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 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.
- 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 activitiesare 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.
- 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.
- 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
- 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.
- 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|
|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|
|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.
- 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|
|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|
|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*|
- 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.
- 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 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.