NONPARTICIPATING PROVIDER MANUAL - Cigna

1 2022 MEDICARE ADVANTAGE NONPARTICIPATING PROVIDER MANUAL Table Contents Medicare 3 Introduction and Ne w 2022 Plan Offer ings .. 3 Ke y Con ta ct 3 2022 ID Ca rd Examples .. 4 Medicare Advantage - 5 Medicare Advantage PPO .. 5 Medicare Advantage Employer Group HMO .. 5 Medicare Advantage Employer Group PPO .. 5 Medicare Advantage Prescription Dr ug - 6 Medicare Advantage Prescription Dr ug 6 Verify Customer Elig ib ilit y an d Benefits .. 6 Referrals and Pr io r Authorizations .. 7 Referrals vs. Pr io r Aut hori z ati 7 Quick Reference Referral Guide .. 8 Requesting an HMO Ref err al .. 8 Request for Pr io r Authorizations t o No n-Participating Providers .. 9 HMO plans .. 9 PPO pl ans .. 9 Billing .. 10 Claims 10 Electronic Submission.

2 10 Paper Claims Submission .. 11 Claims Revi ew .. 11 Timely Filing .. 11 Questions?.. 11 Exchange of Ele ct ron ic Da ta .. 11 Information Protection Requirements and Guidance .. 11 Reimbursemen t of NONPARTICIPATING Providers .. 12 CM S Pre clu sion List .. 13 Why is this important? .. 13 Who is on the list?.. 13 Are providers notified when they are placed on the Preclusion List?.. 13 Vendor Specific Networks .. 14 Jo in Ci gn a 's Ne tw 15 PROVIDER Notification .. 15 Appendix .. 16 Medicare overview Cigna contracts with the Centers for Medicare & Medicaid Services (CMS) to offer Medicare Advantage (MA) plans. Customers are able to select one of several plans offered based on their location, budget and health care needs. Cigna M e dicare Advantage He alth Maintenance Organization (HM O) Plans: Generally, customers are required to select a PCP and must receive all covered services by utilizing in- network providers, except in the case of emergency.

3 Select service areas do not require the use of referrals. See the Referrals and Prior Authorizations section for further information. HM O plans: Cigna Traditions Medicare ( HMO I- SNP*) Cigna TotalCare ( HMO D-SNP**) Cigna Achieve Medicare ( HMO C-SNP**) Cigna Preferred Medicare Cigna Alliance Medicare * Institutional special needs plan ** Dual-eligible special needs plan ** Chronic condition special needs plan Cigna M e dicare Adv antage Pre ferred PROVIDER Organization (PPO) Plan: Generally, customers are not required, but encouraged to select a PCP and referrals are not required to see Medicare- accepting providers in or out of the network. Customers are not limited to their home service area for routine care. PPO plans: Cigna True Choice Plus Medicare Introduction and New 2022 Plan Offerings Cigna continues to expand by offering new product offerings for 2022 in select markets.

4 We are excited to introduce these plans to better improve the health of our customers. As a result, non- participating providers are likely to see more patients wit h these new plans. This out-of-network PROVIDER MANUAL has been created to assist you and your office when providing care to Cigna customers wh o may have an out of network benefit. It is not a binding legal document but it contains important information concerning our policies and procedures including claims payment and submission requirements, prior authorization and referral requirements and other helpful information. This MANUAL is intended to help non-participating providers more effectively do business wit h Cigna Medicare. As a non-participating PROVIDER , note the following: Referrals are not required to see customers enrolled in select plans (check customer ID card).

5 See the Referrals and Prior Authorizations section for further information. No contract is required to see members enrolled in PPO plans, however you must be eligible for reimbursement under CMS rules and regulations. Cigna will reimburse out of network providers wh o provide Covered Services t o its Medicare Advantage PPO plan members in accord with CMS regulations and the member s Benefit Plan design. Customer Identification Cards provide high-level product/network information and indicate the customer s plan, referral requirements and out-of-network benefits. Contact numbers are located on the back of the card for further assistance. Key Contacts Ke y Contacts Claims P r o ce ssi n g Claims questions: 800-230-6138 Electronic Claims may be submitte d through: change Healthcare/Availity (PayorID: 63092 or 52192) SSIG roup/P r oxy me d / Me d ass es ts /Zir me d / OfficeAlly/Gat e w a y EDI (Payor ID: 63092) Relay Health (Professional claims CPID: 2795 or 3839 | Institutional claims CPID: 1556 or 1978) Mail Paper Claims to: Cigna PO Box 981706 El Paso, TX 79998 Mail Reconsideration Requests to.

6 Cigna Reconsiderations PO Box 20002 Nashville, TN 37202 Electr oni c Remitta n c e Advic e (ERA)/Ele ctronic Funds Transfer (EFT) EFT support requests after enrollment, contact 866-506-2830 Option 2 ERA/Cla ims support requests after enrollment, contact 866-742-4355 Option 1 PROVIDER Customer Service Questions: 800-230-6138 2022 ID Card Examples Customer Identification Cards provide high-level product/network information. Remember to contact the phone numbers on the card for assistance and follow guidance in order to verify eligibility, referral/no referral and authorization guidance. Medicare Advantage - HMO Medicare Advantage PPO Medicare Advantage Employer Group HMO Medicare Advantage Employer Group PPO Medicare Advantage Prescription Drug - HMO Medicare Advantage Prescription Drug PPO Verify Customer Eligibility and Benefits To verify customer eligibility and benefits: 1.

7 Ask to see the customer s Identification Card (ID card). Each customer is provided wit h an ID Card. Noted on the ID card is the customer s Cigna identification number, plan code, copayment and effective date. Since changes do occur with eligibility, the card alone does not guarantee the customer is eligible.* 2. Call Cigna Medicare PROVIDER Customer Services at 800-230-6138. An automated Interactive Voice Response ( IVR) system is available 24 hours a day, 7 days a week, or you can speak wit h a PROVIDER Customer Service Representative Monday-F riday, 8 am 5 pm CST. *Customer data is sub ject to change . CMS retroactively terminates customers for various reasons. When this occurs, Cigna s claim recovery unit will request a refund from the PROVIDER . The PROVIDER must then contact CMS Eligibility to determine the customer s actual b enefit coverage for the date of service in question, typically the customer has moved to another plan.

8 Referrals and Prior Authorizations Re fer rals Prior Authorizations HM O: A benefit tool that allows an HMO customer to see a specialist. PPO: PPO customers do not need a referral to see a specialist. However, before receiving services from out-of-network providers, the customer may want to ask for a pre-visit coverage determination. HM O: An HMO customer needs a prior authorization review for any in-network service on the Cigna Medicare prior authorization grid and for all out-of-network care. PPO: A prior authorization is recommended for any out-of-network care to confirm that services are covered and are medically necessary. Quick Reference Referral Guide Market HM O plan offered HM O POS plan offered * PPO plan offered Specialistreferrals required for this HM O plan ** Arizona Alabama Arkansas Colorado Central Florida Connecticut (New England market) Georgia Illinois Kansas City Delaware Maryland Washington, DC Virginia New Mexico New Jersey North Carolina North Florida Ohio Portland (Oregon) Pennsylvania South Carolina Southern Mississippi South Florida St.

9 Louis/Sout h er n Illinois Tennessee Texas Oklahoma Utah Washington * HMO poin t-of -service plan ** Selec t mark e ts with HMO plans only. PPO plan s do not requi r e referr al s. Requesting an HMO Referral For select mark e ts with HM O plans that requi r e specia li s t referr al s only (AZ, CO, Centr a l & Sou t h FL, IL, TX, OK) Referrals can be requested through several methods, such as: Fax Phone Mail Reme m b er : A referral does not guarant e e paymen t services must be a covered benefit. To verify benefits before providing services, call 800-230-6138. Request for Prior Authorizations to Non-Participating Providers HMO plans Prior authorizations to a non-participating PROVIDER are reviewed to determine if there is a continuity of care issue, a network gap has been identified, or in medically necessary circumstances in wh ich the customer s need cannot be met in network, ( , a service or procedure is not provided in-network; delivery of services closer or sooner than provided or allowed by the organization s access or availability standards).

10 Prior authorization is required for non-participating providers and requests are reviewed for specific criteria. It is recommended that a PCP initiate requests for authorizations to non-participating providers, customers or their authorized representatives may request on their o wn behalf. PPO plans Prior authorizations are recommended, but not required, in the following scenarios: A continuity of care issue A network gap has been identified In medically necessary circumstances in which the customer s need cannot be met in network ( , a service or procedure is not provided in-network; delivery of services closer or sooner than provided or allowed by the organization s access or availability standards) To confirm that services are covered and are medically necessary. Prior authorization Cigna requires authorization of certain services, medications, procedures, and/or equipment prior to performing or providing the service to prevent unnecessary utilization while safeguarding beneficiary access to the most appropriate medically necessary care.