA), the HRA results/care plan is sent to the Primary Care Physician’s office for the patient’s medical file. A copy of the HRA can be obtained by calling: our Health Risk Assessment department at 1-800-331-6769.

The assigned PCP will receive a copy of the customer's care plan. To discuss and/or request a copy of the care plan, refer an SNP customer for an Interdisciplinary Care Team meeting or to participate in an Interdisciplinary Care Team meeting, please contact our Case Management department by calling the applicable number below:

State:   Contact:
Alabama, Georgia (All Counties excluding Catossa, Dade, and Walker),
Southern Mississippi, North Carolina, South Carolina and Northwest Florida
 1-866-382-0518
Illinois and Indiana  1-877-376-5193
Tennessee, Northern Georgia, and Eastern Arkansas  1-888-615-2709
Texas and Southwestern Arkansas  1-888-501-1116

When a SNP customer completes a Health Risk Assessment (HRA), a copy of the HRA results/care plan are sent to the Primary Care Physician’s office for the patient’s medical file. A copy of the HRA can be obtained by calling our Health Risk Assessment department at 1-800-331-6769.

The assigned PCP will receive a copy of the customer’s care plan. To discuss and/or request a copy of a customer’s care plan, refer a customer for an Interdisciplinary Care Team meeting or participate in an Interdisciplinary Care Team meeting, please contact our Case Management department by calling the applicable number below:

State:   Contact:
Maryland, Delaware, Washington DC, and Pennsylvania Providers should call: 1-877-562-4395

To discuss and/or request a copy of a customer’s comprehensive assessment results or care plan, refer a customer for an Interdisciplinary Care Team meeting or participate in an Interdisciplinary Care Team meeting, please contact our Care Coordination department at 1-866-487-3004.

Referral Process

The Primary Care Physician (PCP) is the customer's primary point of entry into the health care delivery system for all outpatient Specialist care. The PCP is required to obtain a referral for most outpatient specialist visits for Cigna-HealthSpring customers.

Requesting a Referral (excluding Delaware, Maryland, Pennsylvania, and Washington, DC)

Referrals can be requested through several methods, such as:

  • HSConnect
  • Fax
  • Phone

 

Requesting a Referral (for Delaware, Maryland, Pennsylvania, and Washington, DC)

Referrals can be requested through several methods, such as:

  • HSConnect
  • Phone

 

Your Network Operations representative can provide additional details regarding the preferred method of communication in your area. Likewise, the Specialist is required to ensure that a referral is in place prior to scheduling a visit (except urgent/emergent visits, which do not require referral). The Specialist is also required to communicate to the PCP via consultation reports any significant findings, recommendations for treatment and the need for any ongoing care.

Electronic submission/retrieval of referrals through HSConnect helps to ensure accurate and timely processing of referrals.

All referrals must be obtained prior to services being rendered. No retro-authorizations of referrals will be accepted. Please note that we value the PCP’s role in taking care of our Cigna-HealthSpring customers and that the PCP has a very important role in directing the customer to the appropriate Specialist based on your knowledge of the patient’s condition and health history. It is also absolutely essential that customers are directed to Participating Providers only. In order to ensure this, please refer to our online directory or contact Customer Service for assistance.

Remember: An authorization number does not guarantee payment – services must be a covered benefit. To verify benefits before providing services, call 1-800-230-6138.

  • PCPs should refer only to Cigna-HealthSpring participating specialists for outpatient visits
  • Non-participating Specialist’s visits require Prior Authorization by Cigna-HealthSpring
  • Referrals must be obtained PRIOR to Specialist services being rendered
  • PCPs should not issue retroactive referrals
  • Most referrals are valid for 120 days starting from the issue date
  • All requests for referrals must include the following information:
    • Customer name, date of birth, customer ID
    • PCP name
    • Specialist name
    • Date of referral
    • Number of visits requested

If a customer is in an active course of treatment with a Specialist at the time of enrollment, Cigna-HealthSpring will evaluate requests for continuity of care. A PCP referral is not required, but an authorization must be obtained from Cigna-HealthSpring’s Prior Authorization Department. For further details, please refer to the Continuity of Care section in Health Services. Please note: A Specialist may not refer the patient directly to another Specialist. If a patient needs care from another Specialist, he/she must obtain the referral from his/her PCP.

Self-Referrals (excluding Delaware, Maryland, Pennsylvania, and Washington, DC)
Customers have open access to certain Specialists, known as self-referred visits/ services; these include but are not limited to:

  • Emergency medicine (emergency care as defined in the provider contract)
  • Obstetric and Gynecological care (routine care, family planning).
  • Psychiatrist, Psychologist, Licensed Clinical Social Worker (Behavioral Health Participating Providers)

 

Please refer to Cigna-HealthSpring's website, https://providersearch.hsconnectonline.com/OnlineDirectory, to view the current provider directory for Participating Specialists. If a customer has a preference, the PCP should accommodate this request if possible. Customers may only self-refer to:

  • To a Participating Gynecologist for annual gynecological exam except for infertility and to see a non-participating OB/GYN. The PCP may perform the annual exam if agreed upon by the customer
  • Behavioral health referrals to Cigna-HealthSpring's Behavioral Health Care
  • Vision Exams – customers who have a Vision benefit may self-refer to a Participating Provider
  • Dental Coverage – customers who have a Dental benefit may self-refer to a Participating Dental provider

 

Georgia (All counties excluding Catoosa, Dade, and Walker), North Carolina, and South Carolina only: Customers may self-refer to a participating Dermatologist, Optometrist, or Ophthalmologist.

Self-Referrals (For Delaware, Maryland, Pennsylvania, and Washington, DC)
Customers have open access to certain specialists, known as self-referred visits/ services; these include but are not limited to:

  • Dentist - dental care (certain procedures require a prior authorization)
  • Nephrologist (referral not required for dialysis only)
  • Podiatrist (Pennsylvania plans only)
  • Emergency medicine (emergency care as defined in the provider contract)
  • Optometry routine eye care: annual eye exam (based on the customers benefit allowance for frames, lenses and contact lenses when using a Participating Provider)
  • Obstetric and Gynecological care (routine care, family planning)
  • Psychiatrist, Psychologist, Licensed Clinical Social Worker (mental health Participating Providers)
  • Nutritionist (diabetes and renal disease diagnosis only - 10 session annually by approved provider; additional visits require prior authorization)

 

Customers may be assessed a co-payment or coinsurance for some visits depending on coverage limits.

Referrals to Non-Participating Providers
Referrals to Non-Participating Providers may occasionally be made but only if prior authorization is obtained from the Prior Authorization Department (in special circumstances the Medical Director or his/her designee will approve out-of- network-care). A PCP must initiate requests for authorizations to Non-Participating Providers.

Obtaining and Verifying Referrals
Cigna-HealthSpring's online provider portal HSConnect at https://healthspring.hsconnectonline.com/HSConnect/ is available 24 hours a day, seven (7) days a week for referral requests. This flexibility allows data entry at any time and records the transaction for the referring specialist to verify that a referral is on file prior to the date of the visit. The PCP also has the ability to search for specialty requests for patients on his/her panel. The PCP has the responsibility of notifying the customer that the referral is approved and documenting the communication in the medical record.

For those PCPs who do not have web access, a request for a referral may be obtained by calling 1-888-454-0013. Our hours of operation are Monday through Friday 8:30 a.m. to 5:00 p.m. EST. PCPs that are having difficulty locating a Participating Provider for specialty care are encouraged to go to www.cignahealthspring.com to access our online Provider Directory. A referral is not a guarantee of payment. Payment is subject to eligibility on the date of service, plan benefits, limitations and exclusions under the benefit plan.

A PCP is responsible for ensuring a customer has a referral prior to the appointment with the specialist.

There are three ways a PCP can obtain referral to Specialists:

  1. Log in to HSConnect.
  2. Referral Form: Complete the referral form and fax it into our referral department.
  3. Call the Referral Department: If the referral is an emergency, or you simply would like to speak with a referral department representative, you may obtain a referral by phone by calling:

 

State:Contact:
Alabama 1-800-962-3016
Northwest Florida 1-800-962-3016
Southern Mississippi (Jackson) 1-866-949-7103
Georgia (All counties excluding Catoosa, Dade, and Walker) 1-866-949-7103
or fax to: 1-855-420-4717
North Carolina 1-866-949-7099
South Carolina 1-866-949-7101
Kansas City 1-888-454-0013
Tennessee, Northern Georgia, and Eastern Arkansas 1-800-453-4464
Illinois and Indiana 1-800-230-7298
Texas and Southern Arkansas Cigna-HealthSpring Precert:

Toll Free: 1-800-511-6932
Local: 1-832-553-3456
Toll Free Fax: 1-888-856-3969
Local Fax: 1-832-553-3426

Home Health/DME:
Toll Free: 1-800-511-6932
Local: 1-832-553-3313
Toll Free Fax: 1-888-205-8658
Delaware, Maryland, Pennsylvania, and Washington, DC 1-888-454-0013
Faxed requests not accepted

Specialists must have a referral from a PCP prior to seeing a customer if the customer’s plan requires a referral. Claims will be denied if a Specialist sees a customer without a referral when the health plan requires a referral. Cigna-HealthSpring is unable to make exceptions to this requirement. If a referral is not in place, Specialists must contact the customer’s PCP before the office visit. In order to verify that a referral has been made, the Specialist may log in to HSConnect or the Specialist may call Cigna-HealthSpring to verify.

Instructions for a Specialist to Obtain Referrals
The Specialist can obtain referrals directly for the customer to another Specialist with the following limits:

  1. The PCP referred the customer to the Specialist.
  2. The following five (5) conditions must be met:
    • Diagnosis must be related to the specialty and/or service to be obtained;
    • Diagnosis must be related to reason PCP referred to referring Specialist;
    • Must be a covered benefit of the customer’s Benefit Plan;
    • The customer must be currently under the care of the referring Specialist; and
    • Referral must be made to a Participating Provider.
  3. The Specialist provides follow-up documentation to the PCP for all referrals obtained for further specialty care.
  4. Referrals for the following specialty care are excluded from this process and must be referred back to the PCP to obtain referral: Non-Participating Providers, Chiropractor, Dermatology, Otolaryngology, Maxillofacial Surgeon, Podiatry, Optometry, Transplant Specialist, and Reconstructive (Plastic) Surgeon with the exception of breast reconstruction.
  5. The referral must be obtained prior to the services being rendered.

Note: If all elements within the limits above cannot be met, the Specialist must defer back to the PCP for further services.

The Specialist may obtain referrals via HSConnect or fax. Specialist should use the fax method if the referral is not needed within forty-eight (48) hours. If the referral is needed in less than forty- eight (48) hours, the Specialist must use either the telephone referral process or HSConnect. Requests are not accepted via fax for membership in the Delaware, Maryland, Pennsylvania, and Washington, DC service areas.

Pharmacy Prescription Benefit

Detailed information regarding Part D drugs, their utilization management requirements (prior authorization, step therapy, quantity limits, any plan year negative changes, etc.) and most recent plan formularies is available here.


Cigna-HealthSpring utilizes the United States Pharmacopeia (USP) classification system to develop Part D drug formularies that include drug categories and classes covering a variety of 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 The Centers for Medicare and Medicaid Services (CMS). The national Cigna Pharmacy and Therapeutics (P&T) Committee reviews all formularies for clinical appropriateness, 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
  • Approved by the FDA
  • Used and sold in the US
  • Used for a medically accepted indication
    • Includes both the uses approved by the FDA and off-label uses supported medical compendia as approved by the Social Security Act (SSA)
    • Except for anticancer chemotherapy, the current compendia allowed per CMS include Micromedex and American Hospital Formulary Service Drug Information (AHFS-DI). On their own, uses described by clinical guidelines or peer-reviewed literature are insufficient to establish a medically accepted indication
    • For anticancer chemotherapy, additional sources are available beyond FDA package label, Micromedex, and AHFS-DI. These include National Comprehensive Cancer Network (NCCN), Clinical Pharmacology, and Lexicomp, as well as some use of peer-reviewed literature
  • 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 not otherwise covered under Medicare Part B)

Drugs excluded under Part D include the following:

  • Drugs for 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 are excluded from coverage or otherwise restricted under 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
  • Outpatient 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 other FDA-approved indications such as pulmonary hypertension)

Cigna-HealthSpring formularies include utilization management requirements that include Prior Authorization, Step Therapy and Quantity Limits. The Part D utilization management is available here.

Prior Authorization (PA)
For a select group of drugs, Cigna-HealthSpring requires the customer or their physician to get approval for certain prescription drugs before the customer is able to have the prescription covered at their pharmacy. A PA requirement is placed on certain drugs to gather necessary information to determine if the drug should be covered under the customer’s Medicare Part B or Part D benefit. Another common reason for a drug’s PA requirement is to ensure that a drug is being used for a medically accepted or Part D allowed indication as defined above. Finally, some drugs may have more detailed PA criteria that also require submission of medical information, such as lab results, and current and/or past medication history.

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 customers aged 65 and older to confirm that the benefits outweigh the risks, and that safer alternatives cannot be used.

Step Therapy (ST)
For a select group of drugs, Cigna HealthSpring requires the customer to first try and fail certain drugs/drug classes 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.

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 a customer believes he or she is entitled. Coverage determinations may be received orally or in writing from the customer’s prescribing physicians.
For the provider call center, please call: 1-877-813-5595 7 a.m. CST to 8 p.m. CST Monday through Friday or fax:  1-866-845-7267

The address is:
Coverage Determination and Exceptions
PO Box 20002
Nashville, TN 37202
.

Any call received after 8 p.m. 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, drug-specific CD forms are are available here or by requesting a faxed copy when calling 1-877-813-5595.

For standard requests, the provider will receive the outcome of a coverage determination by fax no later than seventy-two (72) hours after the initial request receipt or receipt of the supporting statement, and  for urgent requests, the provider will receive the outcome notification no later than twenty-four (24) hours after the initial request receipt or receipt of the supporting statement.

The following information will be provided:

  1. The specific reason for the denial taking into account the customer’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 customer’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, or redetermination, must be filed within 60 calendar days from the date printed/written on  the coverage determination denial note. For a standard Part D appeal, Cigna-HealthSpring will provide a decision and written notice no later than seven (7) calendar days from the date the request received. For an expedited/urgent Part D appeal, Cigna-HealthSpring will provide a decision no later than seventy-two (72) hours after receiving the appeal. Requestors may request an expedited appeal in situations where applying the standard time frame could seriously jeopardize the customer’s life, health or ability to regain maximum function. If the request is regarding payment for a prescription drug the customer already received, an expedited appeal is not permitted.

Part D appeals may be received orally or in writing from a customer, customer’s representative, customer’s prescribing physician or other physician.

Part D Appeals Contact Information:

Phone: 1-866-845-6962

Fax: 1-866-593-4482.

Mailing Address:
Part D Appeals
PO Box 24207
Nashville, TN 37202−9910

Pharmacy Network

Cigna-HealthSpring provides access to more than 64,000 network pharmacies throughout the country. This extensive network gives our customers – your patients – convenient access to many pharmacies in their area to choose for their unique pharmacy needs. Options range from large chain pharmacies to locally owned, independent retail pharmacies. Long-term care, home infusion, mail order, home delivery pharmacy options are available, as well.

Preferred Pharmacy Network
Furthermore, we deepened our partnership with a large number of the pharmacies in our existing network to form a preferred pharmacy network to offer lower copays on most prescriptions. Our preferred network of pharmacies includes over 32,000 retail pharmacies across the United States. Large national and regional chains in the preferred pharmacy network include Walmart, Walgreens, and many of the most commonly used grocery store pharmacies. There are also numerous local and independent pharmacies options in the preferred pharmacy network. A more detailed list of preferred pharmacies is available here along with the full listing of the provider directories (by region), which include network pharmacy providers. Preferred pharmacies are identified using a grey shaded box in the provider directories. Customers can choose to use a pharmacy in either the standard or preferred network according to their needs, but only preferred pharmacies can offer savings on prescription costs. This can often result in significant total savings over the course of a year, especially for customers that take multiple prescription medications.

Pharmacy Quality Programs

The Narcotic Case Management Program is designed to identify patterns of inappropriate opioid utilization with the goal to enhance patient safety through improved medication use. Monthly reports are generated using an algorithm that identifies customers at risk of potential opioid overutilization based on the number of prescribers, pharmacies, and calculated morphine equivalent dose (MED) per day. Any individual with cancer or on hospice care is excluded from the program. The Cigna-HealthSpring clinical staff review claims data of all identified customers who meet the established criteria and determine whether further investigation with prescribers is warranted. If intervention is deemed appropriate, clinical staff will send written notification by fax to the prescribers involved in the customer’s care requesting information pertaining to the medical necessity and safety of the current opioid regimen. Cigna-HealthSpring will reach out to discuss the case with the customer’s opioid prescriber(s) in an attempt to reach a consensus regarding the customer’s opioid regimen. If clinical staff is able to engage with prescribers, then action will be taken based on an agreed upon plan. In the most severe cases, clinical staff may collaborate with the prescriber(s) to implement point-of-sale edits—limiting the customer to a specific opioid drug regimen—to assist with control of inappropriate utilization or overutilization of opioid medications. If Cigna-HealthSpring does not receive engagement from the prescribers, despite multiple outreach attempts, then point-of-sale edits may be invoked based on the decision of an internal, multi-disciplinary team.

The Medication Therapy Management program is designed to help improve medication therapy outcomes by identifying gaps in care, addressing medication adherence, and recognizing potential cost savings opportunities. The program is designed for customers that satisfy all three of the following criteria:

  • Have at least three of the following conditions: CHF, Diabetes, Dyslipidemia, Hypertension, and Osteoporosis
  • Take at least seven Part D prescription drugs from select classes; and
  • Are likely to incur annual costs for covered drugs great than or equal to $3,967

Eligible customers are automatically enrolled into the program and sent a welcome letter encouraging each customer to call to complete their Comprehensive Medication Review (CMR) before their annual wellness visit with their primary care provider, so the customer can take their medication list to the appointment. After the completion of the CMR, any potential drug therapy problems (DTPs) that were identified are sent to the prescribing provider and/or primary care provider by mail or fax. Along with DTPs, the provider also receives an updated list of the customer’s medication history through the previous 4 months. Also, an individualized letter, which includes a personal medication record of all medications discussed and a medication action plan, is mailed to the customer. If the customer has any questions or comments about the medication action plan, a fax and phone number are provided for follow up.

In addition to the CMR, customers also receive targeted medication reviews (TMRs) quarterly. The TMRs are automatically generated and completed electronically to review for specific DTPs. If any DTPs are identified, a letter may be mailed or faxed to the prescribing provider and/or primary care provider.

Cigna-HealthSpring completes a monthly review of prescription drug claims data to assess dispensing and use of medications for our customers. Drug Utilization Review (DUR) is a structured and systematic attempt to identify potential issues with drug therapy coordination among prescribers, unintentional adverse drug events (including drug interactions), and non-adherence with drug regimens among targeted classes of drugs. Retrospective Drug Utilization Review (rDUR) evaluates past prescription drug claims data, and concurrent Drug Utilization Review (cDUR) ensures that a review of the prescribed drug therapy is performed before each prescription is dispensed. cDUR is typically performed at the point-of-sale, or point of distribution, by both the dispensing pharmacist and/or through automated checks that are integrated in the pharmacy claims processing system. Cigna-HealthSpring tracks and trends all drug utilization data on a regular basis to enable our clinical staff to determine when some type of intervention may be warranted, whether it is customer-specific or at a population level. Targeted providers and/or customers identified based on DUR activity will receive information regarding the quality initiative by mail. rDUR studies that may be communicated to customers and/or providers include:

  • Overutilization 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
  • Use of multiple antidepressants, antipsychotics, or insomnia agents concurrently
  • Multiple prescribers of the same class of psychotropic drug

Letters to customers will focus on topics such as the importance of appropriate medication adherence or safety issues. Letters to providers will include the rationale for any of the particular concerns listed above that are the subject of the initiative. Provider letters will also include all drug claims data for the selected calendar period applicable to the initiative. If you (as a provider) receive a letter indicating that you prescribed a medication that you did not, in fact, prescribe or that you prescribed a medication for a customer that was not your patient at the time of the drug fill date, please notify Cigna-HealthSpring using the contact information on the letter.

A multidisciplinary team determines the direction of pharmacy quality initiatives for the DUR program. The pharmacy quality initiative concepts originate from a variety of sources, including but not limited to, claims data analysis and trends, the Centers for Medicare and Medicaid Services (CMS) guidance, Pharmacy Quality Alliance (PQA) measures and initiatives, Food and Drug Administration (FDA) notifications, clinical trials or clinical practice guidelines, and other relevant healthcare quality publications.

Prescription Drug Monitoring Programs

Nearly all states currently require pharmacies and other dispensers to submit records on a daily to monthly basis of certain prescription drugs dispensed.  These data are compiled into state-run databases, termed prescription drug monitoring programs (PDMPs), and made available in a searchable format to prescribers and pharmacists for use in monitoring drug utilization and abuse.

In their landmark 2016 Guideline for Prescribing Opioids for Chronic Pain, the CDC features PDMPs prominently in their final recommendations:

Clinicians should review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving opioid dosages or dangerous combinations that put him or her at high risk for overdose. Clinicians should review PDMP data when starting opioid therapy for chronic pain and periodically during opioid therapy for chronic pain, ranging from every prescription to every 3 months.


As part of our ongoing partnership with providers to decrease the unnecessary use and diversion of controlled substances, Cigna-HealthSpring encourages prescribers and pharmacists to fully utilize their state’s PDMP.  You may find your state’s PDMP at: http://www.pdmpassist.org/content/state-pdmp-websites.

 

Low Income Subsidy Program Information

The Federal Medicare “Extra Help” program, also known as the Low Income Subsidy (LIS) program, provides extra help to assist with Medicare prescription drug costs for individuals who have limited income and resources.  Although most beneficiaries who are eligible for Low Income Subsidy benefits will automatically qualify for this program, there are many others who may qualify by applying for this valuable benefit. As a result, many individuals may not even know they are eligible. The Extra Help program has many benefits for qualified individuals including:

  • Low or no monthly Part D premiums
  • Low or no initial Part D deductible
  • Coverage in the Donut Hole or Coverage Gap
  • Greatly reduced costs for prescription drugs that are covered by the Medicare Part D planand/or
  • 90-day supply of Medicare Part D covered drugs for the same cost as a 30-day supply (applies to most but not all beneficiaries who quality for Extra Help)

To be eligible for the Extra Help program individuals must reside in one of the 50 states or the District of Columbia and meet certain income and resource limits.  Resources include items like savings, stocks and money in checking/savings accounts, but will not include an individual’s home or car.  Income limits, set by the federal government, are used to determine eligibility for the Extra Help program and are based on the Federal Poverty Level (FPL) published by Department for Health & Human Services (DHHS).

Individuals with limited income and resources may qualify for Extra Help to reduce their out-of pocket costs.  Applying for Extra Help is easy.  Cigna HealthSpring customers can choose from the following options:

  • Phone call to the Social Security Administration (SSA) at 1-800-772-1213 (TTY 1-800-325-0778) to apply over the phone or to request a paper application
  • Apply online at www.SocialSecurity.gov/extrahelp
  • Phone call to Premium Assist provided by Human Arc 1-877-236-4471
    • Available for all Cigna HealthSpring customers  who have been active for at least  60 days 
    • Assists with screening for LIS eligibility and application submission
    • No charge for customers 

If an individual does not qualify for the Extra Help Program, state programs may be available to help pay for prescription drug cost. Cigna HealthSpring encourages all customers to inquire about these cost savings Federal and State Programs.

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 customers have 20% higher adherence rates when compared to those who use retail pharmacies alone.1 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. Lastly, our customers 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).

1 Cigna Analysis, 2011

Quality Care Management Program



The Centers for Medicare and Medicaid Services (CMS) requires Medicare Advantage organizations to have an ongoing Quality Improvement (QI) program to ensure health plans have the necessary infrastructure to coordinate care, promote quality, performance, and efficiency on an ongoing basis. The requirements for the QI program are based in regulation at 42 CFR§ 422.152.

Cigna-HealthSpring’s QI program is dedicated to improving the health of the community we serve by delivering the highest quality and greatest value in health care benefits and services.

  • Integrity – We always conduct ourselves in a professional and ethical manner
  • Respect – We all have value and will treat others with dignity and respect
  • Team – We recognize that employees are our main asset and encourage their continued development
  • Communications – We encourage the free exchange of thoughts and ideas
  • Balance – We manage both our personal and company priorities
  • Excellence – We continuously strive to exceed our customers’ expectations
  • Prudence – We always use the company’s financial resources wisely

Cigna-HealthSpring shall apply the guiding values described above to its oversight and operation of its system and:

  • Provide services that are clinically driven, cost effective and outcome oriented
  • Provide services that are culturally informed, sensitive and responsive
  • Provide services that enable customers to live in the least restrictive, most integrated community setting appropriate to meet their health care needs
  • Ensure that guidelines and criteria are based on professional standards and evidence- based practices that are adapted to account for regional, rural and urban differences
  • Foster an environment of quality of care and service within Cigna-HealthSpring, the Senior Segment of Cigna and through our provider partners
  • Promote customer safety as an over-riding consideration in decision-making

The Quality Improvement program provides guidance for the management and coordination of all quality improvement and quality management activities throughout the Cigna-HealthSpring organization, its affiliates, and delegated entities.

The program describes the processes and resources to continuously monitor, evaluate and improve the clinical care and services provided to enrollees for both their physical and behavioral health. The program also defines the health plan’s methodology for identifying improvement opportunities and for developing and implementing initiatives to impact opportunities identified.

The scope of the program includes:

  • All aspects of physical and behavioral care including accessibility, availability, level of care, continuity, appropriateness, timeliness and clinical effectiveness of care and services provided through Cigna-HealthSpring and contracted providers and organization
  • All aspects of provider performance relating to access to care, quality of care including provider credentialing, confidentiality, medical record keeping and fiscal and billing activities
  • All covered services 
  • •All professional and institutional care in all settings including hospitals, skilled nursing facilities, outpatient and home health
  • All providers and any delegated or subcontracted providers
  • Management of behavioral health care and substance abuse care and services
  • Aspects of Cigna-HealthSpring internal administrative processes which are related to service and quality of care including credentialing, quality improvement, pharmacy, health education, health risk assessments, Clinical Practice Guidelines, Utilization Management, customer safety, case management, disease management, special needs, complaints, grievances and Appeals, customer service, provider network, provider education, medical records, customer outreach, claims payment and information systems.

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
    • Collaboratively works towards achievement of established goals
    • Monitors progress of improvement efforts to established goals; and 
    • Provides the necessary oversight and leadership reporting
  • Ensure patient care and service is provided according to established goals and metrics
  • Ensure identification and analysis of opportunities for improvement with implementation of actions and follow-up as needed
  • Promote consistency in quality program activities
  • Ensure 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
  • Ensure timely access to and availability of safe and appropriate physical and behavioral health services for the population served by Cigna-HealthSpring
  • Ensure services are provided by qualified individuals and organizations including those with the qualifications and experience appropriate to service customers with special needs
  • Promote the use of evidence-based practices and care guidelines
  • Improve the ability of all Cigna-HealthSpring staff to apply quality methodology through a program of education, training, and mentoring
  • Establish a rigorous delegation oversight process
  • Ensure adequate infrastructure and resources to support the Quality Improvement program.
  • Ensure provider involvement in maintaining and improving the health of Cigna-HealthSpring customers, through a comprehensive provider partnership

Corporate Quality Improvement Committee (CQIC)



The CQIC has oversight authority for Quality Improvement activities across the organization and is responsible for ensuring the development and implementation of Cigna-HealthSpring's QI program Description, the Annual QI/UM/CM Work Plans, review and approval of Health Service Policies; monitoring credentialing, delegation oversight, customer Appeal activity, and reviewing clinical and service quality initiatives.

To monitor and facilitate implementation of the QI program, the CQIC has established appropriate sub- committees that provide oversight of the functions and activities within the scope of the organization’s Quality Improvement program. The CQIC may also appoint and convene ad hoc work groups as indicated.

 

 

Corporate Compliance Program



The purpose of Cigna-HealthSpring’s corporate compliance program is to articulate Cigna-HealthSpring’s commitment to compliance. It also serves to encourage our employees, contractors, and other interested parties to develop a better understanding of the laws and regulations that govern Cigna-HealthSpring’s operations. Furthermore, Cigna-HealthSpring’s corporate compliance program also ensures that all practices and programs are conducted in compliance with those applicable laws and regulations.

Cigna-HealthSpring and its subsidiaries are committed to full compliance with federal and state regulatory requirements applicable to our Medicare Advantage and Medicare Part D lines of business. Non- compliance with regulatory standards undermines Cigna-HealthSpring’s business reputation and credibility with the federal and state governments, subcontractors, pharmacies, providers, and most importantly, its customers. Cigna-HealthSpring and its employees are also committed to meeting all contractual obligations set forth in Cigna-HealthSpring’s contracts with the Centers for Medicare and Medicaid Services (CMS). These contracts allow Cigna-HealthSpring to offer Medicare Advantage and Medicare Part D products and services to Medicare beneficiaries.

The corporate compliance program is designed to prevent violations of federal and state laws governing Cigna-HealthSpring’s lines of business, including but not limited to, health care fraud and abuse laws. In the event such violations occur, the Corporate Compliance program will promote early and accurate detection, prompt resolution, and, when necessary, disclosure to the appropriate governmental authorities.

Cigna-HealthSpring has in place policies and procedures for coordinating and cooperating with MEDIC (Medicare Drug Integrity Contractor), CMS, state regulatory agencies, Congressional Offices, and law enforcement. Cigna-HealthSpring also has policies that delineate that Cigna-HealthSpring will cooperate with any audits conducted by CMS, MEDIC or law enforcement or their designees.

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

Cigna-HealthSpring
Attn: Compliance Department
PO Box 20002
Nashville, TN 37202

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

By mail:
Cigna-HealthSpring
Attn: Benefit Integrity Unit
500 Great Circle Road
Nashville, TN 37228

By phone:
1-800-230-6138
Monday through Friday, 8 a.m. to 6 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 customers, 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 strives 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.

Steps to Meet Your FWA Obligations
Review and revise your coding policies and procedures for compliance and adherence to CMS guidelines necessary to ensure they are consistent with official coding standards.

Complete the mandatory online training at:

 

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

Medicare Advantage Program Requirements



The terms and conditions herein are included to meet federal statutory and regulatory requirements of the federal Medicare Advantage program under Part C of Title XVIII of the Social Security Act (“Medicare Advantage 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 Medicare Advantage program. Such amendment shall not require the consent of provider or Cigna-HealthSpring and will be effective immediately on the effective date thereof.

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.

Provider shall safeguard the privacy and confidentiality of customers and shall ensure the accuracy of the health records of customers. 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 customers, including, but not limited, to the Standards for Privacy of Individually Identifiable Information promulgated pursuant to the Health Insurance Portability and Accountability Act.

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 customer 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, copayments or deductibles specified in the benefit plans. Provider agrees that this provision shall be construed for the benefit of the customer and shall survive expiration, non-renewal or termination of the Agreement regardless of the cause for termination.

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 the 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 (i) directly reviewed by Cigna-HealthSpring, or (ii) 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 Medicare Advantage 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.

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 customers. 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.

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”). Additionally, provider agrees to comply with the Cigna-HealthSpring Provider Manual and all policies and procedures relating to the benefit plans.

Cigna-HealthSpring maintains ultimate accountability for adhering to and otherwise fully complying with all terms and conditions of its contract with CMS. 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 customer 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 customers or benefit plans upon request of Cigna-HealthSpring.

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 (31 U.S.C. 3729 et. seq.) and the anti-kickback statute (section 1128B(b) of the Social Security Act).

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 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 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.

Provider shall continue to provide services under the Agreement to customers in the event of (i) Cigna-HealthSpring’s insolvency, (ii) Cigna-HealthSpring’s discontinuation of operations or (iii) termination of the CMS Contract, throughout the period for which CMS payments have been made to Cigna-HealthSpring, and, to the extent applicable, for customers who are hospitalized, until such time as the customer is appropriately discharged.

In the event of a conflict between any specific provision of your agreement and any specific provision of the manual, the specific provisions of your agreement shall control.

Dispute Resolution



Refer to your agreement.

State Specific Information