PROVIDER MANUAL - Cigna

1 PROVIDER MANUAL . Cigna -HealthSpring CarePlan (Medicare-Medicaid Plan). Tarrant and Hidalgo counties Publication Date: September 2015. PROVIDER Services Department: 1-877-653-0331. medicare-medicaid- H8423_15_29570_PR 2015 Cigna Dear Valued PROVIDER and Staff: I would like to extend a warm welcome and thank you for participating with Cigna -HealthSpring Texas' Network of Participating Providers. We value our relationship with all of our providers and are committed to working with you to meet the needs of your Cigna -HealthSpring patients. Cigna -HealthSpring has provided managed care services to Medicare and dually-eligible members since 1996. We are excited to extend our passion for offering quality health care delivery to Cigna -HealthSpring CarePlan, Medicare-Medicaid Plan members.

2 We look forward to working with you to serve the needs of members in order that they may live life well. Sincerely, Jay Hurt Senior Vice President President Texas Division Cigna -HealthSpring TABLE OF CONTENTS. IMPORTANT PHONE NUMBERS .. 1. INTRODUCTION .. 1. Medicare-Medicaid Plan Program Overview .. 2. Objectives of the MMP Program .. 2. Role of the Primary Care PROVIDER (PCP) .. 3. Role of the Specialty Care 4. Missed Appointments by 4. Role of the Long-Term Services and Supports (LTSS) PROVIDER .. 4. Role of Service 5. Role of the Pharmacy PROVIDER .. 6. Emergency Prescription 6. Network Limitations .. 6. Focus Studies and Utilization Management reporting requirements.. 8. COVERED SERVICES .. 8. Medicare-Medicaid Managed Care Covered Services.

3 8. Behavioral Health Covered Services .. 8. Pharmacy Prescription Benefit .. 16. Pharmacy Quality Programs .. 18. Medical Transportation Program .. 21. EMERGENCY SERVICES .. 21. Definitions .. 21. Emergency Prescription 22. Emergency Transportation .. 22. Non-Emergent Ambulance Transportation .. 22. MEDICARE-MEDICAID PLAN ELIGIBILITY & enrollment .. 22. Cigna -HealthSpring CarePlan (Medicare-Medicaid Plan) 22. enrollment .. 23. Verifying 23. Monthly PCP Panel Reports .. 24. 25. Span of Eligibility .. 25. Retroactive Eligibility Changes .. 25. Long-Term Services and Supports .. 26. Authorization of Services through the Service Coordinator .. 27. Disease Management (DM) .. 27. Care and Service Plans (CSPs) .. 27. Coordination with Other Agency Providers.

4 28. UTILIZATION MANAGEMENT .. 28. Utilization Review Criteria .. 28. Discharge Planning .. 30. Direct Access Services .. 31. Out of Network Authorizations .. 31. Continuity of Care .. 31. Member Moves Out of Service 31. Pre-existing 31. BILLING AND CLAIMS ADMINISTRATION .. 32. Claims Submission .. 32. Claims 32. Claims Filing Deadline .. 33. Claim Filing 33. National PROVIDER Identification (NPI) Numbers .. 34. FQHC Claim Filing Instructions .. 37. RHC Claim Filing Instructions .. 37. Coordination of Benefits .. 53. Prior Authorization .. 53. Claims Payment .. 54. Electronic Funds Transfer .. 54. Claim Status and Resolution of Claims Issues .. 54. Claims 54. Balance Billing .. 55. Private Pay 55. Claim Filing Tips .. 55. Sample of Explanation of Payment (EOP).

5 57. PROVIDER RESPONSIBILITIES .. 57. Communication Among Providers .. 58. PROVIDER Access and Availability Standards .. 58. Demographic Changes .. 59. Advanced Medical 59. Coordination with Texas Department of Family and Protective Services (TDFPS) .. 60. Termination of PROVIDER Contracts .. 60. Attendant Care Enhancement Program (ACEP) .. 60. PROVIDER Complaint and Appeal process .. 62. QUALITY MANAGEMENT .. 63. 63. QI Department Functions .. 63. Quality Improvement Committee (QIC) .. 64. Clinical Practice Guidelines .. 64. Healthcare Plan Effectiveness Data and Information Set (HEDIS ) .. 64. On-Site Assessments .. 64. Medical Record Requirements .. 65. Credentialing .. 68. Direct Access to a Specialty Care PROVIDER for Members with Special Health Care Needs.

6 75. Member Rights and Responsibilities .. 76. Member's Right to Designate an OB/GYN .. 77. Member Complaint and Appeal process .. 77. Hospital Discharge 81. APPENDICES .. 82. Appendix A, Cigna -HealthSpring Member Identification Card .. 83. Appendix B, Sample Texas Benefits Medicaid Card .. 84. Appendix C, Sample Form 1027-A Temporary Medicaid Identification .. 85. Appendix D, Authorization Reqiurements .. 86. Appendix E, Prior Authorization Request Form .. 89. Appendix F, Inpatient Authorization Form .. 90. Appendix G, Outpatient Authorization Form .. 91. Appendix H, Sample UB-04 Claim Form .. 92. Appendix I, Sample CMS 1500 Claim form .. 93. Appendix J, Sample of Claims Appeal Form .. 94. Appendix K, Member Acknowledgement Statement .. 95. Appendix L, Private Pay Agreement.

7 96. Appendix M, Clinical Practice Guidelines .. 97. IMPORTANT PHONE External Contacts NUMBERS. Dental For quick reference information about Cigna -HealthSpring and the Medicare-Medicaid Plan, providers can visit our website at > DentaQuest Providers: 1-888-308-9345: > Members: 1-855-418-1628. or our PROVIDER Portal at Emdeon (EDI) 1-800-845-6592. Quest Diagnostics 1-866-697-8378. Note: Users should not enter "www" prior to entering the web > Clinical Pathology address for the PROVIDER Portal. Also, providers can call the 1-800-595-1275. Laboratories (CPL). following resources for more information: > Laboratory Services 1-888-522-2677. Cigna -HealthSpring Contacts (Labcorp). > ProPath 1-866-776-7284. PROVIDER Services Department 1-877-653-0331 MAXIMUS (Medicaid Member Service Department 1-877-653-0327 1-800-964-2777.)

8 Managed Care Helpline). Behavioral Health Substance Medicaid Managed Care 1-877-725-2539 1-866-566-8989. Abuse Services Helpline Behavioral Health Medicaid Managed Care 1-800-959-4941 1-866-222-4306. Crisis Hotline Helpline TDD. Claims Status Request 1-877-653-0331 Medical Transportation 1-877-633-8747. Compliance Hotline 1-877-653-0331 Program (MTP) - Hidalgo Cigna -HealthSpring Automated Medical Transportation 1-866-467-3126 1-855-687-3255. Eligibility Verification Line Program (MTP)- Tarrant Service Coordination 1-877-725-2688 Texas Department Of Family Utilization Management - And Protective Services 1-800-252-5400. 1-877-725-2688 (TDFPS). Concurrent Review Utilization Management Home Vision 1-800-879-6901. Health / Long-Term Services and 1-877-725-2688.

9 Supports INTRODUCTION. Utilization Management - Inpatient 1-877-725-2688 Welcome to Cigna -HealthSpring CarePlan (Medicare-Medicaid Intake Prior Authorization Plan). Cigna -HealthSpring, Inc. ( Cigna -HealthSpring) and its Utilization Management subsidiaries are wholly-owned by Cigna Corporation ( Cigna ), a 1-877-725-2688. Outpatient Prior Authorization publicly-traded global health service company and the fourth-largest insurer in the United States based on enrollment . Cigna is listed on the New York Stock Exchange (NYSE: CI) and is a component of the S&P 500 Stock Index. External Contacts Cigna was formed in 1982 by the merger of the Connecticut General Life Insurance Company and the 24-Hour Nurse Advice Line 1-855-418-4552 Insurance Company of North America (INA).

10 In 1792, a group TMHP Automated of prominent citizens in Philadelphia formed the Insurance Inquiry System (AIS), 1-800-925-9126 Company of North America (INA), the first marine insurance Eligibility Verification company in the United States. In 1865, the Governor of Comprehensive Care Connecticut signed a special act of the General Assembly 1-800-846-7470 incorporating the Connecticut General Life Insurance Program (CCP). Company (CG). Cigna acquired HealthSpring and its subsidiaries on January 31, 2012. Cigna -HealthSpring is focused on delivering coordinated care plans to Medicare beneficiaries, with a special focus on 1. improving health care for low-income beneficiaries that qualify Providers should use this PROVIDER MANUAL in conjunction with for Medicare-Medicaid (dual eligibles).