1. Medicaid Provider Manual

Individual and family medical and dental insurance plans are insured by Cigna Health and Life Insurance Company (CHLIC), Cigna HealthCare of Arizona, Inc., Cigna HealthCare of Illinois, Inc., and Cigna HealthCare of North Carolina, Inc. Group health insurance and health benefit plans are insured or administered by CHLIC, Connecticut General Life Insurance Company (CGLIC), or their affiliates (see that insure or administer group HMO, dental HMO, and other products or services in your state). Group Universal Life (GUL) insurance plans are insured by CGLIC. Life (other than GUL), accident, critical illness, hospital indemnity, and disability plans are insured or administered by Life Insurance Company of North America, except in NY, where insured plans are offered by Cigna Life Insurance Company of New York (New York, NY). All insurance policies and group benefit plans contain exclusions and limitations.

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While Cigna-HealthSpring prefers electronic submission of claims, both electronic and paper claims are accepted. If interested in submitting claims electronically, contact Cigna-HealthSpring Provider Services for assistance. In January 2009, the U.S. Department of Health and Human Services (HHS) published a final rule requiring the use of International Classification of Diseases version 10 (ICD-10) for diagnosis and hospital inpatient procedure coding. The rule impacts the health care industry – including health plans, hospitals, doctors, and other health care professionals, as well as vendors and trading partners. The implementation of ICD-10 has been delayed a few times.

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Department of Health and Human Services released a rule on July 31, 2014 finalizing October 1, 2015 as the new compliance date for health care providers, health plans, and health care clearing houses to transition to ICD-10, the tenth revision of the International Classification of Diseases. ICD-10 (International Classification of Diseases, 10th Edition, Clinical Modification /Procedure Coding System) consists of two parts:. ICD-10-CM for Diagnosis coding is for use in all U.S. Health care settings. Diagnosis coding under ICD-10-CM uses 3 to 7 characters instead of the 3 to 5 characters used with ICD-9-CM, adding more specificity. ICD-10-PCS for Inpatient Procedure coding is for use in U.S. Inpatient hospital settings only.

ICD- 10-PCS uses 7 alphanumeric characters instead of the 3 or 4 numeric characters used under ICD-9-CM procedure coding. Coding under ICD- 10-PCS is much more specific and substantially different from ICD-9-CM procedure coding. Note: Procedure codes are only applicable to inpatient claims and not prior authorizations. The transition to ICD-10 is occurring because ICD-9 codes have limited data about patients’ medical conditions and hospital inpatient procedures. ICD-9 is 30 years old, has outdated terms, and is inconsistent with current medical practice.

Also, the structure of ICD-9 limits the number of new codes that can be created, and many ICD-9 categories are full. ICD-10 will affect diagnosis and inpatient procedure coding for everyone covered by the Health Insurance Portability Accountability Act (HIPAA), not just those who submit Medicare or Medicaid claims. The change to ICD-10 does not affect CPT or HCPCS coding for outpatient procedures. ICD-10 Claim Submission Guidelines Health care professionals must be prepared to comply with the transition to ICD-10 by October 1, 2015 Cigna-HealthSpring will strictly adhere to the following guidelines:. All electronic transactions must use Version 5010 standards, which have been required since January 1, 2012. Unlike the older Version 4010/4010A standards, Version 5010 accommodates ICD-10 codes. We currently accept the revised CMS 1500 Health Insurance Claim form (version 02/12).

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As of October 1, 2014, Cigna-HealthSpring will only accept the CMS 1500 form (02/12). Although the revised CMS 1500 claim form has the functionality for accepting ICD-10 codes, we will not accept ICD-10 codes on claims until the new compliance date. Professional and outpatient claims submitted with a date of service or inpatient claims submitted with a discharge date prior to the new compliance date must be processed using ICD-9 codes. Professional and outpatient claims submitted with a date-of-service or inpatient claims submitted with a discharge date on or after the new compliance date must be processed using ICD-10 codes.

Claims with ICD-9 codes for date of service or discharge provided on or after the new compliance date will be rejected. Claims with ICD-10 codes for date of service or discharge provided prior to the new compliance date will be rejected. Claims submitted with a mix of ICD-9 and ICD-10 codes will be rejected. Claims should be coded based on date of service (outpatient) or discharge date (inpatient).

Some institutional claims, such as those for long-term or on-going care should be processed as split claims during the transition period. With such a split claim, all services rendered during a particular cycle before the new compliance date would be accounted for on one claim with ICD-9 codes. The other remaining services rendered on or after the new compliance date during that same cycle would be accounted for on a separate claim using ICD-10 codes. We will only process claims after the compliance date with ICD-9 codes with dates of service or discharge dates prior to the new compliance date for a period of time to allow for claim run-off, including the following issues:. Appeals with dates of service or discharge dates before the new compliance date should be submitted with the appropriate ICD-9 codes.

Corrected or resubmitted claims with dates of service or discharge dates before the new compliance date should be submitted with the correct ICD-9 codes to the claim office for adjustment or correction. Non-Billable Codes. A billable ICD-9 or ICD-10 code is defined as a code that has been coded to its highest level of specificity.

A non-billable ICD-9 or ICD-10 code is defined as a code that has not been coded to its highest level of specificity. If a claim is submitted with a non-billable code, the claim will be rejected. The following are examples of billable ICD-9 codes with corresponding non-billable codes. General Definitions Coordination of Benefits (COB) Benefits that a person is entitled to under multiple plan coverage.

Coordinating payment of these plans will provide benefit coverage up to but not exceeding one hundred percent of the allowable amount. The respective primary and secondary payment obligations of the two coverages are determined by the Order of Benefits Determination Rule contained in the National Association of Insurance Commissioners (NAIC) COB Model Regulations Guidelines.

Order of benefit determination rule Rules which, when applied to a particular customer covered by at least two plans, determine the order of responsibility each plan has with respect to the other plan in providing benefits for that customer. A plan will be determine to have Primary or Secondary responsibility for a person’s coverage with respect to other plans by applying the NAIC rules.

Primary This carrier is responsible for costs of services provided up to the benefit limit for the coverage or as if no other coverage exists. Secondary This carrier is responsible for the total allowable charges, up to the benefit limit for the coverage less the primary payment not to exceed the total amount billed (maintenance of benefits). Allowable Expense Any expense customary or necessary, for health care services provided as well as covered by the customer’s health care plan. Conclusion COB is applying the NAIC rules to determine which plan is primarily responsible and secondarily responsible when alternate coverage exists. If COB is to accomplish its purpose, all plans must adhere to the structure set forth in the Model COB regulations.

Basic NAIC Rules for COB Birthday Rule The primary coverage is determined by the birthday that falls earliest in the year, understanding both spouses are employed and have coverage. Only the day and month are taken into consideration. If both customers have the same date of birth, the plan which covered the customer the longest is considered primary. General Rules The following table contains general rules to follow to determine a primary carrier. Subrogation is the substitution of one party in place of another with respect to a legal claim.

Medicaid Provider Manual

In the case of a health plan which has paid benefits for its insured, the health plan is substituted in place of its insured and can make legal claims against the party which should be responsible for paying those bills such as the person who caused the insured’s injuries and their third party insurer (i.e. Property and casualty insurer, automobile insurer, or worker’s compensation carrier).

COB protocol, as mentioned above, would still apply in the filing of the claim. Customers who may be covered by third party liability insurance should only be charged the required copayment. The bill can be submitted to the liability insurer. The provider should submit the claim to Cigna-HealthSpring with any information regarding the third party carrier (i.e.

Auto insurance name, lawyers name, etc.). All claims will be processed per the usual claims procedures. Cigna-HealthSpring uses an outside vendor for review and investigation of all possible subrogation cases. This vendor coordinates all requests for information from the customer, provider and attorney name(s)/office(s) and assists with settlements. For questions related to a subrogated case, please contact Customer Service.

An experienced subrogation representative from our vendor The Rawlings Group will gladly provide assistance. An appeal is a request for Cigna-HealthSpring to review a previously made decision related to medical necessity, clinical guidelines, or prior authorization and referral requirements. You must receive a notice of denial, or remittance advice before you can submit an appeal. Please do not submit your initial claim in the form of an appeal. Appeals can take up to 60 days for review and determination. Timely filing requirements are not affected or changed by the appeal process or by the appeal outcome.

If an appeal decision results in approval of payment contingent upon the filing of a corrected claim, the time frame is not automatically extended and will remain consistent with the timely filing provision in the Cigna-HealthSpring agreement. You may Appeal a previous decision not to pay for a service. For example, claims denied for no authorization or no referral, including a decision to pay for a different level of care; this includes both complete and partial denials. Examples of partial denials include: denials of certain levels of care, isolated claim line items not related to claims reconsideration issues, or a decreased quantity of office or therapy visits not related to claims reconsideration issues.

Total and partial denials of payment may be appealed using the same Appeal process. Your Appeal will receive an independent review by a Cigna-HealthSpring representative not involved with the initial decision.

Requesting an Appeal does not guarantee that your request will be approved or that the initial decision will be overturned. The Appeal determination may fully or partially uphold the original decision. You may Appeal a health services or Utilization Management denial of a service not yet provided, on behalf of a customer. The customer must be aware that you are Appealing on his or her behalf. Customer Appeals are processed according to Medicare guidelines. An Appeal must be submitted within 60 days of the original decision unless otherwise stated in your provider agreement.

With your appeal request, you must include: an explanation of what you are appealing along with the rationale for appealing, a copy of your denial, any medical records that would support the medical necessity for the service, hospital stay, or office visit, and a copy of the insurance verification completed on the date of service. If necessary medical records are not submitted, the request will be returned and action pended until the medical records are submitted. You should submit your Appeal using the “Request for Appeal or Reconsideration” form and medical records. There are several ways to submit your Appeal to Cigna-HealthSpring.

You may send your request via secure e-mail to: or fax the Appeal request to our secure fax line at 1-800-931-0149. Alternatively, for large medical record files, you may mail the Appeal request form attached to a CD containing medical records to: Cigna-HealthSpring Attn: Appeals Unit PO Box 24087 Nashville, TN Phone: Fax: 1-800-931-0149. You have up to 180 days to request reconsideration of a claim. You may request claim reconsideration if you feel your claim was not processed appropriately according to the Cigna-HealthSpring claim payment policy or in accordance with your provider agreement. A claim reconsideration request is appropriate for disputing denials such as coordination of benefits, timely filing, or missing information. Payment retractions, underpayments/ overpayments, as well as coding disputes should also be addressed through the claim reconsideration process. Cigna-HealthSpring will review your request, as well as your provider record, to determine whether your claim was paid correctly.

You may request reconsideration by submitting the completed request form to: Cigna-HealthSpring Attn: Reconsiderations PO Box 20002 Nashville, TN 37202 Fax: 1-615-401-4642. All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Cigna HealthCare of South Carolina, Inc., Cigna HealthCare of North Carolina, Inc., Cigna HealthCare of Georgia, Inc., Cigna HealthCare of Arizona, Inc., Cigna HealthCare of St.

Louis, Inc., HealthSpring Life & Health Insurance Company, Inc., HealthSpring of Tennessee, Inc., HealthSpring of Alabama, Inc., HealthSpring of Florida, Inc., Bravo Health Mid-Atlantic, Inc., and Bravo Health Pennsylvania, Inc. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. Cigna-HealthSpring is contracted with Medicare for PDP plans, HMO and PPO plans in select states, and with select State Medicaid programs.

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