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Table of SFor contracted psychiatrists, psychologists, master-leveltherapists, hospitals, and facility based programs.The Evernorth Behavioral Administrative Guidelines were previously referred to as the Medical Management Program.PCOMM-2021-1080 8/21
Table of contentsIntroduction . 8Inside the guide . 8Our commitment and mission . 8Contact us . 8Notes . 8Regulatory addenda and state-specific information . 10Important contact information . 11Demographic information and directory . 13Benefit plan designs and features . 14Products . 17Cigna Choice Fund . 17Cigna debit card transactions . 17ID cards – quick guide . 18“G” ID cards . 18Strategic Alliances . 18Shared administration . 20Payer solutions segment . 21Medicare Advantage . 22Medicare managed care . 22Access to records and facilities . 22Confidentiality and accuracy of participant records . 22Transfer of medical records . 23Serving a diverse population. 23Complex care, follow-up care and self-care . 24Claims and encounter reporting . 24Appeals and grievance process . 24The role of the physician practitioner . 26Employee Assistance Professionals Association (EAPA) . 31Evernorth Behavioral Health's EAP Models . 31Digital solutions for providers . 40The Evernorth provider website . 41Patient eligibility and benefits . 42Claim information . 43Online remittance reports . 43Page 2 of 114
Cigna Cost of Care Estimator . 44Electronic Data Interchange (EDI) . 44Electronic transaction support . 45Evernorth payer ID for submitting electronic claims . 45IVR user tips . 45ePrescribe . 45Online training and resources. 46Cultural competency . 46Onboarding. 47How to join the Evernorth Behavioral Health network . 47Individual practitioners providing behavioral services at Cigna-participatingmedical practices . 47Clinics . 48Autism clinics . 48Facilities . 49Credentialing for providers . 49Council for Affordable Quality Healthcare (CAQH) credentialing database system . 49Notice of changes of licenses or accreditation . 50Termination appeal process . 50Credentialing process for providers . 50Provider rights . 51Clinic-based programs . 52Recredentialing process for professionals . 52Credentialing requirements for facilities . 53Recredentialing requirements for facilities . 54Provider specialties and urgent access . 54Provider specialties . 54Urgent access. 55Forms . 58Provider participation . 59Service standards and requirements . 59Acceptance and transfer of participants. 60Communication to participants of professional termination . 60Scheduling appointments . 60Telephone response time . 61Professional services . 61Page 3 of 114
Cooperation with programs . 61Referrals . 62Medication . 62Participant billing . 62Denied payment and participant non-liability . 64Self-pay agreements . 64Provider concerns related to administrative processes . 65Resolving participant complaints . 65Confidentiality. 66Eligibility . 67Determining eligibility . 67Eligibility verification . 67Case Management Program . 68Precertification protocol . 68Utilization management – responsibility for precertification . 68Utilization management – precertification for admissions . 68Emergency admissions. 69Extenuating circumstances . 69General considerations – precertification . 70Utilization management (continued stay review). 70Outpatient services . 71Retrospective precertification of Outpatient services. 71Autism spectrum disorder and applied behavior analysis . 71Testing . 71Buprenorphine treatment . 71Evernorth Behavioral Health's compensation . 72Coverage denials . 72Appeals of coverage denials . 72Administrative denial and appeal . 73Pass-through billing . 73Coaching and support programs . 73Claims and compensation . 74Claim submission . 74Electronic claim submission . 74Paper claim submission . 75Definition of a complete claim . 75Page 4 of 114
Supplemental claim information . 79Claim filing deadline. 80Claim inquiry and follow-up . 80Claim payment policies and procedures . 81Standard claim coding/bundling methodology . 81Participant liability collection limitations . 81Copayments . 81Coinsurance and deductibles. 81Fee forgiving/waiver of copayment/coinsurance or deductible . 82Denied payment and participant non-liability . 82Coordination of benefits (COB) . 82Cigna or Evernorth Behavioral Health as primary payer . 82Cigna or Evernorth Behavioral Health as secondary payer . 82Order of benefit determination . 83Workers’ compensation . 84Subrogation and reimbursement requirements . 84Other billing guidelines Overpayment recovery . 84Explanation of payment . 85Explanation of benefits and explanation of payment . 85Electronic funds transfer . 85What are the benefits of EFT? . 86Payment bulking options. 86Enrolling in EFT for Cigna plans . 87EFT enrollment guidelines . 87Electronic remittance advice . 87To enroll for ERA . 88Posting payments and adjustments . 88Applicable rate . 88Rates and changes to coverage . 88Claim quality and cost-effectiveness programs. 89Clinical Claim Review Program . 89Resolving payment questions . 90Prior to providing services . 90Page 5 of 114
Prior to filing a claim . 90Dispute resolution. 91Provider payment appeals . 91Appeals . 91Appeal types and filing instructions . 92National ancillaries: Laboratories . 95Participant Information . 96Alternate Member Identifier (AMI). 96Verification options . 96Participant concern or complaint . 96Provider cooperation . 97Health Insurance Portability and Accountability Act (HIPAA) of 1996 . 97Security regulations . 98National Provider Identifier . 98837 electronic claims . 98835 electronic remittance advice. 99Real-time request transactions (270, 276, 278) . 99Prescription Drug Program . 101Prescription drug list . 101Medications requiring precertification (medical necessity request process) . 101Pharmacy clinical support programs. 102Complex Psychiatric Case Management program . 102Quality Management Program . 103Creating opportunities for quality improvement. 103Coordination of behavioral health and general medical care . 103Participant rights and responsibilities . 104Customers’ rights and responsibilities statement . 105Statement on confidentiality of alcohol and drug use records . 106Improving participant safety. 107Health promotion/preventive health services . 107Educational opportunities for providers . 108Medical necessity criteria . 108State-specific criteria . 109Clinical practice guidelines . 109Clinical screening tools and treatment support toolkits . 110Integration with chronic condition/disease management . 110Page 6 of 114
Treatment record-keeping . 110Clinical and quality improvement studies . 111National quality initiatives . 112National Quality Forum . 112Centers of Excellence . 112Resources and forms . 113Legal Statement . 114Page 7 of 114
IntroductionIntroductionInside the guideWelcome to Evernorth! For starters, we’d like you to know that we’re committed to givingall of our customers access to quality services and benefits. That means working withyou across all the aspects of today’s health care world. To help us stay on the samepage, we have created these Administrative Guidelines for you. It highlights theprograms and policies intended to keep our relationship smooth and productive – for thesake of the people we serve together.The Administrative Guidelines were previously referred to as the “Medical ManagementProgram.” Any agreement or document that references the Medical ManagementProgram, the Provider Guide, the Provider Manual or the Provider AdministrativeGuidelines shall all be construed to reference this document.Your Provider Agreement and these Administrative Guidelines describe the terms underwhich you agree to provide services to all Participants. Those terms include thereimbursement rates applicable to Covered Services provided to Participants. However,the actual benefits payable by a Payer for Covered Services provided to a Participant inall cases are determined by the terms of the Payer’s Benefit Plan.Our commitment and missionWe also understand that a stable provider panel facilitates our goal of consistent andsuperior customer service. For that reason, we seek to build strong, long-standingrelationships with our providers. Our policies and protocols have been developed tominimize time-consuming administrative activities, so you can spend more timeproviding superb service.Evernorth Behavioral Health, Inc. is a subsidiary of Cigna and the behavioral network forcustomers with Cigna health plans. Note, however, we also sell behavioral healthsolutions to clients who may not have Cigna health plans. Evernorth provides behavioralcare benefit management, employee assistance and work/life programs to consumersthrough United States employers of all sizes, national and regional HMOs, Taft-Hartleytrusts and disability insurers. With headquarters in Bloomington MN, we operate fourcare management centers around the United States in support of a national network ofpsychiatrists, psychologists and master-level therapists, clinics and facilities.Contact usPlease contact us if you have questions about the information in this guide, or our plansand programs. The terms of your agreement supersede this guide if a conflict arises. Inall circumstances the parties shall comply with applicable law and the regulatoryaddendum contained herein.NotesEvernorth manages mental health and substance use disorder services of benefit planssponsored and/or administered, in whole or in part, in compliance with applicable laws,rules, and regulations, including without limitation the Federal Mental Health Parity andAddictions Equity Act, Affordable Care Act, state parity laws, and regulations.Page 8 of 114
IntroductionNot all Administrative Guidelines and Program Requirements are outlined in thisguide. Other guidelines and requirements or updates may be posted on the Evernorthprovider website at Provider.Evernorth.com or communicated through notifications wedeliver by mail, email, phone, fax or in person.Page 9 of 114
Regulatory addenda and state-specific informationRegulatory addenda and state-specific informationEnclosed at the end of these Administrative Guidelines are the state specific regulationsand contract provisions applicable to the provider and which govern the ProviderAgreement. These provisions are incorporated into the Provider Agreement to the extentrequired by law and as specified in such Addenda. The regulatory addenda shall befrequently updated to be in compliance with applicable law.Please use the table below to access each state regulatory addendum.Alabama (AL)Alaska (AK)Arizona (AZ)Arkansas (AR)California (CA)Colorado (CO)Connecticut (CT)Delaware (DE)Florida (FL)Georgia (GA)Hawaii (HI)Idaho (ID)Illinois (IL)Indiana (IN)Iowa (IA)Kansas (KS)Kentucky (KY)Louisiana (LA)Maine (ME)Maryland (MD)Massachusetts (MA)Michigan (MI)Minnesota (MN)Mississippi (MS)Missouri (MO)St. LouisMontana (MT)Nebraska (NE)Nevada (NV)New Hampshire (NH)New Jersey (NJ)New York (NY)North Carolina (NC)North Dakota (ND)Ohio (OH)Oklahoma (OK)Oregon (OR)Pennsylvania (PA)Rhode Island (RI)South Carolina (SC)South Dakota (SD)Tennessee (TN)Texas (TX)Utah (UT)Vermont (VT)Virginia (VA)Virgin Islands (VI)Washington DCWashington (WA)West Virginia (WV)Wisconsin (WI)Wyoming (WY)Note: These requirements apply only to the extent required by applicable law and maynot apply to Participants covered under self-funded plans.Page 10 of 114
Important contact informationImportant contact informationFind the contact you need for information about your patients. Please note that call,claim, and service channels may differ based on the participant’s identification (ID) card.If you want to:Use the following:Update your provider directory demographicinformation, or notify us of errors/changes to theway you are currently listed in our providerdirectories, including: Name Type/Degree Specialty National Provider Identifier (NPI) number Clinic or facility affiliation Office email address Address Office phone number Whether you are accepting new patientsLog in to Provider.Evernorth.com to useour updated online change form. If youhaven't registered yet, please go toProvider.Evernorth.com and click“Register” to begin the process.Perform online transactions: Verify patient eligibility Inquire about patient coverage and coveredservices Predict the total cost of service and patientliability for specific procedures Review medical or pharmacy coveragepositions View the prescription drug list View sample ID cards Obtain a Reference GuidePerform transactions using Electronic DataInterchange (EDI): Verify patient eligibility and coverage Inquire about patient coverage and coveredservices Check the status of a claim Request precertification for services Submit claims electronically Receive electronic remittance advicePerform telephone transactions: Learn about electronic services Verify patient eligibility and coverage Check the status of a claim Request precertification for servicesSubmit a paper claimOrEmail: cforms@evernorth.comFax: 860.687.7257Mail: Network Operations6625 W 78th Street, Ste. 100Bloomington, MN 55439Website: Provider.Evernorth.comRefer to Cigna.com/EDIvendors for a listof directly connected Cigna vendors.Phone: 800.926.2273Customer Service numbers are alsoincluded on the patient’s ID card.Refer to patient’s ID cardPage 11 of 114
Important contact informationIf you want to:Use the following:For Cigna or Evernorth:Submit or inquire about an appeal or disputePhone: 800.926.2273Fax: 877.815.4827Mail: Evernorth AppealsPO Box 188064Chattanooga, TN 37422For patients with “G” ID cards:Fax: 877.804.1679Mail: Cigna National AppealsPO Box 23487Chattanooga, TN 37422-8062Inquire about provider credentialingPhone: 800.926.2273Obtain other telephone numbers and addressesRefer to the participant’s ID cardPage 12 of 114
Demographic information and directoriesDemographic information and directoryWe use your demographic information to: Publish online provider directoriesSend communications to providersProcess claimsComply with state laws requiring accurate directory listingsDetermine network adequacyNotify us in writing 90 days before any changes to your practice demographic information.Examples of such changes include changes in service location, billing address, telephonenumber, tax identification number (TIN), specialties, and new individual NPI ororganization NPI. It is also important for you to update your status if you are no longeraccepting new patients as this element is included in provider directory and relied uponby consumers.It is essential that you consistently identify yourself in written communications and claimsubmissions. Using abbreviations, variations of names, physician licensure or TINs notlisted in a provider agreement and/or not provided to Evernorth Behavioral Health, Inc. inadvance of the change may result in delayed changes to the provider directory andincorrect claim payments. The latest provider directory is available at Cigna.com.Submit demographic changes to Evernorth Behavioral Health, Inc. electronically bylogging in to Provider.Evernorth.com Working With Cigna Update DirectoryInformation.You may also submit demographic changes using the following fax and email address:Fax: 860.687.7257Email: cforms@evernorth.comPage 13 of 114
Benefit plan designs and featuresBenefit plan designs and featuresEvernorth Behavioral Health provides a menu of services, which include the provision ofbehavioral care services to Cigna HealthCare participants. Benefit plan types may includeHMO, OAP, PPO or employee assistance program (EAP). In addition, Evernorth BehavioralHealth provides behavioral services to other plans nationwide.Below is a summary of Cigna HealthCare benefit plan types:PlanHighlightsCigna SureFitCigna SureFit benefit plans build networks around local physician andhospital groups providing customers access to personal, patient-centeredcare.Highlights: PCP selection is required, where permitted. Referrals are not required for behavioral services. No out-of-network coverage unless an emergency or urgent care. You are responsible fo
care benefit management, employee assistance and work/life programs to consumers through United States employers of all sizes, national and regional HMOs, Taft-Hartley trusts and disability insurers. With headquarters in Bloomington MN, we operate four care management centers around the United States in support of a national network of
