2021 Medicare Provider Manual

1 PCOMM-2021-1083 8/21 HEALTH CARE PROFESSIONALS Provider Manual Medicare ADVANTAGE 2021 Return to Table of Contents Page 2 of 113 All 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 Cigna Table of contents Introduction and new 2021 plan offerings .. 9 Medicare overview .. 10 Key contacts .. 10 Eligibility .. 12 Verify customer 13 2021 example ID cards .. 13 Exchange of electronic data .. 14 Information protection requirements and guidance .. 14 Experience the ease of HSConnect .. 14 Vendor-specific networks .. 14 CLIA certification required for laboratory services .. 15 High-tech radiology, diagnostic cardiology, radiation therapy and medical oncology management programs.

2 16 Program overview .. 16 Credentialing .. 16 Practitioner and organizational selection criteria .. 16 Practitioner .. 16 Organizational Provider .. 18 Credentialing and recredentialing process .. 19 Credentialing committee and peer review process .. 20 Office site evaluations .. 20 Accreditation for DME, orthotics, and prosthetic providers .. 20 Non-discrimination in the decision-making process .. 21 Provider notification .. 21 Appeals process and notification of authorities .. 21 Confidentiality of credentialing information .. 21 Ongoing monitoring .. 22 CMS preclusion list .. 22 Provider directory and requirements .. 23 Requirements .. 23 Additional quarterly Provider directory data attestation details .. 23 Provider 23 Plan notification requirements for providers .. 24 Practitioners .. 24 Return to Table of Contents Page 3 of 113 All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation.

3 The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. 2021 Cigna Facility / ancillary providers .. 25 Continuity of care .. 26 Billing .. 27 Claims submission .. 27 Electronic submission .. 27 Paper claims submission .. 28 Timely filing .. 29 Claim format .. 29 Claim format standards .. 29 Offsetting .. 29 Pricing .. 29 Claims encounter data .. 30 Explanation of payment (EOP)/Remittance advice (RA) .. 30 Prompt payment .. 30 Non-payment/claim denial .. 30 Pricing of inpatient claims .. 30 SNF consolidated billing (SNF CB) .. 30 Processing of hospice claims .. 31 ICD-10 diagnosis and procedure code reporting .. 32 Coordination of benefits .. 34 Medicare secondary payer (MSP) and subrogation .. 34 Guidelines .. 34 General terms & definitions .. 34 Common situations of primary vs. secondary payer responsibility .. 35 Basic processing guidelines for COB.

4 37 Worker's compensation .. 37 Subrogation .. 37 Dual eligible .. 38 Dual eligible individuals .. 38 Medicaid coverage groups .. 38 Appeals .. 39 Provider appeals .. 39 Submit an appeal .. 40 Customer appeals .. 41 Claim disputes/reconsiderations .. 41 Provider information, roles and responsibilities .. 41 Return to Table of Contents Page 4 of 113 All 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 Cigna Access and availability standards for providers .. 41 After-hours access standards .. 42 Primary care and specialist 43 Providers designated as primary care physicians (PCPs) .. 43 Communication among providers .. 45 Customer assignment to new PCP (HMO Only) .. 45 Procedure .. 46 Delegation .. 46 Non-discrimination and cultural competency.

5 47 Physician rights and responsibilities .. 47 Physician responsibilities .. 47 Organizational site surveys .. 49 Provider participation .. 49 Emergency or disaster situations .. 49 Provider directory update requirements .. 50 Provider communications and marketing .. 51 Guidelines .. 51 Behavioral health .. 52 Responsibilities of the PCP .. 52 Access to care .. 52 Medical record documentation .. 53 Continuity of care for behavioral health .. 53 Utilization management for behavioral health .. 53 Contract exclusions for behavioral health .. 54 Pharmacy .. 54 Pharmacy prescription benefit .. 54 Part D drug formulary .. 54 Part D utilization management .. 55 Prior authorization (PA) .. 55 Step therapy (ST) .. 55 Quantity limits (QL) .. 55 How to file a coverage determination (CD) .. 56 How to file a Part D appeal .. 56 Pharmacy networks .. 57 Preferred pharmacy network .. 57 Pharmacy quality programs.

6 57 Return to Table of Contents Page 5 of 113 All 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 Cigna Narcotic case management .. 58 Medication therapy management .. 58 Drug utilization review .. 59 Low Income Subsidy program .. 60 Overview .. 60 Eligibility .. 61 Applying For Extra Help .. 61 Home delivery pharmacy .. 61 Express Scripts .. 62 Specialty pharmacy .. 62 Medical health services .. 62 Overview .. 62 63 Departmental functions .. 63 Prior authorization .. 63 Prior authorization department .. 65 Prior authorization requests and time frames .. 66 Denial or adverse organization determination .. 67 Retrospective review .. 67 Drugs/Biologics Part B (medical benefit) .. 67 Home health services .. 68 Concurrent review.

7 69 Readmission .. 71 Skilled nursing facility care and levels .. 71 SNF notice of Medicare non-coverage (NOMNC) .. 75 Adverse determinations concurrent review .. 76 Rendering of adverse determinations (denials) .. 76 Notification of adverse determinations (denials) .. 77 Discharge planning and acute care management (ACCM) .. 77 Outpatient Observation Notice .. 77 Referrals .. 78 Referral guidelines .. 78 Quick reference referral guide .. 78 ** Select markets with HMO plans only. PPO plans do not require referrals.. 79 PPO products - referrals .. 79 HMO products - referrals .. 79 Return to Table of Contents Page 6 of 113 All 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 Cigna Obtaining and verifying referrals.

8 80 Part B step therapy .. 82 Care management .. 82 Care management program goals .. 82 Care management approach .. 82 How to use services .. 83 Coordination with network providers .. 83 Program evaluation .. 84 Quality programs .. 84 Quality improvement organization program changes .. 84 Quality care management program .. 85 Overview .. 85 Values .. 85 Quality principles .. 86 Program scope .. 86 Goals .. 87 Corporate Quality Improvement Committee (CQIC) .. 88 Health Care Plan Effectiveness Data and Information Set (HEDIS) .. 88 Special Needs Plans (SNP) .. 89 Background .. 89 SNP MOC process .. 90 SNP contact information .. 91 Customer information closing customer panels .. 92 Transmission of lab results .. 92 Customer information, rights and responsibilities .. 92 Medical record standards .. 92 Programs and services .. 93 Benefits and 93 Emergency services and care after hours.

9 93 Emergency services .. 93 Urgent care services .. 94 Excluded services .. 94 Customer rights .. 94 Advance medical directives .. 97 Customer responsibilities .. 97 Policies .. 98 Return to Table of Contents Page 7 of 113 All 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 Cigna Corporate compliance program .. 98 Overview .. 98 Medicare advantage program requirements .. 100 Overview .. 100 Books and records; governmental audits and inspections .. 100 Privacy and confidentiality safeguards .. 101 Patient hold harmless .. 101 Non-covered services .. 101 Delegation of activities or responsibilities .. 102 Compliance with Cigna's obligations, Provider Manual , policies and procedures .. 102 Subcontracting .. 102 Compliance with laws.

10 103 Program integrity .. 103 Continuation of benefits .. 103 Incorporation of other legal requirements .. 103 Conflicts .. 103 Dispute resolution .. 103 APPENDIX .. 104 2021 plan offerings/service maps .. 104 Alabama, Florida, and South Mississippi .. 104 Arkansas .. 104 Arizona .. 105 Central Florida (Daytona, Orlando & Tampa) .. 105 South Florida (Leon Medical Center) .. 106 South Florida East .. 106 Colorado .. 107 Georgia .. 107 Illinois .. 108 Kansas City .. 108 Mid-Atlantic .. 109 New Jersey .. 109 New Mexico .. 110 North and South Carolina .. 110 Ohio .. 111 Oklahoma .. 111 Pennsylvania .. 112 Return to Table of Contents Page 8 of 113 All 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 Cigna Tennessee, North Georgia, and Southwest Virginia.