Transcription
PROVIDER MANUALCigna STAR PLUSThe Tarrant Service AreaDenton, Hood, Johnson, Parker, Tarrant,and Wise countiesPublication date:03/02/2020The Hidalgo Service AreaProvider Services -CareProviders/Cameron, Duval, Hidalgo, Jim Hogg,Maverick, McMullen, Starr, Webb, Willacy,and Zapata countiesThe MRSA-Northeast Service AreaAnderson, Angelina, Bowie, Camp, Cass,Cherokee, Cooke, Delta, Fannin, Franklin,Grayson, Gregg, Harrison, Henderson,Hopkins, Houston, Lamar, Marion, Montague,Morris, Nacogdoches, Panola, Rains, Red River,Rusk, Sabine, San Augustine, Shelby, Smith, Titus,Trinity, Upshur, Van Zandt, and Wood CountiesMCDTX 20 71747 PR
Dear Valued Provider and Staff:I would like to extend a warm welcome and thank you for participating with Cigna Texas’ Network of ParticipatingProviders. We value our relationship with all of our providers and are committed to working with you to meet theneeds of your Cigna Medicaid patients.Cigna has provided managed care services to Medicare and Dually-eligible Members since 1996. We are excited toextend our passion for offering quality health care delivery to Texas STAR PLUS Members.We look forward to working with you to serve the needs of Texas STAR PLUS Members in order that they may livelife well.Sincerely,Cigna Medicaid OperationsCigna STAR PLUS Provider Manaul – Version 1MCDTX 20 71747 PR2
Table of ContentsImportant Phone Numbers7Introduction7STAR PLUS Program Overview9Objectives of the STAR PLUS Program9Role of the Primary Care Provider (PCP)9Role of the Specialty Care Provider10Missed appointments by Membership11Role of the Long-Term Services and Supports (LTSS) Provider11Role of Service Coordinator12Role of the Pharmacy Provider13Role of Main Dental Home13Network Limitations13Focus Studies and Utilization Management reporting requirements.14Covered Services14Medicaid Managed Care Covered Services14Covered Services for Individuals with Intellectual Disability (ID) or Developmental Disability (DD)15Covered Services for Individuals in Medicaid for Breast and Cervical Cancer (MBCC)15Behavioral Health Covered Services16Long-Term Support Covered Services22Pharmacy Benefits27Lock-In Program29Prescription Drug Monitoring Programs31Morphine Equivalent Dose (MED)31Value-Added Services31Non-Medicaid Managed Care Covered Services (Non-Capitated Services)32Texas Health Steps Services33Components of a Texas Health Steps Medical Checkup33Timeframe for a Texas Health Steps appointment34Members are not limited to In-Network Providers for Texas Health Steps Services34Texas Health Steps Provider Enrollment34Texas Health Steps Provider Responsibilities34How to Help a Member Find Dental Care35Children of Migrant Farm Workers35Documentation of completed Texas Health Steps components and elements35Emergency Services37Cigna STAR PLUS Provider Manaul – Version 1MCDTX 20 71747 PR3
Definitions37Emergency Prescription Supply38Emergency Transportation38Emergency Dental Services38Non-Emergency Dental Services39Non-Emergent Ambulance Transportation39STAR PLUS Eligibility & Enrollment39STAR PLUS Eligibility39Enrollment40Newborn Enrollment40Enrollment for Individuals in Medicaid for Breast and Cervical Cancer (MBCC)40Verifying Eligibility41Monthly PCP Panel Reports42Disenrollment42Automatic Re-Enrollment43Span of Eligibility43Retroactive Eligibility Changes43Service Coordination and Disease Management44Service Coordinator Assignments44Long-Term Services and Supports45Authorization of Services through the Service Coordinator45Disease Management (DM)45Care and Service Plans (CSPs)46Medical Management/Utilization Management47Utilization Review Criteria47Authorization Process48Limits of Authorization52Direct Access Services53Out of Network Authorizations53Continuity of Care53Discharge Planning55Billing and Claims Administration56Claims Submission56Claims Addresses56Claims Responsibility for Vision and Dental Services57Claims Filing Deadline57Claim Filing Formats58Cigna STAR PLUS Provider Manaul – Version 1MCDTX 20 71747 PR4
National Provider Identification (NPI) Numbers59National Drug Code (NDC)60National Drug Code (NDC)63Coverage in prenatal period79Coverage for Newborn92Breast pump coverage & billing79Coordination of Benefits83Prior Authorization83Claims Payment83Electronic Funds Transfer83Claim Status and Resolution of Claims Issues84Claims Appeals84Balance Billing86Private Pay Agreement87Claim Filing Tips87Sample of Explanation of Payment (EOP)89Communication Among Providers90Provider Access and Availability Standards90Demographic Changes92Advanced Medical Directives92Coordination with Texas Department of Family and Protective Services (TDFPS)92Termination of Provider Contracts93Provider Marketing Guidelines93Attendant Care Enhancement Program (ACEP)94Continuing Provider Training101Cigna Provider Compliance and Waste, Abuse, and Fraud Policy101Provider Complaint and Appeal Process104Quality Management124Overview124QI Department Functions107Quality Improvement Committee (QIC)107Clinical Practice Guidelines107Healthcare Plan Effectiveness Data and Information Set (HEDIS )108On-Site Assessments110Medical Record Requirements110Cigna STAR PLUS Provider Manaul – Version 1MCDTX 20 71747 PR5
Credentialing112Member Services119Special Access Requirements119Direct Access to a Specialty Care Provider for Members with Special Health Care Needs120Member Rights and Responsibilities121Member’s Right to Designate an OB/GYN123Member Complaint and Appeal Process123Appendices128Appendix A, Cigna Member Identification Card129Appendix B, Cigna Member Identification Card130Appendix C, Sample Texas Benefits Medicaid Card131Appendix D, Sample Form 1027-A Temporary Medicaid Identification132Appendix E, List of Prior Authorization Services – Acute, Long Term Support Services (LTSS) and BehavioralHealth Services133Appendix F, Texas Standard Prior Authorization Form136Appendix G, Outpatient Prior Authorization Form137Appendix H, Inpatient Prior Authorization Form138Appendix I, Sample UB-04 Claim Form139Appendix J, Sample CMS 1500 Claim form140Appendix K, Sample of Claims Appeal Form141Appendix L, Disease Management Patient Referral Form142Appendix M, Member Acknowledgement Statement143Appendix N, Private Pay Agreement144Cigna STAR PLUS Provider Manaul – Version 1MCDTX 20 71747 PR6
Important Phone NumbersFor quick reference information about Cigna and the STAR PLUS program, providers can visit our websiteat https://starplus.cigna.com/health-care-providers or our Provider Portal at https://starplus.hsconnectonline.com.PLEASE NOTE: Users should not enter "www" prior to entering the web address for the Provider Portal. Also,providers can call the following resources for more information.Cigna-ContactsProvider Services DepartmentMember Services DepartmentBehavioral Health and Substance AbuseBehavioral Health Crisis HotlineCigna Pharmacy Prior AuthorizationClaims Status RequestCompliance HotlineCigna Automated Eligibility Verification LineService CoordinationUtilization Management - Concurrent ReviewUtilization Management – Home Health / Long-Term Services and SupportsUtilization Management - Inpatient Intake Prior AuthorizationUtilization Management – Outpatient Prior AuthorizationExternal Contacts24-Hour Health Information LineTMHP Automated Inquiry System (AIS), Eligibility VerificationExpress Scripts Pharmacy Help DeskChange Healthcare - EDI (formerly Emdeon)Comprehensive Care Program (CCP)Dental – DentalQuestQuest DiagnosticsClinical Pathology Laboratories (CPL)Laboratory Services (Labcorp)ProPathMAXIMUS (Medicaid Managed Care Helpline)Ombudsman Medicaid Managed Care HelplineOmbudsman Medicaid Managed Care Helpline TYYMedical Transportation Program (MTP) HidalgoMedical Transportation Program (MTP) MRSATexas Department Of Family And Protective Services (TDFPS)Vision – Superior VisionIntroductionCigna STAR PLUS Provider Manaul – Version 1MCDTX 20 71747 -1995
Welcome to the Cigna's STAR PLUS program. In 2011, Cigna was selected by the Texas Health and HumanServices Commission (HHSC) to be one of the STAR PLUS HMOs serving the Tarrant Service Area, HidalgoService Area, and the MRSA Northeast Service Area with an effective date of September 1, 2014.We look forward to partnering with you to meet the needs of your patients, our Members. This Provider Manual is areference for providers concerning Cigna's STAR PLUS operating requirements. Providers should use this ProviderManual in conjunction with the Cigna participating provider agreement to understand important participationrequirements such as: Services that are covered under STAR PLUS,How to determine Member eligibility,How to access health care services within Cigna's network,How to file claims with Cigna,Provider roles and responsibilities,How and when to obtain authorization for services,Cigna's Quality Management Program, andMember roles and responsibilities.Cigna cultivates strong business relationships with Members, providers, HHSC and local community organizations,with the goal of delivering excellent service to each. Our promise to providers is to bring value to their businesses byoffering expeditious claims processing and simple administrative requirements. For Members, we strive to: Ensure Members receive the appropriate level of care, in the least restrictive setting, and consistent with theirpersonal health and safety;Improve access to health care;Improve the quality of health care; andAssure satisfaction.Cigna conducts its business affairs in accordance with Federal and State laws. Cigna takes the privacy andconfidentiality of Members' health information seriously. Cigna complies with the Health Insurance Portability andAccountability Act of 1996 (HIPAA) and Texas regulatory requirements.This Provider Manual is current as of its publication date. Cigna reserves the right to make updates as necessaryand will make updates available to providers promptly.Cigna STAR PLUS Provider Manaul – Version 1MCDTX 20 71747 PR8
STAR PLUS Program OverviewSTAR PLUS is a Texas Medicaid managed care program designed to coordinate and provide preventive, primary,acute care and Long-Term Services and Supports (LTSS) through a managed care delivery system for persons of allages with disabilities as well as for elderly persons age sixty-five (65) and over who qualify for Medicaid throughSupplemental Security Income (SSI) or Medical Assistance Only (MAO). The STAR PLUS Program assistsMedicaid Members who have disabilities, special health care needs or chronic and complex conditions and requiremore extensive care than acute care services alone. For this reason, service coordination is a key feature ofSTAR PLUS. Service coordination allows Medicaid Members, their family Members, and providers to work togetherto coordinate acute care services, LTSS, and other community services. In the STAR PLUS Program, Memberschoose an HMO from those available in their Service Area and receive Medicaid services and service coordinationthrough that HMO. Eligibility and Enrollment for STAR PLUS, including Members who are Dual eligible, is discussedin greater detail in the STAR PLUS Eligibility & Enrollment section of this Provider Manual.Objectives of the STAR PLUS ProgramThrough contracts with HMOs, HHSC's goal is to integrate acute care and LTSS, including services provided throughMedicare Advantage Dual Special Needs Plans (MA-Dual SNP); and provide continuity of care and timely access toquality care through an adequate provider network that includes behavioral health services and disease managementservices.The objective of the STAR PLUS Program is to: Prevent or delay the institutionalization of Members through effective use of home and Long-Term Servicesand Supports; Assign Medicaid-only Members to a medical home; Conduct utilization management to ensure appropriate access to and utilization of Medicaid services; Assess Member’s health risks and functional needs; Notify the Member’s medical home and other providers about the Member’s service utilization and associatedcosts; Reduce inappropriate emergency room utilization; Provide competent service coordination which includes assessing, service planning, monitoring andcoordinating care for Members with complex, chronic, or high cost health care or social support needs,including services Members need to remain in the community; Coordinate services between Medicaid and Medicare managed care products for Dual eligible Members; and Provide comprehensive, community-based education to Members regarding STAR PLUS, while ensuringaccess to services for Members with physical or mental disabilities and Members with limited Englishproficiency.Role of the Primary Care Provider (PCP)Except for Dually-eligible Members, Cigna Members must select an in-network Primary Care Provider (PCP) tooversee their care. PCPs are normally selected by the Member during the enrollment process. If a Member does notselect a PCP during the enrollment process, one will be auto-assigned to them based on PCP proximity by HHSC'senrollment broker, MAXIMUS. Members may change PCPs at any time by calling the Cigna Member ServicesDepartment at 1-877-653-0327.A PCP may specialize in the following specialties: General practice; Family practice; Internal medicine; Obstetrics/Gynecology (OB/GYN); or Pediatrics.Cigna STAR PLUS Provider Manaul – Version 1MCDTX 20 71747 PR9
When practicing under the supervision of a participating Cigna physician, advanced practice nurses (APNs) mayserve as PCPs. Rural Health Clinics (RHCs), Federally Qualified Health Centers (FQHCs), and Community Clinicsmay serve as PCPs. Specialty Care Providers serve as PCPs under specific circumstances. The circumstancesunder which this may occur are discussed in the Member Services section of this Provider Manual.The PCP serves as the "medical home” or the entry point for access to health care services. The PCP provides orarranges for all medically necessary primary care services and refers Member for specialty care when necessary.Cigna PCPs are responsible for the following: Verifying Member eligibility prior to rendering services;If indicated, obtaining authorizations prior to rendering services;Managing the health care needs of all assigned Members;Providing continuity of care for Members;Ensuring that each Member receives medically necessary treatment based on the Member’s condition;Providing behavioral health services within his or her scope of practice;Complying with Cigna’s prior authorization procedures;Using appropriate ancillary services;Referring Members to participating Cigna providers;Referring Members for a second opinion, if requested;Complying with Cigna's emergency care procedures;Notifying Cigna of any barriers to a Member's care;Adhering to Cigna’s medical record standards as outlined in this Provider Manual;Complying with Cigna’s Quality Management and Utilization Management programs;Complying with preventive screening and clinical guidelines;Being culturally sensitive to Members;Complying with Cigna's credentialing and re-credentialing requirements;Complying with Cigna's access and availability standards as outlined in this Provider Manual;Using a National Provider Identification (NPI) number;Billing services in accordance with the billing procedures outlined in this Provider Manual; andWhen billing for services provided, using specific coding to capture the acuity and complexity of a Member’scondition and ensuring that submitted codes are supported by the medical record.Notifying Cigna and HHSC’s administrative services contractor of any changes to the provider’s address,telephone number, group affiliation, etc.Notifying Cigna of any changes to member demographic information that is changed and/or differs from whatCHS shows as our demographic information, including but not limited to, address, phone #, homeless status,etc.Role of the Specialty Care ProviderSpecialty Care Providers play an essential role in caring for Members. A Cigna Specialty Care Provider isresponsible for providing health care services to Members who require care beyond the capabilities of a PCP.Specialty Care Providers must render covered health services within the scope of their practice and license, in thesame manner, according to the same standards, and within the same time availability as offered to their otherpatients. It is the responsibility of the Specialty Care Provider to communicate their findings and recommendationswith each Member's PCP in order to promote coordination and continuity of care.Cigna Specialty providers are responsible for the following: Verifying Member eligibility prior to rendering services; If required, obtaining authorizations prior to rendering services; Providing specialty health care services to Members as needed;Cigna STAR PLUS Provider Manaul – Version 1MCDTX 20 71747 PR10
Collaborating with the Member’s PCP to ensure continuity of care and appropriate treatment;Providing consultative and follow-up reports to the PCP in a timely manner;Referring Members to participating Cigna providers;Complying with Cigna’s prior authorization procedures;Complying with Cigna's access and availability standards as outlined in this Provider Manual;Complying with Cigna’s Quality Management and Utilization Management programs;Adhering to Cigna’s medical record standards as outlined in this Provider Manual;Using a National Provider Identification (NPI) number;Billing services to Cigna in accordance with the billing procedures outlined in this Provider Manual; andWhen billing for services provided, using specific coding to capture the acuity and complexity of a Member’scondition and ensuring that submitted codes are supported by the medical record.Notifying Cigna of any changes to member demographic information that is changed and/or differs than what CHSshows as their demographic information, including but not limited to, address, phone #, homeless status, etc.Missed appointments by MembershipMembers may sometimes cancel or not appear for necessary appointments and fail to reschedule the appointment.This can be detrimental to their health. Cigna requests providers to attempt to contact Members who have not shownup for or canceled an appointment without rescheduling the appointment. The contact may be by telephone, allowingthe provider to educate the Member about the importance of keeping appointments. It’s also a good time for theprovider to encourage the Member to reschedule the appointment. Cigna Members who frequently cancel or fail to show up for appointments without rescheduling may need additionaleducation in appropriate methods of accessing care. In these cases, providers can call Provider Services at 1-877653-0331. ForBehavoiral Health Providers contact our Behavioral Health Team at 1-877-725-2539. Our staffcontacts the Member and offers more extensive education through our case management team. It is imperative thatour Members recognize the importance of maintaining preventive health visits and following their PCP’srecommended plan of care.Role of the Long-Term Services and Supports (LTSS) ProviderLong-Term Services and Supports (LTSS) providers deliver a continuum of care and assistance ranging from inhome and Long-Term Services and Supports. At times, LTSS is necessary as a preventative service to avoid moreexpensive hospitalizations, emergency room visits, or institutionalization. At other times, LTSS is necessary toassure that Membe
2 Cigna STAR PLUS Provider Manaul – Version 1 MCDTX_20_71747_PR Dear Valued Provider and Staff: I would like to extend a warm welcome and
