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2021HEALTH CARE PROFESSIONALSPROVIDER MANUALMEDICARE ADVANTAGEPCOMM-2021-1083 8/21
Table of contentsIntroduction and new 2021 plan offerings . 9Medicare overview . 10Key contacts . 10Eligibility . 12Verify customer eligibility. 132021 example ID cards. 13Exchange of electronic data . 14Information protection requirements and guidance . 14Experience the ease of HSConnect . 14Vendor-specific networks . 14CLIA certification required for laboratory services . 15High-tech radiology, diagnostic cardiology, radiation therapy and medical oncologymanagement programs . 16Program overview . 16Credentialing . 16Practitioner and organizational selection criteria . 16Practitioner . 16Organizational provider. 18Credentialing and recredentialing process . 19Credentialing committee and peer review process . 20Office site evaluations . 20Accreditation for DME, orthotics, and prosthetic providers. 20Non-discrimination in the decision-making process . 21Provider notification . 21Appeals process and notification of authorities . 21Confidentiality of credentialing information. 21Ongoing monitoring . 22CMS preclusion list . 22Provider directory and requirements . 23Requirements. 23Additional quarterly provider directory data attestation details . 23Provider termination. 23Plan notification requirements for providers. 24Practitioners. 24Page 2 of 113All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation. The Cigna name,logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. 2021 CignaReturn to Table of Contents
Facility / ancillary providers. 25Continuity of care. 26Billing . 27Claims submission . 27Electronic submission . 27Paper claims submission . 28Timely filing. 29Claim format . 29Claim format standards. 29Offsetting . 29Pricing. 29Claims encounter data . 30Explanation of payment (EOP)/Remittance advice (RA). 30Prompt payment . 30Non-payment/claim denial . 30Pricing of inpatient claims . 30SNF consolidated billing (SNF CB) . 30Processing of hospice claims . 31ICD-10 diagnosis and procedure code reporting . 32Coordination of benefits . 34Medicare secondary payer (MSP) and subrogation . 34Guidelines . 34General terms & definitions . 34Common situations of primary vs. secondary payer responsibility . 35Basic processing guidelines for COB . 37Worker's compensation . 37Subrogation. 37Dual eligible . 38Dual eligible individuals . 38Medicaid coverage groups. 38Appeals . 39Provider appeals . 39Submit an appeal . 40Customer appeals . 41Claim disputes/reconsiderations . 41Provider information, roles and responsibilities . 41Page 3 of 113All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation. The Cigna name,logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. 2021 CignaReturn to Table of Contents
Access and availability standards for providers . 41After-hours access standards . 42Primary care and specialist responsibilities. 43Providers designated as primary care physicians (PCPs) . 43Communication among providers . 45Customer assignment to new PCP (HMO Only) . 45Procedure . 46Delegation . 46Non-discrimination and cultural competency. 47Physician rights and responsibilities . 47Physician responsibilities . 47Organizational site surveys . 49Provider participation . 49Emergency or disaster situations . 49Provider directory update requirements . 50Provider communications and marketing . 51Guidelines . 51Behavioral health . 52Responsibilities of the PCP . 52Access to care . 52Medical record documentation . 53Continuity of care for behavioral health . 53Utilization management for behavioral health . 53Contract exclusions for behavioral health . 54Pharmacy . 54Pharmacy prescription benefit . 54Part D drug formulary . 54Part D utilization management . 55Prior authorization (PA) . 55Step therapy (ST) . 55Quantity limits (QL). 55How to file a coverage determination (CD) . 56How to file a Part D appeal . 56Pharmacy networks . 57Preferred pharmacy network . 57Pharmacy quality programs . 57Page 4 of 113All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation. The Cigna name,logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. 2021 CignaReturn to Table of Contents
Narcotic case management . 58Medication therapy management . 58Drug utilization review . 59Low Income Subsidy program. 60Overview. 60Eligibility. 61Applying For Extra Help . 61Home delivery pharmacy . 61Express Scripts . 62Specialty pharmacy . 62Medical health services . 62Overview . 62Goals. 63Departmental functions . 63Prior authorization . 63Prior authorization department . 65Prior authorization requests and time frames . 66Denial or adverse organization determination . 67Retrospective review . 67Drugs/Biologics Part B (medical benefit) . 67Home health services . 68Concurrent review . 69Readmission . 71Skilled nursing facility care and levels . 71SNF notice of Medicare non-coverage (NOMNC) . 75Adverse determinations – concurrent review . 76Rendering of adverse determinations (denials) . 76Notification of adverse determinations (denials) . 77Discharge planning and acute care management (ACCM) . 77Outpatient Observation Notice . 77Referrals . 78Referral guidelines . 78Quick reference referral guide. 78** Select markets with HMO plans only. PPO plans do not require referrals. . 79PPO products - referrals . 79HMO products - referrals . 79Page 5 of 113All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation. The Cigna name,logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. 2021 CignaReturn to Table of Contents
Obtaining and verifying referrals . 80Part B step therapy . 82Care management . 82Care management program goals . 82Care management approach . 82How to use services . 83Coordination with network providers . 83Program evaluation. 84Quality programs . 84Quality improvement organization program changes . 84Quality care management program . 85Overview. 85Values. 85Quality principles . 86Program scope . 86Goals . 87Corporate Quality Improvement Committee (CQIC) . 88Health Care Plan Effectiveness Data and Information Set (HEDIS) . 88Special Needs Plans (SNP). 89Background . 89SNP MOC process . 90SNP contact information . 91Customer information closing customer panels . 92Transmission of lab results . 92Customer information, rights and responsibilities . 92Medical record standards . 92Programs and services . 93Benefits and services. 93Emergency services and care after hours . 93Emergency services . 93Urgent care services . 94Excluded services . 94Customer rights. 94Advance medical directives. 97Customer responsibilities . 97Policies . 98Page 6 of 113All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation. The Cigna name,logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. 2021 CignaReturn to Table of Contents
Corporate compliance program . 98Overview. 98Medicare advantage program requirements . 100Overview. 100Books and records; governmental audits and inspections . 100Privacy and confidentiality safeguards. 101Patient hold harmless . 101Non-covered services . 101Delegation of activities or responsibilities . 102Compliance with Cigna's obligations, provider manual, policies and procedures . 102Subcontracting. 102Compliance with laws . 103Program integrity . 103Continuation of benefits . 103Incorporation of other legal requirements. 103Conflicts . 103Dispute resolution . 103APPENDIX . 1042021 plan offerings/service maps . 104Alabama, Florida, and South Mississippi . 104Arkansas. 104Arizona . 105Central Florida (Daytona, Orlando & Tampa) . 105South Florida (Leon Medical Center) . 106South Florida East . 106Colorado . 107Georgia . 107Illinois. 108Kansas City . 108Mid-Atlantic . 109New Jersey . 109New Mexico . 110North and South Carolina . 110Ohio . 111Oklahoma . 111Pennsylvania . 112Page 7 of 113All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation. The Cigna name,logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. 2021 CignaReturn to Table of Contents
Tennessee, North Georgia, and Southwest Virginia . 112Texas . 113Utah . 113Page 8 of 113All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation. The Cigna name,logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. 2021 CignaReturn to Table of Contents
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 and proceduresincluding claims payment and submission requirements, prior authorization and referralrequirements and other helpful information. It also serves as an extension of your networkparticipation 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, theterms of your network participation agreement will control. This manual is also intended to helpproviders more effectively do business with Cigna Medicare, so please make time to review itcarefully.You will notice new product offerings for 2021, and we are excited to introduce new plans in selectmarkets. This manual will guide you through the differences in the HMO or PPO plans that yourcustomer’s may have.The table below outlines things you need to know as you navigate through thismanual.TopicReferralsWhat you need to know HighlightsKey contactsQuick reference guide Local network informationHMO: Referral required in select plansPPO: No referral required 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 verif
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