While Cigna-HealthSpring prefers electronic submission of claims, both electronic and paper claims are accepted. If 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:
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)
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 services 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
As a contracted Cigna-HealthSpring provider, you will be informed of any overpayments or other payments you may owe us within 365 days of the date on the Explanation of Benefits or within the timeframe as noted in your Agreement. You will have sixty (60) 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 sixty (60) 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.
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.
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.
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:
- 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.
- 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-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.
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.
- Appeals with dates of service or discharge dates before the new compliance date should be submitted
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.
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.
This carrier is responsible for costs of services provided up to the benefit limit for the coverage or as if no other coverage exists.
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).
Any expense customary or necessary, for health care services provided as well as covered by the customer’s health care plan.
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
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.
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 an outside 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 should 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:
Attn: Appeals Unit PO Box 24087
Nashville, TN 37202-4087
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 may request reconsideration by submitting the completed request form to:
PO Box 20002
Nashville, TN 37202