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2021HEALTH CAREPROFESSIONALSPROVIDER MANUALMEDICARE ADVANTAGE2021 Cigna Medicare Advantage Provider Manual - Version 1INT 21 92475

Table ContentsMedicare Overview. 13Eligibility . 13Verify Customer Eligibility . 132021 Example ID Cards . 14Exchange of Electronic Data . 14Information Protection Requirements and Guidance . 14Experience the Ease of HSConnect . 15Need More Help? . 15Vendor-Specific Networks . 16CLIA Certification Required for Laboratory Services . 16High-Tech Radiology, Diagnostic Cardiology, Radiation Therapy & Medical OncologyManagement Programs . 17Program Overview . 17Credentialing . 17Practitioner and Organizational Selection Criteria . 17Practitioner . 17Organizational Provider . 19Credentialing and Recredentialing Process . 20Credentialing Committee and Peer Review Process . 21Office Site Evaluations . 21Accreditation for DME, Orthotics, and Prosthetic Providers . 21Non-discrimination in the Decision-Making Process . 21Provider Notification . 22Appeals Process and Notification of Authorities . 22Confidentiality of Credentialing Information. 22Ongoing Monitoring . 22CMS Preclusion List . 23Provider Directory and Requirements . 23Requirements. 23Additional Quarterly Provider Directory Data Attestation Details . 24Provider Termination . 24Plan Notification Requirements for Providers . 24Practitioners . 252020 Cigna Medicare Advantage Provider Manual - Version 2Return to Table of Contents2 Page

Facility / Ancillary Providers . 25Continuity of Care. 26Billing. 28Claims . 28Claims Submission . 28Timely Filing. 29Claim Format . 29Claim Format Standards . 30Offsetting . 30Pricing . 30Claims Encounter Data . 31Explanation of Payment (EOP)/Remittance Advice (RA) . 31Prompt Payment . 31Non-Payment/Claim Denial . 31Pricing of Inpatient Claims . 31SNF Consolidated Billing (SNF CB). 31Processing of Hospice Claims . 31ICD-10 Diagnosis and Procedure Code Reporting . 33Coordination of Benefits . 35Medicare Secondary Payer (MSP) and Subrogation Guidelines . 35General Terms & Definitions . 35Common Situations of Primary vs. Secondary Payer Responsibility . 36Basic Processing Guidelines for COB . 38Worker's Compensation . 38Subrogation. 38Dual Eligible . 39Dual Eligible Individuals . 39Medicaid Coverage Groups . 39Appeals . 40Provider Appeals . 40Submit an Appeal . 41Customer Appeals . 42Claim Disputes/Reconsiderations . 42Provider Information, Roles and Responsibilities . 42Access and Availability Standards for Providers . 422020 Cigna Medicare Advantage Provider Manual - Version 2Return to Table of Contents3 Page

After-hours Access Standards . 43Primary Care and Specialist Responsibilities . 44Providers Designated as Primary Care Physicians (PCPs) . 44Administrative, Medical and Reimbursement Policy Changes . 45Communication among Providers . 46Customer Assignment to New PCP (HMO Only) . 46Delegation . 47Non-Discrimination and Cultural Competency . 47Physician Rights and Responsibilities . 48Organizational Site Surveys . 49Provider Participation . 50Emergency or Disaster Situations . 50Provider Communications and Marketing. 51Guidelines . 51Behavioral Health . 53Responsibilities of the Primary Care Physician . 53Access to Care . 53Medical Record Documentation . 53Continuity of Care for Behavioral Health . 53Utilization Management for Behavioral Health . 54Contract Exclusions for Behavioral Health . 54Pharmacy . 54Pharmacy Prescription Benefit . 54Part D Drug Formulary . 54Part D Utilization Management . 56How to File a Coverage Determination . 56How to File a Part D Appeal . 57Pharmacy Networks . 58Preferred Pharmacy Network . 58Pharmacy Quality Programs . 58Narcotic Case Management . 58Medication Therapy Management . 59Drug Utilization Review . 59Prescription Drug Monitoring Programs Low Income Subsidy Program Information . 61Overview . 612020 Cigna Medicare Advantage Provider Manual - Version 2Return to Table of Contents4 Page

Eligibility . 61Applying For Extra Help . 61Home Delivery Pharmacy . 62Express Scripts . 62Specialty Pharmacy . 62Medical Health Services . 62Overview . 62Goals. 63Departmental Functions . 63Prior Authorization . 63Prior Authorization Department. 66Denial or Adverse Organization Determination . 67Adverse Determinations – Concurrent Review . 72Rendering of Adverse Determinations (Denials) . 72Notification of Adverse Determinations (Denials) . 73Discharge Planning and Acute Care Management (ACCM) . 73Outpatient Observation Notice . 73Referrals . 73Referral Guidelines . 73Referrals Crosswalk . 74PPO Products - Referrals . 75HMO Products - Referrals . 75Part B Step Therapy . 77Care Management. 78Care Management Program Goals . 78Care Management Approach . 78How to Use Services . 78Coordination with Network Providers . 79Program Evaluation. 79Quality Programs . 80Quality Improvement Organization Program Changes . 80Quality Care Management Program . 81Overview . 81Values. 81Quality Principles . 812020 Cigna Medicare Advantage Provider Manual - Version 2Return to Table of Contents5 Page

Program Scope . 82Goals . 82Corporate Quality Improvement Committee (CQIC) . 83Health Care Plan Effectiveness Data and Information Set . 83Special Needs Plans (SNP) . 84Background . 84Special Needs Plan Eligibility Criteria . 84SNP MOC Process . 85SNP Contact Information . 86Customer Information Closing Customer Panels . 87Transmission of Lab Results . 87Customer Information, Rights and Responsibilities . 87Medical Record Standards . 87Programs and Services . 88Benefits and Services . 88Emergency Services and Care After Hours . 88Emergency Services . 88Urgent care services . 89Excluded Services . 89Customer Rights . 89Advance Medical Directives . 92Customer Responsibilities. 94Policies . 94Corporate Compliance Program . 94Overview . 94Fraud, Waste, and Abuse . 96Medicare Advantage Program Requirements . 97Overview . 97Books and Records; Governmental Audits and Inspections . 97Privacy and Confidentiality Safeguards . 97Patient Hold Harmless . 98Non-Covered Services . 98Delegation of Activities or Responsibilities . 99Compliance with Cigna’s Obligations, Provider Manual, Policies and Procedures . 99Subcontracting . 992020 Cigna Medicare Advantage Provider Manual - Version 2Return to Table of Contents6 Page

Compliance with Laws . 100Program Integrity . 100Continuation of Benefits . 100Incorporation of Other Legal Requirements . 100Conflicts . 100Dispute Resolution. 100APPENDIX . 1012021 Plan Offerings/Service Maps . 101Alabama, Florida, and South Mississippi . 101Arkansas . 101Arizona . 102Central Florida (Daytona, Orlando & Tampa) . 102South Florida (Leon Medical Center) . 103South Florida East . 103Colorado . 104Georgia . 104Illinois. 105Kansas City . 105Mid-Atlantic . 106New Jersey . 106New Mexico . 107North and South Carolina . 107Ohio . 108Oklahoma . 108Pennsylvania . 109Tennessee, North Georgia, and Southwest Virginia . 109Texas . 110Utah . 1102020 Cigna Medicare Advantage Provider Manual - Version 2Return to Table of Contents7 Page

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 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 this manual.TopicReferralsQuick Reference GuideLocal Network InformationWhat you need to know HMO: Referral required in selectplans PPO: No referral requiredHighlights Key Contacts Regional Product Maps are located inthe Appendix. Market-specific contacts are locatedthroughout the Provider Manualdepending on the topic. Customer Identification Cards providehigh-level product/network information.Remember to contact the phonenumbers on the card for assistance andfollow guidance in order to verifyeligibility, referral/no referral andauthorization guidance.2020 Cigna Medicare Advantage Provider Manual - Version 2Return to Table of Contents8 Page

BehavioralHealth/SubstanceUse DisordersClaims ProcessingKEY CONTACTSCigna 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) eway EDI (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 37202Appeals questions: 1-800-511-6943 Fax: 1-800-931-0149Mail Appeals to:CignaAttn: Part C AppealsPO Box 24087Nashville, TN 37202www.cigna.com/codingeducationTo report potential fraud, waste or abuse please contactCigna’s Special Investigations UnitBy mail:CignaAttn: Special Investigations UnitPO Box 20002, Nashville, TN 37228By email: specialinvestigations@cigna.comAttn: Cigna Medicare OperationsBy phone: 1-800-667-714510 P a g e 1 0 P a g e2020 Cigna Medicare Advantage Provider Manual - Version 2Return to Table of Contents10 P a g e

Council forhttps://proview.caqh.orgAffordable QualityHealthcare (CAQH )Dental ServicesDentaQuest: Call: 1-800-241-6554 or on /Co-PaymentInformationHSConnect(Online Portal)Dental Allowance: Call: 1-866-213-7295For questions concerning Supplemental Benefits, please callProvider Services Call: 1-800-230-6138Customer Service: 1-800-668-3813 Provider Portal: ce the ease of HSConnect. Your online solution forreferral entry and inquiry, inpatient authorization inquiry,eligibility verification, and claims payment review.Call: 1-866-952-7596 Email:HSConnecthelp@hsconnectonline.com To register for HSConnect tpatientPlease visit the Provider Online Directory for a complete listingLaboratory Services of participating outpatient laboratoriesPrior Authorization(Non-Pharmacy)Prior AuthorizationHigh TechRadiology,DiagnosticCardiology,Radiation Therapy,Medical OncologyPharmacyPrior Authorization must be obtained for the followingservices: Inpatient and Elective Admission Notification, HomeHealth Care, DME, and Outpatient Services.Prior Authorization can be obtained through HSConnectProvider Portal: https://www.hsconnectonline.com/login.aspxor by calling Provider Customer Service at 1-800-230-6138.Please see the Medicare Advantage Provider QuickReference Guide here for additional information onsubmitting prior authorization requests to eviCore foroutpatient, non-emergent high tech radiology anddiagnostic cardiology, radiation therapy and medicaloncology servicesPrior Authorization Requests:Electronic: www.covermymeds.com (Preferred method)Forms: www.cigna.com/medicare/resources/drug-searchPhone: 1-877-813-559511 P a g e 1 1 P a g e2020 Cigna Medicare Advantage Provider Manual - Version 2Return to Table of Contents11 P a g e