Evernorth Behavioral Administrative Guidelines

1 Table of Contents PCOMM-2021-1080 8/21 Evernorth Behavioral Administrative Guidelines For contracted psychiatrists, psychologists, master-level therapists, hospitals, and facility based programs. The Evernorth Behavioral Administrative Guidelines were previously referred to as the Medical Management Program. Page 2 of 114 Table of contents Introduction .. 8 Inside the guide .. 8 Our commitment and mission .. 8 Contact us .. 8 Notes .. 8 Regulatory addenda and state-specific information .. 10 Important contact information .. 11 Demographic information and directory .. 13 Benefit plan designs and features .. 14 Products .. 17 Cigna Choice Fund .. 17 Cigna debit card transactions.

2 17 ID cards quick guide .. 18 G ID cards .. 18 Strategic Alliances .. 18 Shared administration .. 20 Payer solutions segment .. 21 Medicare Advantage .. 22 Medicare managed care .. 22 Access to records and facilities .. 22 Confidentiality and accuracy of participant records .. 22 Transfer of medical records .. 23 Serving a diverse population .. 23 Complex care , follow-up care and self- care .. 24 Claims and encounter reporting .. 24 Appeals and grievance process .. 24 The role of the physician practitioner .. 26 Employee Assistance Professionals Association (EAPA) .. 31 Evernorth Behavioral Health's EAP Models .. 31 Digital solutions for providers .. 40 The Evernorth provider website .. 41 Patient eligibility and benefits.

3 42 Claim information .. 43 Online remittance reports .. 43 Page 3 of 114 Cigna Cost of care Estimator .. 44 Electronic Data Interchange (EDI) .. 44 Electronic transaction support .. 45 Evernorth payer ID for submitting electronic claims .. 45 IVR user tips .. 45 ePrescribe .. 45 Online training and resources .. 46 Cultural competency .. 46 Onboarding .. 47 How to join the Evernorth Behavioral Health network .. 47 Individual practitioners providing Behavioral services at Cigna-participating medical practices .. 47 Clinics .. 48 Autism clinics .. 48 Facilities .. 49 Credentialing for providers .. 49 Council for Affordable Quality Healthcare (CAQH) credentialing database system .. 49 Notice of changes of licenses or accreditation.

4 50 Termination appeal process .. 50 Credentialing process for providers .. 50 Provider rights .. 51 Clinic-based programs .. 52 Recredentialing process for professionals .. 52 Credentialing requirements for facilities .. 53 Recredentialing requirements for facilities .. 54 Provider specialties and urgent access .. 54 Provider specialties .. 54 Urgent 55 Forms .. 58 Provider participation .. 59 Service standards and requirements .. 59 Acceptance and transfer of 60 Communication to participants of professional termination .. 60 Scheduling appointments .. 60 Telephone response time .. 61 Professional services .. 61 Page 4 of 114 Cooperation with programs .. 61 Referrals .. 62 Medication.

5 62 Participant billing .. 62 Denied payment and participant non-liability .. 64 Self-pay agreements .. 64 Provider concerns related to Administrative processes .. 65 Resolving participant complaints .. 65 66 Eligibility .. 67 Determining eligibility .. 67 Eligibility verification .. 67 Case Management Program .. 68 Precertification protocol .. 68 Utilization management responsibility for precertification .. 68 Utilization management precertification for admissions .. 68 Emergency admissions .. 69 Extenuating circumstances .. 69 General considerations precertification .. 70 Utilization management (continued stay review) .. 70 Outpatient services .. 71 Retrospective precertification of Outpatient 71 Autism spectrum disorder and applied behavior analysis.

6 71 Testing .. 71 Buprenorphine treatment .. 71 Evernorth Behavioral Health's compensation .. 72 Coverage denials .. 72 Appeals of coverage denials .. 72 Administrative denial and appeal .. 73 Pass-through billing .. 73 Coaching and support programs .. 73 Claims and compensation .. 74 Claim submission .. 74 Electronic claim submission .. 74 Paper claim submission .. 75 Definition of a complete claim .. 75 Page 5 of 114 Supplemental claim information .. 79 Claim filing 80 Claim inquiry and follow-up .. 80 Claim payment policies and procedures .. 81 Standard claim coding/bundling methodology .. 81 Participant liability collection limitations .. 81 Copayments .. 81 Coinsurance and deductibles.

7 81 Fee forgiving/waiver of copayment/coinsurance or deductible .. 82 Denied payment and participant non-liability .. 82 Coordination of benefits (COB) .. 82 Cigna or Evernorth Behavioral Health as primary payer .. 82 Cigna or Evernorth Behavioral Health as secondary payer .. 82 Order of benefit determination .. 83 Workers compensation .. 84 Subrogation and reimbursement requirements .. 84 Other billing Guidelines Overpayment recovery .. 84 Explanation of payment .. 85 Explanation of benefits and explanation of payment .. 85 Electronic funds transfer .. 85 What are the benefits of EFT? .. 86 Payment bulking options .. 86 Enrolling in EFT for Cigna plans .. 87 EFT enrollment Guidelines .. 87 Electronic remittance advice.

8 87 To enroll for ERA .. 88 Posting payments and adjustments .. 88 Applicable rate .. 88 Rates and changes to coverage .. 88 Claim quality and cost-effectiveness programs .. 89 Clinical Claim Review Program .. 89 Resolving payment questions .. 90 Prior to providing services .. 90 Page 6 of 114 Prior to filing a claim .. 90 Dispute resolution .. 91 Provider payment appeals .. 91 Appeals .. 91 Appeal types and filing instructions .. 92 National ancillaries: Laboratories .. 95 Participant Information .. 96 Alternate Member Identifier (AMI) .. 96 Verification options .. 96 Participant concern or complaint .. 96 Provider cooperation .. 97 Health Insurance Portability and Accountability Act (HIPAA) of 1996.

9 97 Security regulations .. 98 National Provider Identifier .. 98 837 electronic claims .. 98 835 electronic remittance 99 Real-time request transactions (270, 276, 278) .. 99 Prescription Drug Program .. 101 Prescription drug list .. 101 Medications requiring precertification (medical necessity request process) .. 101 Pharmacy clinical support programs .. 102 Complex Psychiatric Case Management program .. 102 Quality Management Program .. 103 Creating opportunities for quality improvement .. 103 Coordination of Behavioral health and general medical care .. 103 Participant rights and responsibilities .. 104 Customers rights and responsibilities statement .. 105 Statement on confidentiality of alcohol and drug use records.

10 106 Improving participant safety .. 107 Health promotion/preventive health services .. 107 Educational opportunities for providers .. 108 Medical necessity criteria .. 108 State-specific criteria .. 109 Clinical practice Guidelines .. 109 Clinical screening tools and treatment support toolkits .. 110 Integration with chronic condition/disease management .. 110 Page 7 of 114 Treatment record-keeping .. 110 Clinical and quality improvement studies .. 111 National quality initiatives .. 112 National Quality Forum .. 112 Centers of Excellence .. 112 Resources and forms .. 113 Legal Statement .. 114 Introduction Page 8 of 114 Introduction Inside the guide Welcome to Evernorth ! For starters, we d like you to know that we re committed to giving all of our customers access to quality services and benefits.