WORKING WITH CIGNA - Tennessee HFMA HFMA Slide... · KEY TRENDS IMPACTING THE HEALTH CARE DELIVERY...

KEY TRENDS IMPACTING THE HEALTH CARE DELIVERY SYSTEM

2019 TN HFMA Kelly Miller Payer Summits

WORKING WITH CIGNA


AGENDA

2Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2019 Cigna

• Introductions

• Provider Digital Solutions

• Claims 101

• Appeals 101

• Keeping you updated

• Resources

• Q&A

Cigna offers a variety of delivery system engagement models that will help providers move

toward a greater value orientation, which is our primary focus.

Open Access Plus LocalPlus®

networks, Cigna

Care Network,

Connect Network,

Cigna SureFit®

Cigna

Collaborative

Care

Ex

am

ple

s IPA*, physician

organized delivery

(POD)

TRADITIONAL

NETWORK

PARTNER

• Fee for service

• Traditional

contracting

relationship

ENHANCED

NETWORK

PARTNER

• Expanded fee for

service

• Flexible network

solutions with

focus on quality

CLINICAL

COLLABORATOR

• Quality bonus and

cost targets

• Embedded care

resources for

coordination

• Data aggregation

and exchange

DELIVERY

SYSTEM

ORGANIZER

• Organizes

independent

providers to

improve health

• Shared risk

• Management

services

Degree of collaboration and provider risk

Low High

engagementour delivery system

models


* Independent practice association


Tools to make your life easier

PROVIDER DIGITAL SOLUTIONS



Provider type

A “provider type” field has

been added. This added

field helps you distinguish

between a physician group

and a facility that share the

same name.

Provider record view

Easily view all records

(names or NPI* numbers)

by TIN**, and their EFT

status in an expanded

table format

Enhancements to Enroll in EFT Options screen


Effective November 2017

Auto-select records

A record that is not enrolled

will be automatically

selected for enrollment.

You have the ability to

uncheck records you do

not wish to enroll.

*National Provider Identifier

**Taxpayer Identification Number



Enroll in EFT

Options

Fully enroll in EFT

quickly and easily.


Enhancements to Enroll in EFT Options screen



HRA, HSA, and FSA*

information and plan

renewal indicator

Quickly see when your

patient’s plan renews and if

your patient has one of

these health accounts.

Patient and Plan Detail tab enhancements – plan renewal indicator

and health account status

Effective November 2017 & April 2018

*Health reimbursement account, health savings account, and flexible spending account



Am I in-network for

this patient?

Click a link to quickly view

the plans and networks you

participate in and see if you

are in network for this

patient.

Effective February 2018, updated July 2018

Am I in-network for this patient?

Patient and Plan Detail tab enhancements – network status



Link to provider

directory

Need to search for an in-

network specialist or facility

when referring a patient?

Now you can link to the

provider directory from the

patient screens.

Notification, Referral, and Precertification Requirements tab

enhancements – provider directory links

Effective March 2018



Referral Required

The Referral Required

indicator is now available

for SureFit and non-SureFit

patients.

Effective March 2018

Notification, Referral, and Precertification Requirements tab

enhancements – Referral Required indicator



Frequency and

utilization data

For certain patient benefits,

you will be able to see the

number of visits used and

the number remaining.

Effective May 2018

Frequency and utilization data



Pended claim attachments

• Electronically submit

supporting documentation

for pended claims

• Pend reason codes

clearly explain what

additional information is

needed.

Claim Details screen enhancements

When you use this feature, we’ll be able to process your pended claims more quickly.


Pended claim attachments details


About attachments

You can:

• Send up to six files at a time,

for a total file size of 35 MB.

(The maximum size for an

individual file is 10 MB.)

• Submit files in any of these

formats: BMP, GIF, JPEG, PDF,

PNG, or TIF.

• Easily convert a Microsoft file

into a PDF. Note that PDF files

cannot be more than 998

pages.

• Name files with a maximum of

128 characters, including the

file extension.



LocalPlus and SureFit web and EDI* enhancements


Cigna Cost of Care

Estimator®

You can now use the

estimator for patients with

Cigna LocalPlus and Cigna

SureFit coverage.

ERA (835)

You will be informed if the

claim was adjudicated as a

Cigna SureFit benefit.

SureFit provider

directory

From the patient screens,

you will be able to access a

patient-specific SureFit

directory from the Useful

Links and the Notifications,

Referrals & Pre-Cert

category.


*Electronic data interchange



PCP* Panel Reports

You will have the ability to

pull a PCP Panel Report

for your designated SureFit

patients.

Patient Coverage Details screen enhancements


*Primary care provider



if coverage details indicate

that outpatient services

require precertification:

Click View Medical

Precertification Information.

This will bring you to the

Precertification Policies

page.

Does this outpatient service require precertification?

Cigna for Health Care Professionals website



From the Resources tab,

you can also find:

• General precertification

information. Click

Precertification.

• The Master Outpatient

Precertification List. Click

Reimbursement and

Payment Policies >

Precertification Policies >

Master Outpatient

Precertification List.

General precertification information and the Master Outpatient Precertification List





Click Master Outpatient

Precertification List

This is a searchable, detailed

listing of procedures and

corresponding codes for

services that require

precertification.

To search for a procedure

code, click Ctrl + F.

Master Outpatient Precertification List


ELECTRONIC TRANSACTION SAVINGS OPPORTUNITIES

TransactionEstimated per transaction:

Provider cost Potential savings

Claim submissionManual $2.37

$0.92Electronic $1.45

Eligibility and

benefit verification

Manual $3.61$2.60

Electronic $1.01

Prior authorizationManual $6.61


Claim status

inquiry

Manual $7.12$5.23

Electronic $1.89

Claim payment*Manual $2.11


Remittance

reports

Manual $2.99$1.84

Electronic $1.15

Source: CAQH, 2018 Index

Significant savings are available to providers who choose electronic over manual transactions

*Electronic funds transfer (EFT) is the required method for providers to receive reimbursements.

Tips to make the claims filing and resolution process easier

CLAIMS 101


CLAIM DENIAL REASONS


Frequent claim denial reasons:

– Duplicate claim submissions

– claim already in process

– claim previously processed

– Missing information

– Medicare explanation of benefit (EOB)

– Other insurance EOB

– Revenue codes itemization

Carefully review the message(s) on your Explanation of Payment (EOP) to determine the

reason for a denial of services or a payment reduction. If you have questions about a

denial, please call the Cigna Customer Service toll-free number on the patient’s ID card.

Avoid potential claim payment delays.

DUPLICATE CLAIM DENIALS


• Use the Claim Frequency Type Code in loop 2300, segment CLM05, to

specify the frequency of the claim. (This is the third position of the UB04

bill type.)

• Use one of the following codes to indicate the claim type:

• 1 – Original (admit through discharge claim)

• 7 – Replacement (of a prior claim), include Payer Claim Control # in

segment REF*F8

• 9 – Void (or cancellation of prior claim), include Payer Claim Control

# in segment REF*F8

When a corrected claim is submitted, you will receive a “duplicate to claim

already in process” denial message and the corrections will be applied to the

original claim.

Submit corrected claims electronically.

MEDICARE AND OTHER INSURANCE


• Both primary and secondary (COB) claims can be submitted to us electronically.

• You don’t have to submit Medicare Part A and Part B coordination of benefits

agreement (COBA) claims to us, as the Medicare EOB or ERA will show that those

claims have been forwarded to us as the secondary payer.

• Talk to your EDI vendor about COB information.

• It should be billed in loops 2320 and 2330 in the electronic claim form. Values in those

loops must balance with loop 2300 Monetary Amount reported.

Submit COB (coordination of benefits) claims electronically.

REQUESTS FOR ADDITIONAL INFORMATION


Cigna routinely evaluates claims for coding, billing accuracy, and appropriateness and

may request supporting claim payment information such as:

– An itemized bill

– Medical records

Once the claims review is completed, we will:

– process and reimburse the claim accordingly

– issue an explanation of payment

– send you a letter explaining any charges determined to be not payable

Visit the secure Cigna for Health Care Professionals website for a list of the Not-Payable

Reason Codes, including descriptions and reconsideration criteria, at CignaforHCP.com >

Resources > Reimbursement and Payment Policies > Clinical Claim Review Not Payable

Reason Codes.

Respond to requests for information timely.

CLAIM SUBMISSION TIPS


• Include the Present On Admission (POA) indicator for all diagnosis codes submitted on

the inpatient claim form. Refer to the Hospital Acquired Conditions Reimbursement

Policy located on the secure Cigna for Health Care Professional website at

CignaforHCP.com > Resources > Clinical Reimbursement Policies and Payment

Policies > Modifiers and Reimbursement Policies for more information.

• Submit newborn claims with the following information:

– the subscriber’s Cigna ID number without the suffix

– the subscriber’s first and last names (not the mother, unless she is the subscriber)

– the patient’s first name and last name, or Newborn, Baby Boy, Baby Girl, Twin A,

Twin B, etc.)

– the patient’s date of birth

– the patient’s gender

Refer to these additional claim submission tips.

PAYER SOLUTIONS: THIRD-PARTY ADMINISTRATORS


Cigna contracts with third-party administrators (TPAs), selected insurers, and claim administrators

(referred to collectively as “payers”) to share the administration of self-funded Administrative Services

Only (ASO) plans. We also contract with several insurance companies that issue individual and group

insurance policies.

For these relationships, we:

• provide access to our network

• perform medical management and utilization reviews

• re-price claims according to our contracted rates and claims logic

• provide clinical appeals management

• provide contract dispute resolution

TPAs and insurance companies:

• maintain eligibility

• administer benefits

• pay claims for these shared accounts on their own systems

Understand the Payer Solutions we offer.

PAYER SOLUTIONS: POINTS OF INTERACTION


Claim flow:

• Claims should be submitted to Cigna (payer ID 62308

or to the claims mailing address on the patient’s ID card

• Cigna prices the claims based on the network

contracted rates

• The priced claim is then forwarded to the payer

for payment based on the patient’s eligibility

and benefits

• The payers then remit payment following

contractually agreed upon turnaround requirements

Clinical and contract-related appeals:

• Appeals of clinical denials should be sent to Cigna

using the contact information supplied in the

denial letter(s)

• Appeals of application of contract rates should go to

the address on the patient’s ID card

Contact the payer* for:

• Eligibility

• Benefits

• Precertification

• Claims status

• Non-pricing appeals

* The contact phone number is

located on the patient’s

ID card

Contact Cigna* for:

• Reimbursement issues

• Pricing appeals

• General contract

questions

* The contact phone number for

Cigna is 1.888.663.8081

CLEAR CLAIM CONNECTION™


Click “I ACCEPT.”

On CignaforHCP.com:

1. Hover over claims

2. Click on View Claim Coding Edits

3. Window will come up with Agreement

4. Click I ACCEPT

5. Sample screen will appear to enter patient

information (see below):

CLEAR CLAIM CONNECTION (CON’T)


Sample screen will come up where you can enter customer’s information.

Click “Review Claim Audit Results.”

CLEAR CLAIM CONNECTION (CON’T)


Note that one claim will be accepted, and one claim will not. To determine why the claim will

not be accepted, click “Disallow.”

The next screen provides a detailed explanation.

Tips for filing an appeal

APPEALS 101


Cigna strives to informally resolve issues raised by providers on initial

contact whenever possible. If issues cannot be resolved informally:

– Cigna offers a single-level, internal appeal process to resolve contractual

disputes regarding post-service payment denials and payment disputes. Processes

may vary due to state mandates or contract provisions.

– The appeal must be initiated within 180 calendar days of the date of the initial

payment or denial decision.

– Arbitration may be used as a final resolution step after the internal Cigna process is

complete.


Patients with Cigna ID cards

Patients with GWH-Cigna or “G” ID cards

Cigna Appeals Unit PO Box 188011 Chattanooga, TN 37422 Fax: 1.877.815.4827

Cigna Appeals Unit PO Box 188062 Chattanooga, TN 37422 – 8062 Fax: 1.877.804.1679

APPEAL PROCESS

FILING AN APPEAL


• Most claim issues can be remedied quickly by providing requested information to a

claim service center, contacting us, or resubmitting the claim. Carefully review the

message(s) on your EOP to determine the reason for a denial of services or a

payment reduction.

We recommend contacting Cigna Customer Service before filing an appeal for:

– Claim errors

– Contract and fee disputes

– Out-of-network claim payment disputes

For additional information on how to submit an appeal, please review the Claim

Adjustment & Appeals Guidelines on CignaforHCP.com > Resources > Clinical

Reimbursement Policies and Payment Policies > Claims Appeals Policies and

Procedures > Appeal Policy and Procedures.

Understand the denial before you file an appeal.

34

This review provides an

opportunity to provide additional

clinical information.

Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2019 Cigna

Request a peer-to-peer review

before filing an appeal. It may

result in a reversal of a previous

coverage decision.

If the peer-to-peer review does not

result in a revised coverage

decision, you may still submit an

appeal through our appeal process.

Initiate by

calling:

1.800.88Cigna

(882.4462),

option 3

Peer-to-peer process

NATIONAL ANCILLARIES



National Ancillary Programs*providing your patients with

quality and

cost-effective

care

20% decrease in

unnecessary

radiology

procedures1

45%–80% savings with national labs over other lab services2

45%–50%

savings on total

chiropractic costs4

Up to $50,000 per

case savings using

in-network outpatient

dialysis facilty3

Accessible

Quality focused

Cost efficient

Patient oriented

Service National ancillary providers*

Chiropractic American Specialty Health®

Dialysis• Davita

• Fresenius

Durable medical equipment, home

health care, infusion therapyCareCentrix

Hearing Amplifon Hearing Health Care

High-technology radiology and

diagnostic cardiologyeviCore healthcare

Integrated Oncology Management

ProgrameviCore healthcare

Laboratory**• LabCorp®

• Quest Diagnostics®

Musculoskeletal and pain management eviCore healthcare

Orthotics and prosthetics Linkia

Physical and occupational therapy American Specialty Health®

Radiation therapy eviCore healthcare

Sleep management services CareCentrix

Vision services Vision Services Plan*List is not all-inclusive of every national ancillary provider. Ancillary providers do

not manage services in all states and markets.

**We currently contract with numerous local and national laboratories, including LabCorp® and Quest

Diagnostics, Inc. and other reference, pathology, genetic, and esoteric labs, to provide quality laboratory

services at in-network, cost-effective rates.

The latest information on policy and coverage updates.

KEEPING YOU UPDATED


RECENT COVERAGE POLICY AND PRECERTIFICATION UPDATES

38Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2019 Cigna 38

Policy and coverage updates April 2019

• Peripheral angioplasty

—Percutaneous Revascularization of the Lower

Extremities in Adults (0537)

March 2019

• Perfusionist services

—Facility Routine Services, Supplies and Equipment

Reimbursement Policy (R12)

• Ashkenazi Jewish laboratory panel

—Genetic Testing Panels (R28)

—Genetic Testing for Reproductive Carrier

Screening and Prenatal Diagnosis (0514)

February 2019

—Diagnostic Microbe Testing for Sexually Transmitted

Diseases (0530)

—National Correct Coding Initiatives for Facilities

Reimbursement Policy (R09)

January 2019

—Cardiac Electrophysiological Studies (0532)

Information about these updates and others is available on the


(CignaforHCP.com).

Precertification changes

Codes added to the precertification list on January 1, 2019

We added 27 new Current Procedural Terminology (CPT®) codes.

• 0045U through 0061U

• 0505T through 0508T

• 22551 and 22554

• 22600

• 93653

• 93656 and 93657

We added seven Centers for Medicare & Medicaid Services (CMS)

Healthcare Common Procedure Coding System (HCPCS) codes.

• C9030

• C9301

• C9032

• Q5105

• Q5106

• Q9993

• Q9995

Codes to be removed from the precertification list on

March 17, 2019

• 81287

• 81324

• 81412

A complete list of precertification changes is available on the Cigna for Health

Care Professionals website (CignaforHCP.com).

DEMOGRAPHIC CHANGES


Please notify us in writing 90 days before changing your office or billing address, telephone number, Taxpayer Identification Number (TIN), National Provider Identifier (NPI), or specialty. You can submit your demographic changes by email, fax, mail, or online. Refer to the chart below to identify the contact information for your state.*

How you can submit changes

Email: [email protected]

Fax: 1.877.358.4301

Mail: Cigna

Provider Data Management

Two College Park Drive

Hooksett, NH 03106

Online: Cigna for Health Care

Professionals website (CignaforHCP.com

> Resources > Forms)

New requests and existing contract

inquiries


Fax: 1.866.509.4544

Credentialing status inquiries

Telephone: 1.800.88Cigna (882.4462) select

the options for credentialing


mailto:[email protected]

Email: [email protected] to be added to the distribution.


resourcesfor you

• Quarterly Network News

• Use material in meeting packet

• Go to the Cigna for Health Care

Professionals website (CignaforHCP.com)


CONTACTS AND SUPPORT

your

resourcesyour

way

• Webinars

(CignaforHCP.com > News You Can Use)

• General eServices product information

(CignaforHCP.com > Resources > Doing

Business with Cigna > eServices)

• eCourses


Business with Cigna > eServices )

• EFT payment calendars


Business with Cigna > eServices )

• Your EDI vendor

Don’t have an EDI vendor?

Visit Cigna.com/EDIvendors

for more information

• 1.800.88Cigna

• Your Experience Manager or

Experience Consultant

http://www.cigna.com/EDIvendors

QUESTIONS?



All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company,

Connecticut General Life Insurance Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation. The Cigna name, logo,

and other Cigna marks are owned by Cigna Intellectual Property, Inc.

THN-2019-174-TN 03/19 © 2019 Cigna. Some content provided under license.

WORKING WITH CIGNA - Tennessee HFMA HFMA Slide... · KEY TRENDS IMPACTING THE HEALTH CARE DELIVERY...

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Transcript of WORKING WITH CIGNA - Tennessee HFMA HFMA Slide... · KEY TRENDS IMPACTING THE HEALTH CARE DELIVERY...