Evernorth Behavioral Adminstirative 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.

2 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 .. 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.

3 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.

4 46 Cultural 46 Onboarding .. 47 How to join the Evernorth Behavioral health 47 Individual practitioners providing Behavioral services at Cigna-participating medical practices .. 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.

5 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.

6 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.

7 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 .. 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.

8 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.

9 86 Subrogation and reimbursement requirements .. 86 Other billing 86 Overpayment recovery .. 86 Explanation of payment .. 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.

10 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.