Preventive screenings

Cigna-HealthSpring Quality Improvement program focuses on many preventive screenings. In this report, we will focus on three:

  • Breast cancer screening
  • Colorectal cancer screening
  • Diabetic retinal eye exam (for customers with diabetes)

Breast cancer screening
In 2014, Cigna-HealthSpring aimed to have 83% of women complete a breast mammogram. Most of our market areas scored on or above this goal.

Colorectal cancer screening
Colorectal cancer screenings are very important because it is usually difficult to know if you have symptoms for colorectal cancer. It was our goal for 77% of our customers to have a colorectal cancer screening in 2014. Most of our market areas scored above or very near this goal.

Diabetic retinal eye exam
Customers with diabetes should have a retinal eye exam every year. If you had a diabetic eye exam this year and you do not have any problems with retinal eye changes, you can wait two years to have your next exam. Our goal was for 82% of our customers with diabetes to complete this eye exam. Most of our market areas improved their scores.

Managing your own health

Cigna-HealthSpring recognizes the importance of customers understanding and managing their own health care. Our Quality Improvement program attempts to help track this in many different methods. In this report, we will focus on high blood pressure.

High blood pressure screening
Blood pressure control scores showed improvement in 2014. The percentage of customers with high blood pressure who have controlled their blood pressure ranged from 49% to 94%, with some areas missing our goal of 78%. This is measured by evaluating the health of each customer with high blood pressure, including but not limited to healthy diet, exercising, and taking prescribed blood pressure medications from their doctor.

2016 Assessment of Customer Experience
In 2016, customer survey responses showed a decline in satisfaction in some areas.  However, nine plans scored at or above National and State scores with Getting Needed Prescription Drugs.  Questions asked in this area addressed ease of getting your medications filled as your doctor prescribed and using your prescription drug plan at a pharmacy.  It is important to us to ensure that you feel confident in Cigna-HealthSpring and the care we provide.  We are continually striving to improve customer satisfaction in many areas, including:

  • Ease getting an appointment with a specialist
  • Getting needed care right away
  • Being treated with courtesy and respect by health plan’s customer service
  • Getting timely notification of your results from x-rays or blood tests

If you have any questions, or to find results specific to your region, please call Customer Service.

Organization determination

Cigna-HealthSpring must provide in a timely manner a written organization determination to enrollees who request this information. A written organization determination is a determination by the plan prior to a provider furnishing a service confirming whether that service is both medically necessary and a plan-covered service and in consequence will be paid for by the MA plan.

Asking for a coverage decision
Start by calling, writing, or faxing our plan to make your request for the type of coverage decision you want. You, your doctor, or a representative can do this. If your health requires a quick response, you should ask our plan to make a Fast Decision. To get a Fast Decision, you must meet two requirements:

  1. You are asking for coverage for medical care or a drug you have not yet received; and
  2. Using the standard deadlines could cause serious harm to your health or hurt your ability to function. If your doctor tells us that your health requires a Fast Decision, we will automatically agree to give you a Fast Decision. If you ask for a Fast Decision on your own, our plan will decide whether your health requires that we give you a Fast Decision. Unless you ask for a Fast Decision, we will use the Standard Decision deadlines for giving you our decision. The following table shows when you can expect our plan to give you a decision:

Decisions about Medical Care
Standard decision 14 Days
Fast decision 72 hours*
Decisions about Part D Prescription Drugs
Standard decision 72 hours
Fast decision 24 hours*

*We will give you an answer sooner if your health requires us to do so.

If you disagree with a coverage decision we have made, you can appeal our decision. For more information about organization determinations, coverage determinations,
and appeals, see your Evidence of Coverage.

Affirmative statement on incentives

Cigna-HealthSpring Utilization Management associates base utilization decisions on the clinical needs of the members, benefit availability, and appropriateness of care. Objective, scientifically-based clinical criteria and treatment guidelines such as InterQual criteria and Medicare National Coverage Guidelines, in the context of provider or member-supplied clinical information, guide the decision-making process. Cigna-HealthSpring in no way rewards or incentivizes, either financially or otherwise, practitioners, utilization reviewers, case managers, physician advisers, or other individuals involved in conducting utilization review, for issuing denials of coverage or service, or inappropriately restricting care.

Cigna-HealthSpring's evaluation of new technologies

Cigna-HealthSpring takes pride in giving our customers medical and pharmacy benefits. The Pharmacy & Therapeutics Committee and Clinical Guidelines Committee carefully review new medications, medical and behavioral procedures, and devices as potential benefit additions for our customers. The Cigna-HealthSpring Pharmacy & Therapeutics Committee is made up of practicing physicians, pharmacists, and Cigna-HealthSpring Medical Directors. Together, these professionals review new medications while evaluating available clinical guidelines, evidence-based medicine, and pharmacoeconomic studies. The Clinical Guidelines Committee is made up of Cigna-HealthSpring Medical Directors, Pharmacists and Behavioral Health Specialists. The Clinical Guidelines Committee evaluates medical and behavioral technologies by reviewing pertinent data including evidence based guidelines, safety data, appropriate CMS and other regulatory information, and expert specialist input. Based on these reviews, the Committees then vote on which medications, medical and behavioral procedures and devices to offer that are deemed efficacious and efficient and will benefit Cigna-HealthSpring customers.

A message for Tennesseans from TennCare

TennCare is not responsible for payment for these benefits, except for appropriate cost sharing amounts. TennCare is not responsible for guaranteeing the availability or quality of these benefits.