CASE MANAGEMENT SERVICES

The Cigna-HealthSpring case management program is an administrative and clinically proactive process that focuses on coordination of services for customers with multiple comorbidities, complex care needs and/ or short term requirements for care. The program is designed to work as a partnership between customers, providers, and other health services staff. The goal is to provide the best clinical outcomes for customers. The central concept is early identification, education, and measurement of compliance with standards of care. The case management staff strives to enhance the customer's quality of life, facilitates provision of services in the appropriate setting, and promotes quality cost effective outcomes. Staff customers with specific clinical expertise provide support services and coordination of care in conjunction with the treating provider.

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 customer 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 providerwithin 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.