Evernorth Behavioral Administrative Guidelines

1 Table of Contents PCOMM-2021-1806 5/22 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 117 Table of contents Introduction .. 8 Inside the guide .. 8 Our commitment and 8 Contact us .. 8 Notes .. 8 Regulatory addenda and state-specific 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 .. 17 ID cards quick guide .. 18 G ID 18 Strategic Alliances .. 18 Shared administration .. 20 Payer solutions 21 Medicare Advantage .. 22 Medicare managed care .. 22 Access to records and 22 Confidentiality and accuracy of participant records.

2 22 Transfer of medical records .. 23 Serving a diverse population .. 23 Complex care, follow-up care and 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 31 Digital solutions for providers .. 40 The Evernorth provider 41 Patient eligibility and benefits .. 42 Claim 43 Online remittance reports .. 43 Page 3 of 117 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 .. 46 Online training and resources .. 46 Cultural 46 Onboarding .. 47 How to join the Evernorth Behavioral Health 47 Individual practitioners providing Behavioral services at Cigna-participating medical practices.

3 47 Clinics .. 48 Autism clinics .. 48 49 Credentialing for providers .. 49 Council for Affordable Quality Healthcare (CAQH) credentialing database 49 Notice of changes of licenses or accreditation .. 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 Ancillary Providers .. 54 Credentialing Attestation .. 54 Provider specialties and urgent 55 Provider specialties .. 55 Urgent access .. 56 Forms .. 59 Provider participation .. 60 Service standards and requirements .. 60 Acceptance and transfer of participants .. 61 Communication to participants of professional termination .. 61 Scheduling appointments .. 61 Page 4 of 117 Telephone response time .. 62 Professional services.

4 62 Cooperation with programs .. 62 Referrals .. 63 Medication .. 63 Participant billing .. 63 Denied payment and participant 65 Self-pay 65 Provider concerns related to Administrative 66 Resolving participant complaints .. 66 Confidentiality .. 67 Eligibility .. 68 Determining eligibility .. 68 Eligibility 68 Case Management Program .. 69 Precertification protocol .. 69 Utilization management responsibility for precertification .. 69 Utilization management precertification for 69 Emergency admissions .. 70 Extenuating circumstances .. 70 General considerations precertification .. 71 Utilization management (continued stay review) .. 71 Outpatient services .. 72 Retrospective precertification of outpatient services .. 72 Autism spectrum disorder and applied behavior analysis .. 72 Testing .. 72 Buprenorphine treatment .. 73 Evernorth Behavioral Health's 73 Coverage 73 Appeals of coverage denials.

5 74 Administrative denial and 74 Pass-through billing .. 74 Coaching and support programs .. 74 Claims and compensation .. 76 Claim submission .. 76 Electronic claim 76 Page 5 of 117 Paper claim 77 Definition of a complete claim .. 77 Supplemental claim information .. 81 Claim filing deadline .. 82 Claim inquiry and 82 Claim payment policies and 83 Standard claim coding/bundling methodology .. 83 Participant liability collection limitations .. 83 83 Coinsurance and 83 Fee forgiving/waiver of copayment/coinsurance or deductible .. 84 Denied payment and participant non-liability .. 84 Coordination of benefits (COB) .. 84 Cigna or Evernorth Behavioral Health as primary payer .. 84 Cigna or Evernorth Behavioral Health as secondary payer .. 84 Order of benefit 85 Workers compensation .. 86 Subrogation and reimbursement requirements .. 86 Other billing 86 Overpayment recovery .. 86 Explanation of payment.

6 87 Explanation of benefits and explanation of payment .. 87 Electronic funds transfer .. 88 What are the benefits of EFT? .. 88 Payment bulking options .. 88 Enrolling in EFT for Cigna plans .. 89 EFT enrollment Guidelines .. 89 Electronic remittance advice .. 89 To enroll for 90 Posting payments and adjustments .. 90 Applicable 90 Rates and changes to coverage .. 91 Claim quality and cost-effectiveness programs .. 91 Page 6 of 117 Clinical Claim Review 91 Resolving payment questions .. 92 Prior to providing services .. 92 Prior to filing a claim .. 92 Dispute resolution .. 93 Provider payment appeals .. 93 Appeals .. 93 Appeal types and filing instructions .. 94 National ancillaries: 97 Participant Information .. 98 Alternate Member Identifier (AMI).. 98 Verification options .. 98 Participant concern or complaint .. 98 Provider 99 Health Insurance Portability and Accountability Act (HIPAA) of 99 Security 100 National Provider Identifier.

7 100 837 electronic claims .. 100 835 electronic remittance 101 Real-time request transactions (270, 276, 278) .. 101 Prescription Drug Program .. 103 Prescription drug list .. 103 Medications requiring precertification (medical necessity request process).. 104 Pharmacy clinical support 104 Complex Psychiatric Case Management program .. 104 Quality Management Program .. 106 Creating opportunities for quality improvement .. 106 Coordination of Behavioral health and general medical care .. 106 Participant rights and 107 Customers rights and responsibilities statement .. 108 Statement on confidentiality of alcohol and drug use records .. 109 Improving participant safety .. 110 Health promotion/preventive health services .. 111 Educational opportunities for 111 Medical necessity criteria .. 111 Clinical practice Guidelines .. 112 Page 7 of 117 Clinical screening tools and treatment support toolkits.

8 113 Integration with chronic condition/disease management .. 113 Treatment record-keeping .. 113 Clinical and quality improvement studies .. 114 National quality initiatives .. 115 National Quality 115 Centers of Excellence .. 115 Resources and 116 Legal 117 Introduction Page 8 of 117 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. That means working with you across all the aspects of today s health care world. To help us stay on the same page, we have created these Administrative Guidelines for you. It highlights the programs and policies intended to keep our relationship smooth and productive for the sake of the people we serve together. The Administrative Guidelines were previously referred to as the Medical Management Program. Any agreement or document that references the Medical Management Program, the Provider Guide, the Provider Manual or the Provider Administrative Guidelines shall all be construed to reference this document.

9 Your Provider Agreement and these Administrative Guidelines describe the terms under which you agree to provide services to all Participants. Those terms include the reimbursement rates applicable to Covered Services provided to Participants. However, the actual benefits payable by a Payer for Covered Services provided to a Participant in all cases are determined by the terms of the Payer s Benefit Plan. Our commitment and mission We also understand that a stable provider panel facilitates our goal of consistent and superior customer service. For that reason, we seek to build strong, long-standing relationships with our providers. Our policies and protocols have been developed to minimize time-consuming Administrative activities, so you can spend more time providing superb service. Evernorth Behavioral Health, Inc. is a subsidiary of Cigna and the Behavioral network for customers with Cigna health plans.

10 Note, however, we also sell Behavioral health solutions to clients who may not have Cigna health plans. Evernorth provides Behavioral care benefit management, employee assistance and work/life programs to consumers through United States employers of all sizes, national and regional health maintenance organizations (HMO s), 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 psychiatrists, psychologists and master-level therapists, clinics and facilities. Contact us Please contact us if you have questions about the information in this guide, or our plans and programs. The terms of your agreement supersede this guide if a conflict arises. In all circumstances, the parties shall comply with applicable law and the regulatory addendum contained herein. Notes Evernorth manages mental health and substance use disorder services of benefit plans sponsored and/or administered, in whole or in part, in compliance with applicable laws, Introduction Page 9 of 117 rules, and regulations, including without limitation the Federal Mental Health Parity and Addictions Equity Act, Affordable Care Act, state parity laws, and regulations.