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, Interqual Criteria, Milliman Guidelines, 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
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
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.
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.
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 providing the service.
- 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.
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
Skilled Nursing Facility (SNF) Reviews should be faxed to:
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:
Concurrent and SNF/Rehab Request/Reviews:
Concurrent and SNF/Rehab Request/Reviews:
Illinois and Indiana
Concurrent and SNF fax line: 1-855-784-7599
Southwestern Arkansas and Texas
Skilled Nursing Facility (SNF) Reviews should be faxed to:
Delaware, Maryland, Pennsylvania, and Washington, DC
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 (ADD /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 (ADD , 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 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 (Interqual) 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.
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.