cigna overview important information that will help guide our relationship november 16, 2012 aaham...

Cigna OverviewImportant information that will help guide our relationship

November 16, 2012AAHAM

Dara SayarathExperience Manager

2Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2012 Cigna

TOPICS

I. Cigna benefit plans• Cigna benefit plans• Strategic alliances• Shared Administrationsm

• Cigna limited benefit medical plans• Cigna global health benefits

II. Electronic Solutions• Cigna eServices - cignaforhcp.com & gwhcignaforhcp.com• Electronic data interchange (EDI)• Clear claim connection (CCC)• Cost of care estimator (COCE)• ERA, EFT & DDAR

III. Claim submission & Administrative Guidelines• Claim submission • Appeals process• Precertification• National vendors• Demographic changes

Cigna Benefit Plans


CIGNA BENEFIT PLANS

Cigna offers several medical benefit plan designs. Each is listed below along with its requirements.

• Preferred Provider Organization (PPO)– No referrals required– Some plans offer in-network coverage only

• Open Access– Primary care physician (PCP) selection encouraged– No referrals required– Some plans offer out-of-network coverage

• Managed Care– PCP selection required– Referrals required– Some plans offer out-of-network coverage

Coverage and Requirements


CIGNA BENEFIT PLANS

• A health care fund can be packaged with an underlying PPO or Open Access Plus medical plan.

• Two funding options are available:– Health Reimbursement Account (HRA) – Health Savings Account (HSA)

• Preventive care is generally paid at 100%.

• No copayments apply.

• If funds are available, you may receive coinsurance and deductible payments from a patient’s HRA or HSA account through the automatic claim forwarding function.

Cigna Choice Fund® Plans


STRATEGIC ALLIANCES

• Cigna’s strategic alliances include:– Tufts Health Plan (CareLinkSM) in Massachusetts and Rhode Island– Health Alliance Plan (HAP) in Michigan– HealthPartners in Minnesota, Western Wisconsin and North Dakota– MVP/Preferred Care in upstate New York

• Covered individuals in these areas access the alliance’s network of health care professionals. Note: In Massachusetts and Rhode Island, some individuals may access Cigna’s network while others access the Tufts CareLinkSM network of health care professionals.

• Outside these areas, individuals can use Cigna’s network of health care professionals, and Cigna contracted rates apply.

• A covered individual’s ID card will display the Cigna name for easy identification.

• Check the covered patient’s ID card for the correct contact information.

Network Coverage for Multi-Site Clients

SHARED ADMINISTRATION

• Cigna contracts with Taft-Hartley trusts and federal employee health benefit plans to share administration of these self-funded plans.

• Participating individuals have access to Cigna’s network, and Cigna contracted rates apply.

• Cigna performs medical management; precertification and medical necessity review.

• A third party administrator (TPA) maintains eligibility, administers benefits and pays claims for these accounts on their systems.

• Check the covered individual’s ID card for correct contact information.

Taft-Hartley and Federal Employee Benefit Plans


CIGNA LIMITED BENEFIT PLANS

• Starbridge® and Fundamental Care provide medical coverage for basic health care services to part-time, hourly or other employees who do not have access to traditional coverage.

• Cigna customers carry an ID card with a separate Cigna telephone number.

• Fundamental Care provides a higher level of coverage than Starbridge® and the limited benefit plans provide an annual allowance.

• Check the covered patient’s ID card for correct contact information.

Starbridge® and Fundamental Care


CIGNA GLOBAL HEALTH BENEFITS

• Cigna Global Health Benefits provide coverage for: – Expatriate employees and dependents living outside the U.S. when they return

to the U.S. for care– Foreign nationals and dependents working in the U.S.– American employees living outside the country, working for defense contractors

with dependents living in the U.S.

• Authorizations are required for inpatient admissions.

• Check the covered patient’s ID card for correct contact information.

Electronic Solutions


CIGNA eSERVICES

Enter your User ID and Password to log in to the Cigna for Health Care Professionals website (CignaforHCP.com)

http://www.cignaforhcp.com/


Here are some of the functions you can use in the website:

• View patient eligibility and benefits• Estimate patient liability• View and submit precertification requests• View claim status• Access remittance reports• View claim coding edits• Email Cigna

CIGNA eSERVICES

Log in CignaforHCP.com to:

• Easily access all your tools from your new Dashboard

• Flag patients and claims to quickly and easily save information to your dashboard

• Save your work automatically so it’s available the next timeyou log in



Under Resources, you can:

• Access the Cigna reference guides

• View claim appeals policy• View claim submission

addresses and requirements• Review disease

management programs• Access electronic

prescription submission• View pharmacy formulary• View the provider directory

Remember to check the siteoften for policy and Procedure updates.

CIGNA eSERVICES


CIGNA eSERVICES

Online training content is:

• Available free to registered users

• Requires no special software

• Can be accessed 24x7

• Can be downloaded or printed to review offline

Examples of available material:

Learn more about Cigna eServices by accessing our online training material. Log in to (CignaforHCP.com)>eCourses.



• Enter your User ID and password to log in to the Secured Provider Portal (GWHCignaforHCP.com)

• If you are not already registered to use the website, click “Register Now”.

CIGNA eSERVICES

http://www.gwhcignaforhcp.com/


Log in to the SecuredProvider Portal(GWHCignaforHCP.com)to:

• View important updates to plans and services

• Check the details of processed claims

• View precertification requirements

• Access helpful resources, including:– Clinical guidelines– Payment guidelines– Dispute resolution– Reference Guides

CIGNA eSERVICES


ELECTRONIC DATA INTERCHANGE (EDI)

You have two options for exchanging EDI transactions with Cigna – by directly connecting to the Cigna systems using free software from Post-N-Track or by using a clearinghouse.

• Post-N-Track™ is a web-based service that allows you to submit claims directly to Cigna:– Claims are immediately delivered to Cigna; eliminates clearinghouse problems

– Built-in claim tracking reports

– For enrollment and additional information, visit www.post-n-track.com – installation takes less than 5 minutes

• Clearinghouses – Clearinghouse services allow you to:– Submit claims to Cigna

– Receive Electronic Remittance Advice (ERA) statements

– Exchange Electronic Claim Status Inquiry and Response transactions (276/277)

– Exchange Electronic Eligibility and Benefit Inquiry and Response transactions (270/271)

– Submit Electronic Pre-certification and Authorization requests (278)

• Payer IDs to use when submitting electronic claims to Cigna:

Payer ID Claim Type

62308 Medical (including GWH-Cigna and Payer Solutions network), behavioral PPO,dental, and Arizona Medicare Advantage HMO

SX071 Employee Assistance Program (EAP) and behavioral HMO

59225 Starbridge Beech Street claims

http://www.post-n-track.com/

CLEAR CLAIM CONNECTION (CCC)

• Claim Coding Edit disclosure tool powered by McKesson, Inc.

• Accessible through CignaforHCP.com and GWHCignaforHCP.com.

• Users can enter CPT and HCPCS codes and immediately view audit results.

• Can review the rationale for disallowed codes.

• No PHI (Personal Health Information) exchanged.

• Professional claims only.



Features of the CIGNA Cost of Care EstimatorCOST OF CARE ESTIMATOR ® (COCE)

• Can be used in all care settings(professional services in all locations, outpatient and inpatient facilities).

• Only available for health care professionals who participate in the Cigna network.

• Available for patients in Cigna HMO/Network medical plans, Cigna PPO, EPO and Open Access Plus (OAP/OAPIN) benefit plans, including individuals with Cigna Choice Fund.

• Estimates includes anticipated payment from individual’s FSA/HRA/HSA account when Automatic Claim Forwarding is enabled.

• Estimated costs are specific to the health care professional or facility requesting the estimate, the treatment or service, and the covered individual’s benefits at the time the estimate is generated.

• Estimates can be generated pre-care (at scheduling) or while the patient is in the office (before check-in or at checkout).

,,

CIGNA eSERVICES

Click Print Explanation of Estimate to print a copy for your patient.

After you submit the estimate, you will see this Explanation of Estimate.

Explanation of Estimate


CIGNA eSERVICES

Electronic Remittance

Advice (ERA) ANSI 835

• ERA, or the ANSI 835, is the HIPAA-compliant detailed explanation of how your claim was processed.

• ERA is available for patients with Cigna or GHW-Cigna ID cards.• The ERA may be automatically loaded into your account receivable system, which can:

– Help reduce costs– Save time – Reduce posting errors– Shorten the payment cycle

Electronic Funds

Transfer (EFT)

(Not currently available for

payments associated

with patients with GWH-

Cigna ID cards)

• EFT (or direct deposit) claim payments are deposited directly into your bank account, avoiding mail delays.

• Payments are available the day of the deposit, increasing efficiency and improving cash flow.

• A separate Direct Deposit Activity Report (DDAR) or Remittance Report is made available for each deposit on the Cigna for Health Care Professionals website (CignaforHCP.com). The Remittance Report provides details of the claims processing payments included in the fund transfer.

Important information about EFT:• For savings account deposits, you should verify that your bank supports EFT.• If you use more than one tax ID number (TIN), you must complete a separate EFT

enrollment for each TIN .• If your TIN, billing address or bank account changes, you must submit a change request

by logging into (CignaforHCP.com) > Working with Cigna > Manage EFT Settings• To check the status of your EFT application, log in to CignaforHCP.com > Working with

Cigna, and view the Enrollment/Update Status.

Electronic Remittance (ERA) and Electronic Funds Transfer (EFT)




DIRECT DEPOSIT ACTIVITY REPORT (DDAR)

• Immediate online access to your remittance reports (DDAR) and checkless EOP the same day you receive your electronic funds transfer.

• A single tracking number on your DDAR, ERA and EFT helps make reconciling payments easier.

• To access report, log-in to CignaforHCP.com. Under “Remittance Reports” choose how you want to search for your report.

• If you are enrolled for Electronic Remittance Advice (ERA)/ANSI 835, you will still receive your ERA through your EDI vendor.

• Not available for patients with GWH-Cigna ID Cards at this time.


Claims Submission &Administrative Guidelines


CLAIM SUBMISSION

• Electronic claim submission can improve claim accuracy.

• If Cigna is the:

– Primary payer, then claims must be submitted within 90 days of the date of service

– Secondary payer, then the claim must be submitted within 90 days of the date of receipt of the Explanation of Benefits (EOB) from the primary payer

• To help ensure timely and accurate payments, include the following complete and correct information on each claim submission:

– Contracted Tax Identification Number (TIN)

– Health care professional’s name as reported to Cigna

– TIN owner’s name, billing address, and telephone number as reported to the Internal Revenue Service

• Cigna accepts National Provider Identifiers (NPIs) on standard HIPAA transactions, but the federal TIN must also be included for tax reporting purposes.

• Cigna accepts CMS-1500 forms for professional claims and UB-04 forms for institutional claims; Cigna also accepts older versions of these claim forms.

Improving Processing and Payment Accuracy

SUBMIT CORRECTED CLAIMS ELECTRONICALLY

• Did you know that you can also submit corrected claims electronically? To submit your corrected claim, make the necessary corrections, update the Claim Frequency Code and submit. It’s that easy!

• For corrected claims, the Claim Frequency Type Code in Loop 2300, Segment CLM05 should specify the frequency of the claim (this is the third position of the Uniform Billing Claim Form Bill Type) using one of the following codes:

– 1 – Original (admit through discharge claim)– 7 – Replacement (replacement of prior claim)– 8 – Void (void/cancel of prior claim)

• This applies to Cigna and GWH-Cigna


APPEALS PROCESS

Cigna offers two levels of appeal for participating health care professionals.

• First appeal must be sent within 180 calendar days of the date of initial payment or denial.

• Second appeal must be sent within 60 calendar days of the date of the first appeal decision letter.

• For more information about appeals refer to the Health Care Professional Reference Guide available on both CignaforHCP.com and GWHCignaforHCP.com.

Note: Appeals policies may vary by state; statute supersedes Cigna policy. For details on state-specific dispute policies, refer to the claim appeal information posted on our website.

Individuals with

Cigna ID cards

Individuals with

GWH-Cigna ID cards

CignaNational Appeals UnitP.O. Box 188011Chattanooga, TN 37422

Cigna GWH-Cigna National Appeals P.O. Box 668 Kennett, MO 63857

To Resolve Payment Disputes




PRECERTIFICATION

• The referring physician is responsible for obtaining approval for all that require precertification prior to services being rendered.

• Check the back of the patient’s ID card or our secure websites for coverage and precertification requirements; the websites will have the most up-to-date information.

• Submit requests for elective procedures at least 72 hours before the scheduled service.

• On-line precertification: – Get an immediate response to your precertification request – some may get immediate approval– Receive a tracking number on every request– Print responses for your patient records– View the status of any precertification request – including those submitted by phone or by fax.

• For Cigna ID Cards, use the following channels: – Log in website (CignaforHCP.com) > View and Submit Precertification Requests– Call: 1.800.88Cigna (882.4462)– https://navinet.navimedix.com

• For GWH-Cigna ID Cards, use the following channels: – Log in to the Secured Provider Portal (GWHCignaforHCP.com) > Precertifications– Call: 1.866.494.2111


https://navinet.navimedix.com/



NATIONAL VENDORS

For laboratory referrals, select from either one of the nation’s largest preferred laboratories listed below, or refer to the health care professional online directory for a list of other available in-network laboratories.

• For patients with Cigna ID cards, access the directory at CignaforHCP.com.

• For patients with GWH-Cigna ID cards access the directory at GWHCignaforHCP.com.

Laboratory Referrals

Laboratory Corporationof America (LabCorp)

Quest Diagnostics, Inc. (Quest)

Call1.888.522.2677for account set-up

1.866.MyQuest (697.8378) for account set-up

Website labcorp.com questdiagnostics.com

Patient Service Centers

To find the nearest location: Call 1.888.522.2677

Visit labcorp.com/psc

Make an appointment at the nearest location: Call 1.800.377.7220 Visit questdiagnostics.com/appointment



http://www.labcorp.com/

NATIONAL VENDORS

– CareCentrix is the national provider of home health care, home infusion and durable medical equipment. For a complete list of services and CPT codes covered by CareCentrix, log in to CignaforHCP.com > Resources > Clinical Reimbursement Policies and Payment Policies > CareCentrix DME HCPCS Codes.

– Call CareCentrix at 1.800.666.6127 to complete an order for these services (precertification may be required).

Orthotics/Prosthetics Linkia– For Orthotic and/or Prosthetic devices contact Linkia at 1.877.754.6542

MedSolutions (MSI)– To precertify high-tech imaging services (MRI, CT , PET, Nuclear Cardiology

Imaging), contact MSI at 1.888.693.3297 or www.cigna.medsolutionsonline.com.– [email protected] or 1.800.575.4517 option #2.

Home Health Care - CareCentrix


Please notify us in writing 90 days before changing your office or billing address,telephone number, tax identification number or specialty. Submit your demographicchanges to:

State Submission Options

Connecticut, Delaware, Illinois, Indiana,Iowa, Maine, Massachusetts, Michigan,Minnesota, New Hampshire, New Jersey,New York, Ohio, Pennsylvania, RhodeIsland, Vermont, West Virginia, Wisconsin

• GWH phone: 1.888.663.8081• Cigna phone: 1.800.882.4462 • Fax: 1.877.358.4301• Email: [email protected]

Alabama, Arkansas, Florida, Georgia,Kentucky, Louisiana, Maryland,Mississippi, North Carolina, Oklahoma,Puerto Rico, South Carolina, Tennessee,Texas, Virginia, Virgin Islands, Washington DC


Alaska, Arizona, California, Colorado,Hawaii, Idaho, Kansas, Missouri, Montana,Nebraska, Nevada, New Mexico, NorthDakota, Oregon, South Dakota, Utah,Washington, Wyoming


DEMOGRAPHIC CHANGES

REMINDERS

• Reference Guides containing our administrative guidelines for physicians, hospitals, and ancillary facilities are continually updated and posted on the HCP website.

− CignaforHCPcom > Resources > Reference Guides.

− GWHCignaforHCP.com >Tools & Resources > Healthcare professional Reference Guide.

• Cigna Tel-Drug Specialty Pharmacy is available for medications administered in the office. Tel-Drug will work directly with Cigna to facilitate the precertification process on your behalf, and will bill Cigna directly for dispensed medications. Visit Cigna.com or call Cigna Tel-Drug Specialty Pharmacy at 1.800.351.3606 for more information.

• Network News, our network newsletter, is available quarterly via email or hard copy and online at CignaforHCP.com.

"Cigna" is a registered service mark and the "Tree of Life" logo and “GO YOU” are service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company, Cigna Health and Life Insurance Company, and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. All models are used for illustrative purposes only.

THN-2012-431 © 2012 Cigna. Some content provided under license.

cigna overview important information that will help guide our relationship november 16, 2012 aaham...

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