BETTER HEALTH WERE IN IT TOGETHER Working together
BETTER HEALTH. WE’RE IN IT TOGETHER. Working together to provide affordable, accessible, quality health care. Date Presenter name
Better health. We’re in it together. • • Introductions Provider Digital Solutions Claims 101 Appeals 101 Keeping you updated Resources Q&A AGENDA Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2017 Cigna 2
Better health. We’re in it together. PROVIDER DIGITAL SOLUTIONS Tools to make your life easier Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2017 Cigna 3
PROVIDER DIGITAL SOLUTIONS OVERVIEW Tools that help streamline your office workflow and increase productivity Tool Solution Cigna for Health Care Professionals website • Access patient eligibility, benefits, claim status, resource information and much more 24/7 at Cignafor. HCP. com. For an overview of the website, click here: https: //cignaforhcp. cigna. com/public/content/pdf/resource. Library/e. Courses/medical/using. This. Websi te/website. Overview. pdf Electronic data interchange (EDI) • Reduce time and costs by accessing eligibility, benefits, claims, and more • Transmit health care information quickly and securely between providers, payers, and vendors • To learn more about EDI vendors, click here: Cigna. com/EDIvendors. Eligibility and benefits • Access detailed patient coverage and benefit information • To learn more about eligibility and benefits, click here: https: //cignaforhcp. cigna. com/public/content/pdf/resource. Library/e. Courses/medical/using. This. Websi te/eligibility. pdf Patient out-ofpocket cost estimator • Use the Cigna Cost of Care Estimator® tool to provide patients with accurate medical and behavioral out-of-pocket estimates and facilitate financial discussions before care, at check-in, or check-out • To learn more about the Cigna Cost of Care Estimator, click here: https: //cignaforhcp. cigna. com/secure/content/pdf/resource. Library/e. Courses/using. This. Website/medi cal/cigna. Cost. Of. Care. Estimator. pdf Online precertification • Submit and track medical and behavioral precertification requests • To learn more about online precertification, click here: https: //cignaforhcp. cigna. com/public/content/pdf/resource. Library/e. Courses/medical/using. This. Websi te/online. Precertification. pdf Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2017 Cigna 4
PROVIDER DIGITAL SOLUTIONS OVERVIEW (CONT. ) Tools that help streamline your office workflow and increase productivity Tool Electronic claims submission and claims status inquiry Solution • • • Decrease the chance of transcription errors or missing data Track claims received electronically, which are automatically archived before processing View, track and monitor claim status reports Save time on resubmissions – incomplete or invalid claims can be reviewed and corrected online To learn more about electronic claims submission, click here: https: //cignaforhcp. cigna. com/public/content/pdf/resource. Library/e. Courses/medical/edi. Options/med Behavior. Claim. Submit. pdf • To learn more about claims status inquiry, click here: https: //cignaforhcp. cigna. com/public/content/pdf/resource. Library/e. Courses/medical/edi. Options/edi. pdf Electronic funds transfer (EFT) and electronic remittance advice (ERA) • Receive and reconcile your payments faster with EFT and ERA • Use ERA with your accounts receivable system to help save time and reduce costs and posting errors • Avoid mail delays with EFT deposits. Claim payments are deposited directly into your bank account. Funds are available the day of the deposit, which increases efficiency and improves cash flow • To learn more about EFT and online remittance reports, click here: https: //cignaforhcp. cigna. com/public/content/pdf/resource. Library/global/e. Dieftorr. pdf • To learn more about ERA, click here: https: //cignaforhcp. cigna. com/public/content/pdf/resource. Library/global/e. Dipra. pdf Online remittance reports • Get detailed payment information at your fingertips and access to your remittance reports the same day you receive your electronic payment • To learn more about online remittance reports, click here: https: //cignaforhcp. cigna. com/public/content/pdf/resource. Library/global/e. Dieftorr. pdf Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2017 Cigna 5
Better health. We’re in it together. CLAIMS 101 Tips to make the claims filing and resolution process easier Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2017 Cigna 6
CLAIM DENIAL REASONS Avoid potential claim payment delays. Frequent claim denial reasons: – Duplicate claim submissions – claim already in process – claim previously processed – Missing information – Medicare explanation of benefit (EOB) – Other insurance EOB – Revenue codes itemization Carefully review the message(s) on your Explanation of Payment (EOP) to determine the reason for a denial of services or a payment reduction. If you have questions about a denial, please call the Cigna Customer Service toll-free number on the patient’s ID card. Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2017 Cigna 7
DUPLICATE CLAIM DENIALS Submit corrected claims electronically. • Use the Claim Frequency Type Code in loop 2300, segment CLM 05, to specify the frequency of the claim. (This is the third position of the UB 04 bill type. ) • Use one of the following codes to indicate the claim type: • 1 – Original (admit through discharge claim) • 7 – Replacement (of a prior claim), include Payer Claim Control # in segment REF*F 8 • 9 – Void (or cancellation of prior claim), include Payer Claim Control # in segment REF*F 8 When a corrected claim is submitted, you will receive a “duplicate to claim already in process” denial message and the corrections will be applied to the original claim. Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2017 Cigna 8
MEDICARE AND OTHER INSURANCE Submit COB (coordination of benefits) claims electronically. • Both primary and secondary (COB) claims can be submitted to us electronically. • You don’t have to submit Medicare Part A and Part B coordination of benefits agreement (COBA) claims to us, as the Medicare EOB or ERA will show that those claims have been forwarded to us as the secondary payer. • Talk to your EDI vendor about COB information. • It should be billed in loops 2320 and 2330 in the electronic claim form. Values in those loops must balance with loop 2300 Monetary Amount reported. Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2017 Cigna 9
REQUESTS FOR ADDITIONAL INFORMATION Respond to requests for information timely. Cigna routinely evaluates claims for coding, billing accuracy, and appropriateness and may request supporting claim payment information such as: – An itemized bill – Medical records Once the claims review is completed, we will: – process and reimburse the claim accordingly – issue an explanation of payment – send you a letter explaining any charges determined to be not payable Visit the secure Cigna for Health Care Professionals website for a list of the Not-Payable Reason Codes, including descriptions and reconsideration criteria, at Cignafor. HCP. com > Resources > Reimbursement and Payment Policies > Clinical Claim Review Not Payable Reason Codes. Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2017 Cigna 10
CLAIM SUBMISSION TIPS Refer to these additional claim submission tips. • Include the Present On Admission (POA) indicator for all diagnosis codes submitted on the inpatient claim form. Refer to the Hospital Acquired Conditions Reimbursement Policy located on the secure Cigna for Health Care Professional website at Cignafor. HCP. com > Resources > Clinical Reimbursement Policies and Payment Policies > Modifiers and Reimbursement Policies for more information. • Submit newborn claims with the following information: – the subscriber’s Cigna ID number without the suffix – the subscriber’s first and last names (not the mother, unless she is the subscriber) – the patient’s first name and last name, or Newborn, Baby Boy, Baby Girl, Twin A, Twin B, etc. ) – the patient’s date of birth – the patient’s gender Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2017 Cigna 11
PAYER SOLUTIONS: THIRD-PARTY ADMINISTRATORS Understand the Payer Solutions we offer. Cigna contracts with third-party administrators (TPAs), selected insurers, and claim administrators (referred to collectively as “payers”) to share the administration of self-funded Administrative Services Only (ASO) plans. We also contract with several insurance companies that issue individual and group insurance policies. For these relationships, we: • provide access to our network • perform medical management and utilization reviews • re-price claims according to our contracted rates and claims logic • provide clinical appeals management • provide contract dispute resolution TPAs and insurance companies: • maintain eligibility • administer benefits • pay claims for these shared accounts on their own systems Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2017 Cigna 12
PAYER SOLUTIONS: POINTS OF INTERACTION Claim flow: • Claims should be submitted to Cigna (payer ID 62308 or to the claims mailing address on the patient’s ID card • Cigna prices the claims based on the network contracted rates • The priced claim is then forwarded to the payer for payment based on the patient’s eligibility and benefits • The payers then remit payment following contractually agreed upon turnaround requirements Clinical and contract-related appeals: • Appeals of clinical denials should be sent to Cigna using the contact information supplied in the denial letter(s) • Appeals of application of contract rates should go to the address on the patient’s ID card Contact the payer* for: • • • Eligibility Benefits Precertification Claims status Non-pricing appeals * The contact phone number is located on the patient’s ID card Contact Cigna* for: • • • Reimbursement issues Pricing appeals General contract questions * The contact phone number for Cigna is 1. 888. 663. 8081 Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2017 Cigna 13
Better health. We’re in it together. APPEALS 101 Tips for filing an appeal Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2017 Cigna 14
APPEAL PROCESS Cigna strives to informally resolve issues raised by providers on initial contact whenever possible. If issues cannot be resolved informally: – Cigna offers a single-level, internal appeal process to resolve contractual disputes regarding post-service payment denials and payment disputes. Processes may vary due to state mandates or contract provisions. – The appeal must be initiated within 180 calendar days of the date of the initial payment or denial decision. – Arbitration may be used as a final resolution step after the internal Cigna process is complete. Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2017 Cigna 15
APPEAL PREVENTION TIPS Avoid having to file an appeal. There are steps you can take to avoid having to file an appeal: – Confirm the plan information on the patient’s ID card matches your contract (e. g. , PPO, Open Access Plus, Network POS). – Verify benefits by asking clarifying questions to confirm if the procedure or CPT® code is covered under the plan, and that you have met all plan requirements for coverage. – Check the Cigna for Health Care Professionals website at Cignafor. HCP. com to confirm conditions for coverage based upon the medical criteria outlined. – Verify precertification requirements. – Refer patients to Cigna-participating providers. Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2017 Cigna 16
FILING AN APPEAL Understand the denial before you file an appeal. • Most claim issues can be remedied quickly by providing requested information to a claim service center, contacting us, or resubmitting the claim. Carefully review the message(s) on your EOP to determine the reason for a denial of services or a payment reduction. We recommend contacting Cigna Customer Service before filing an appeal for: – Claim errors – Contract and fee disputes – Out-of-network claim payment disputes For additional information on how to submit an appeal, please review the Claim Adjustment & Appeals Guidelines on Cignafor. HCP. com > Resources > Clinical Reimbursement Policies and Payment Policies > Claims Appeals Policies and Procedures > Appeal Policy and Procedures. Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2017 Cigna 17
FILING AN APPEAL (CONT. ) Submit the right information when you file an appeal. Always attach the appropriate documents to support the coverage request and the patient’s condition: • Authorization of coverage or medical necessity – attach clinical documents, medical records, etc. • Inpatient facility denial (level of care or days) – attach a complete facility record. • Failure to obtain precertification – if urgent, emergent, or extenuating circumstances prevented you from obtaining precertification, include this information along with supporting clinical documentation. • Untimely claim submission – include proof of timely filing. • Claim bundling edits and modifiers - review claim bundling edit information using the Clear Claim Connection tool, and the modifier reimbursement information both located at www. Cignafor. HCP. com. Submit supporting documentation if you disagree with this information. To ensure efficient routing and handling of an appeal, complete the Request for Health Care Professional Payment Review form located on the Cigna for Health Care Professionals website (Cignafor. HCP. com > Resources > Form Center > Medical Forms). Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2017 Cigna 18
PEER-TO-PEER PROCESS Request a peer-to-peer review before filing an appeal. It may result in a reversal of a previous coverage decision. This review provides an opportunity to provide additional clinical information. Initiate by calling: 1. 800. 88 Cigna (882. 4462), option 3 If the peer-to-peer review does not result in a revised coverage decision, you may still submit an appeal through our appeal process. Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2014 Cigna Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2017 Cigna 19
Better health. We’re in it together. KEEPING YOU UPDATED The latest information on policy and coverage updates. Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2017 Cigna 20
USING THE DIGITAL ID CARD TOOL Key features • • Interactive, easy-to-navigate tool on Cigna. com Quick online access to patient ID card samples, plan details and requirements, direct links to the provider directory, Provider Digital Solutions options, my. Cigna mobile app overview, important contacts, and more. View demo View tool Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2017 Cigna 21
RECENT COVERAGE POLICY UPDATES October 2017 • Omnibus Reimbursement Policy (R 24): Urgent Care Services • Pharmacy and Infusion Services (R 14) • Omnibus Reimbursement Policy (R 24): Site of Service policy and coverage updates August 2017 • Uniform Billing Editor Transthoracic Echocardiography in Adults (0510) • Transthoracic Echocardography in Children (0523) • Implantable Hormone Pellets (1504) July 2017 • Facility Routine Services, Supplies and Equipment • (R 12), and Respiratory Services and Supplies (R 15) reimbursement policies May 2017 • Hearing Aids (0093) • Transthoracic Echocardiography in Children (0523) Information about these updates are available on the Cigna for Health Care Professionals website (Cignafor. HCP. com). Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2017 Cigna 22
RECENT PRECERTIFICATION UPDATES Effective July 1, 2017 Current Procedural Terminology (CPT®) codes Precertification changes For more information Visit Cignafor. HCP. com for an outline of monthly precertification updates and a complete list of services that require precertification for coverage. See Precertification Policies under Useful Links. • 0472 T and 0473 T: Device evaluation, interrogation, and initial programming of intraocular retinal electrode array (e. g. , retinal prosthesis) • 0474 T: Insertion of anterior segment aqueous drainage device, with creation of intraocular reservoir, internal approach, into the supraciliary space • 0475 T, 0476 T, 0477 T, 0478 T: Recording of fetal magnetic cardiac signal using at least three channels Health Care Common Procedure Coding System (HCPCS) codes • C 9489: Injection, nusinersen, 0. 1 mg • C 9745: Nasal endoscopy, surgical; balloon dilation of eustachian tube • C 9746: Transperineal implantation of permanent adjustable balloon continence device, with cystourethroscopy, when performed and/or fluoroscopy, when performed • C 9747: Ablation of prostate, transrectal, high-intensity focused ultrasound (HIFU), including imaging guidance • Q 9986: Injection, hydroxyprogesterone caproate (Makena), 10 mg • Q 9989: Ustekinumab, for intravenous injection, 1 mg Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2017 Cigna 23
PROVIDER DIGITAL SOLUTIONS UPDATES e. Service updates Electronic Funds Transfer Cigna’s required standard payment method Effective January 2017, electronic funds transfer (EFT) is Cigna’s required standard method for providers to receive reimbursements. All providers and facilities must enroll. Provider Digital Solutions Enrolling for EFT is easy updates If you’re already enrolled for Cigna EFT payments, you’re all set – there’s nothing more you need to do. Otherwise, you can enroll directly on the: Cigna for Health Care Professionals website (Cignafor. HCP. com) – Log in to Cignafor. HCP. com > Working with Cigna > Enroll in Electronic Funds Transfer (EFT) Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2017 Cigna 24
DEMOGRAPHIC CHANGES Please notify us in writing 90 days before changing your office or billing address, telephone number, Taxpayer Identification Number (TIN), National Provider Identifier (NPI), or specialty. You can submit your demographic changes by email, fax, mail, or online. Refer to the chart below to identify the contact information for your state. * demographic changes How you can submit changes Email: Intake_PDM@Cigna. com Fax: 1. 877. 358. 4301 Mail: Cigna Provider Data Management Two College Park Drive Hooksett, NH 03106 Online: Cigna for Health Care Professionals website (Cignafor. HCP. com > Resources > Forms) * Third-party vendor states are Idaho, Iowa, Montana, Nebraska, New Mexico, North Dakota and South Dakota. For these states, submit your changes directly to the third-party vendor. Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2017 Cigna 25
Better health. We’re in it together. RESOURCES Tools to make your life easier Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2017 Cigna 26
resources for you • Quarterly Network News • Use material in meeting packet • Go to the Cigna for Health Care Professionals website (Cignafor. HCP. com) Email: Network. News. Editor@Cigna. com to be added to the distribution Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2017 Cigna 27
CONTACTS AND SUPPORT • Webinars (Cignafor. HCP. com > News You Can Use) • General e. Services product information (Cignafor. HCP. com > Resources > Doing Business with Cigna > e. Services) • e. Courses (Cignafor. HCP. com > Resources > Doing Business with Cigna > e. Services ) • EFT payment calendars (Cignafor. HCP. com > Resources > Doing Business with Cigna > e. Services ) • Your EDI vendor Don’t have an EDI vendor? Visit Cigna. com/EDIvendors for more information • 1. 800. 88 Cigna • Your Experience Manager or Experience Consultant your resources way your Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2017 Cigna 28
resources for your patients with Cigna coverage • 1. 800. Cigna 24 • Health advocacy • Cigna. com/healthwellness • Supportive programs • Health and wellness apps Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2017 Cigna 29 29
Shaping healthier behavior through technology YOUR HEALTH HAS MET ITS APP SM Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © 2017 Cigna 30
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Offered by: Connecticut General Life Insurance Company or Cigna Health and Life Insurance Company. All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Cigna Behavioral Health, Inc. , and HMO or service company subsidiaries of Cigna Health Corporation. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. 877987 THN-2017 --486 © 2017 Cigna. Some content provided under license.
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