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2021HEALTH CAREPROFESSIONALSPROVIDER MANUALMEDICARE ADVANTAGE2021 Cigna Medicare Advantage Provider ManualPCOMM-2021-305 / INT 21 92475

Table ContentsIntroduction and New 2021 Plan Offerings . 9Medicare Overview . 10Key Contacts . 11Eligibility . 14Verify Customer Eligibility . 142021 Example ID Cards . 15Exchange of Electronic Data. 16Information Protection Requirements and Guidance . 16Experience the Ease of HSConnect. 16Need More Help? . 16Vendor-Specific Networks . 17CLIA Certification Required for Laboratory Services. 17High-Tech Radiology, Diagnostic Cardiology, Radiation Therapy & Medical OncologyManagement Programs. 18Program Overview. 18Credentialing . 18Practitioner and Organizational Selection Criteria. 18Practitioner . 18Organizational Provider . 20Credentialing and Recredentialing Process. 21Credentialing Committee and Peer Review Process . 22Office Site Evaluations . 22Accreditation for DME, Orthotics, and Prosthetic Providers . 22Non-discrimination in the Decision-Making Process . 23Provider Notification . 23Appeals Process and Notification of Authorities . 23Confidentiality of Credentialing Information . 23Ongoing Monitoring . 23CMS Preclusion List . 23Provider Directory and Requirements . 24Requirements . 24Additional Quarterly Provider Directory Data Attestation Details . 25Return to Table of Contents2 Pa ge

Provider Termination . 25Plan Notification Requirements for Providers . 25Practitioners . 26Facility / Ancillary Providers . 26Continuity of Care . 27Billing . 29Claims . 29Claims Submission . 29Timely Filing . 30Claim Format. 31Claim Format Standards . 31Offsetting . 31Pricing. 31Claims Encounter Data. 32Explanation of Payment (EOP)/Remittance Advice (RA) . 32Prompt Payment . 32Non-Payment/Claim Denial . 32Pricing of Inpatient Claims. 32SNF Consolidated Billing (SNF CB) . 32Processing of Hospice Claims . 33ICD-10 Diagnosis and Procedure Code Reporting . 34Coordination of Benefits . 36Medicare Secondary Payer (MSP) and Subrogation Guidelines . 36General Terms & Definitions . 36Common Situations of Primary vs. Secondary Payer Responsibility . 37Basic Processing Guidelines for COB. 39Worker's Compensation. 39Subrogation . 39Dual Eligible . 40Dual Eligible Individuals. 40Medicaid Coverage Groups . 40Appeals . 42Provider Appeals . 42Return to Table of Contents3 Pa ge

Submit an Appeal . 42Customer Appeals . 43Claim Disputes/Reconsiderations . 43Provider Information, Roles and Responsibilities . 43Access and Availability Standards for Providers . 43After-hours Access Standards . 44Primary Care and Specialist Responsibilities . 45Providers Designated as Primary Care Physicians (PCPs) . 45Administrative, Medical and Reimbursement Policy Changes . 46Communication among Providers . 47Customer Assignment to New PCP (HMO Only) . 47Procedure . 48Delegation. 48Non-Discrimination and Cultural Competency. 49Physician Rights and Responsibilities. 49Physician Responsibilities . 49Organizational Site Surveys . 51Provider Participation . 51Emergency or Disaster Situations . 52Provider Communications and Marketing . 54Guidelines . 54Behavioral Health . 55Responsibilities of the Primary Care Physician . 55Access to Care . 55Medical Record Documentation . 55Continuity of Care for Behavioral Health. 56Utilization Management for Behavioral Health . 56Contract Exclusions for Behavioral Health . 56Pharmacy . 57Pharmacy Prescription Benefit . 57Part D Drug Formulary . 57Part D Utilization Management . 58Prior Authorization (PA). 58Return to Table of Contents4 Pa ge

Step Therapy (ST) . 58Quantity Limits (QL) . 58How to File a Coverage Determination . 58How to File a Part D Appeal . 59Pharmacy Networks . 60Preferred Pharmacy Network . 60Pharmacy Quality Programs. 60Narcotic Case Management. 60Medication Therapy Management . 61Drug Utilization Review . 61Prescription Drug Monitoring Programs Low Income Subsidy Program Information . 63Overview . 63Eligibility. 63Applying For Extra Help. 63Home Delivery Pharmacy . 64Express Scripts . 64Specialty Pharmacy . 64Medical Health Services. 65Overview . 65Goals . 65Departmental Functions . 65Prior Authorization . 65Prior Authorization Department. 68Prior Authorization Requests and Time Frames . 68Denial or Adverse Organization Determination . 69Retrospective Review . 69Drugs/Biologics Part B (Medical Benefit) . 70Home Health Services . 70Concurrent Review. 71Readmission . 73Skilled Nursing Facility Care and Levels. 73SNF Notice of Medicare Non-Coverage (NOMNC). 77Adverse Determinations – Concurrent Review. 77Return to Table of Contents5 Pa ge

Rendering of Adverse Determinations (Denials). 77Notification of Adverse Determinations (Denials) . 78Discharge Planning and Acute Care Management (ACCM) . 79Outpatient Observation Notice . 79Referrals . 79Referral Guidelines . 79Referrals Crosswalk. 80PPO Products - Referrals . 80HMO Products - Referrals . 80Part B Step Therapy . 83Care Management . 83Care Management Program Goals . 83Care Management Approach . 84How to Use Services . 84Coordination with Network Providers . 85Program Evaluation. 85Quality Programs . 86Quality Improvement Organization Program Changes . 86Quality Care Management Program . 87Overview . 87Values . 87Quality Principles . 87Program Scope . 88Goals . 88Corporate Quality Improvement Committee (CQIC) . 89Health Care Plan Effectiveness Data and Information Set . 89Special Needs Plans (SNP) . 90Background . 90Special Needs Plan Eligibility Criteria. 90SNP MOC Process . 91SNP Contact Information. 92Customer Information Closing Customer Panels . 93Transmission of Lab Results . 93Return to Table of Contents6 Pa ge

Customer Information, Rights and Responsibilities . 93Medical Record Standards . 93Programs and Services. 94Benefits and Services . 94Emergency Services and Care After Hours . 94Emergency Services . 94Urgent care services . 95Excluded Services . 95Customer Rights . 95Advance Medical Directives . 98Customer Responsibilities . 99Policies . 100Corporate Compliance Program . 100Overview . 100Fraud, Waste, and Abuse. 100Medicare Advantage Program Requirements . 102Overview . 102Books and Records; Governmental Audits and Inspections . 102Privacy and Confidentiality Safeguards . 102Patient Hold Harmless . 102Non-Covered Services . 103Delegation of Activities or Responsibilities . 103Compliance with Cigna’s Obligations, Provider Manual, Policies and Procedures 104Subcontracting . 104Compliance with Laws . 104Program Integrity . 104Continuation of Benefits . 105Incorporation of Other Legal Requirements . 105Conflicts . 105Dispute Resolution. 105APPENDIX . 1062021 Plan Offerings/Service Maps . 106Alabama, Florida, and South Mississippi . 106Return to Table of Contents7 Pa ge

Arkansas . 106Arizona . 107Central Florida (Daytona, Orlando & Tampa) . 107South Florida (Leon Medical Center) . 108South Florida East . 108Colorado . 109Georgia . 109Illinois . 110Kansas City . 110Mid-Atlantic. 111New Jersey. 111New Mexico. 112North and South Carolina . 112Ohio . 113Oklahoma . 113Pennsylvania . 114Tennessee, North Georgia, and Southwest Virginia . 114Texas . 115Utah . 115Return to Table of Contents8 Pa ge

Introduction and New 2021 Plan OfferingsThank you for participating with Cigna Medicare Advantage! This provider manual has beencreated to assist you and your office staff in partnering with us to help improve our customer’shealth and wellbeing. It contains important information concerning our policies andprocedures including claims payment and submission requirements, prior authorization andreferral requirements and other helpful information. It also serves as an extension of yournetwork participation agreement in which all providers are required to comply with it.This manual replaces and supersedes all other prior versions. To the extent there is anyinconsistency between the terms of this manual and your network participation agreement,the terms of your network participation agreement will control. This manual is also intended tohelp providers more effectively do business with Cigna Medicare, so please make time toreview it carefully.You will notice new product offerings for 2021, and we are excited to introduce new plans inselect markets. This manual will guide you through the differences in the HMO or PPO plansthat your customer’s may have.The table below outlines things you need to know as you navigate through thismanual.TopicWhat you need to knowReferrals HMO: Referral required in select plans PPO: No referral requiredHighlights Key Contacts Regional Product Maps are located in theAppendix. Market-specific contacts are located throughoutthe Provider Manual depending on the topic. Customer Identification Cards provide high-levelproduct/network information. Remember to contactthe phone numbers on the card for assistance andfollow guidance in order to verify eligibility,referral/no referral and authorization guidance.Quick Reference GuideLocal Network InformationReturn to Table of Contents9 Pa ge

Medicare OverviewCigna contracts with the Centers for Medicare & Medicaid Services (CMS) to offer MedicareAdvantage (MA) plans. Customers are able to select one of several plans offered based ontheir location, budget and health care needs.Health MaintenanceOrganization (HMO) Plans Selection of aPrimary CarePhysician (PCP)Referrals toSpecialists Cigna ID CardRequires customers toselect a PCP. Customers are allowedto select a different PCPat anytime.Referral requirements areindicated on the customer’sCigna ID Card.Select service areas do notrequire the use of referrals.Preferred ProviderOrganization (PPO) PlanNot Required; althoughencouraged to select a PCPfrom the point of enrollmentand throughout their CignaMedicare Advantage journeyNot required.The customer’s type of plan will be indicated at the top of thecustomer’s Cigna Identification card. See the 2021 Example IDCards section.Return to Table of Contents10 P a g e

Key ContactsKEY CONTACTSBehavioralHealth/SubstanceUse DisordersClaims ProcessingCigna Network (Please call for authorizations)Call: 1-866-780-8546Fax: 1-866-949-4846Claims questions: 1-800-230-6138Electronic Claims may be submitted through: Change Healthcare/Availity (Payor ID: 63092 or 52192) ewayEDI (Payor ID: 63092) Relay Health (Professional claims CPID: 2795 or 3839 Institutional claims CPID: 1556 or 1978)Mail Paper Claims to:CignaPO Box 981706El Paso, TX 79998Part C AppealsCoding andDocumentationComplianceMail Reconsideration Requests to:Cigna ReconsiderationsPO Box 20002Nashville, TN 37202Appeal

2021 HEALTH CARE PROFESSIONALS PROVIDER MANUAL MEDICARE ADVANTAGE 2021 Cigna Medicare