Nursing Facility Authorizations and Claims

Nursing Facility Claims

Nursing Facility Providers must submit Unit Rate claims to Cigna-HealthSpring within three hundred sixty-five (365) days from the date the covered service was rendered.

  • Cigna-HealthSpring is required to process Nursing Facility Unit Rate clean claims within 10 days of submission.
  • Add-on Services claims must be sent to Cigna-HealthSpring within ninety-five (95) days from the date the covered service was rendered.

There are three ways to file a claim with Cigna-HealthSpring:

  1. File claims electronically through a clearinghouse.
  2. Via TMHP State’s website – Visit the website http://www.tmhp.com/ and click on “Providers" in the top header. Then Click “Go to TexMedConnect" in the upper right corner. TMHP claims are forwarded to Cigna-HealthSpring.
  3. File individual or batch claims through Cigna-HealthSpring's Provider Portal

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Nursing Facility Authorizations

How to Request Prior Authorization for Unit Rate Services
Unit Rate Services can be authorized by filling out a Form 3618 and/or Form 3619 and sent to TMHP. Nursing Facility Unit Rate means the types of services included in the DADS daily rate for nursing facility providers, such as room and board, medical supplies and equipment, personal needs items, social services, and over- the-counter drugs. The Nursing Facility Unit Rate also includes applicable nursing facility staffing rate enhancements and professional and general liability insurance. Nursing Facility Unit Rates exclude Nursing Facility Add-on Services. For additional information regarding Unit Rate services, contact Cigna-HealthSpring Provider Services department at 1-877-653-0331. For modifier requirements please reference: https://www.dads.state.tx.us/providers/hipaa/. For additional authorization requirements reference the Nursing Facility Provider Manual.

How to Request Prior Authorization for Add-on Services
Nursing Facility Add-on Services means the types of services that are provided in the Facility setting by the Provider or another network provider, but are not included in the Nursing Facility Unit Rate, including but not limited to emergency dental services; physician-ordered rehabilitative services; customized power wheel chairs; and augmentative communication devices. For additional information regarding add-on services, contact Cigna-HealthSpring Provider Services department at 1-877-653-0331.

There are three ways to request a prior authorization for Add-on Services.

  1. Fax a Outpatient Authorization Form or a Texas Standard Prior Authorization Request Form for Health Care Services to the Service Coordination department at Cigna-HealthSpring at 1-877-809-0789.
  2. Request a Prior Authorization online through Cigna-HealthSpring's Provider Portal.
  3. Request a Prior Authorization online through Cigna-HealthSpring's Speak with a Cigna- HealthSpring representative in the Prior Authorization Department by calling 1-877-725-2688.

To determine the status of an authorization request, call the Service Coordination Department at 1-877-725-2688.

Additional Resources