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PROVIDER MANUALCigna-HealthSpring CarePlan (Medicare-Medicaid Plan)Hidalgo countyPublication Date:February 2017Provider Services icare/healthcare-professionals/tx-mmpH8423 16 52212 PR 02202017 2017 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 ParticipatingProviders. We value our relationship with all of our providers and are committed to working with you to meet the needs of your CignaHealthSpring patients.Cigna-HealthSpring has provided managed care services to Medicare and dually-eligible members since 1996. We are excited toextend our passion for offering quality health care delivery to Cigna-HealthSpring CarePlan, Medicare-Medicaid Plan members.We look forward to working with you to serve the needs of members in order that they may live life well.Sincerely,Jay HurtSenior Vice PresidentPresident – Texas DivisionCigna-HealthSpring
TABLE OF CONTENTSTABLE OF CONTENTS . 2IMPORTANT PHONE NUMBERS . 5INTRODUCTION . 5Medicare-Medicaid Plan Program Overview . 6Objectives of the MMP Program . 6Role of the Primary Care Provider (PCP) . 7Role of the Specialty Care Provider. 8Missed Appointments by Members. 8Role of the Long-Term Services and Supports (LTSS) Provider . 8Role of Service Coordinator. 9Role of the Pharmacy Provider . 10Network Limitations . 10Focus Studies and Utilization Management reporting requirements. . 12COVERED SERVICES . 12Medicare-Medicaid Managed Care Covered Services . 12Behavioral Health Covered Services . 13Long-Term Support Covered Services . 17Pharmacy Prescription Benefit . 20Pharmacy Quality Programs . 22Non-Medicaid Managed Care Covered Services (Non-Capitated Services) . 25Medical Transportation Program (MTP) . 26EMERGENCY SERVICES . 26Definitions . 26Emergency Prescription Supply. 27Emergency Transportation . 27Emergency Dental Services . 27Non-Emergent Ambulance Transportation . 27Non-Emergency Dental Services. 28Durable Medical Equipment and Other Products Normally Found in a Pharmacy . 28MEDICARE-MEDICAID PLAN ELIGIBILITY & ENROLLMENT . 28Cigna-HealthSpring CarePlan (Medicare-Medicaid Plan) Eligibility. 28Enrollment . 28Verifying Eligibility. 29Disenrollment. 30Span of Eligibility . 31Automatic Re-Enrollment. 31Retroactive Eligibility Changes . 31Long-Term Services and Supports . 32Authorization of Services through the Service Coordinator . 32Disease Management (DM) . 32Care and Service Plans (CSPs) . 33Coordination with Other Agency Providers . 33UTILIZATION MANAGEMENT . 33Utilization Review Criteria . 34Discharge Planning . 36Direct Access Services . 36Out of Network Authorizations . 36Continuity of Care . 36Member Moves Out of Service Area. 37Pre-existing Conditions. 372
BILLING AND CLAIMS ADMINISTRATION . 37Claims Submission . 37Claims Addresses. 38Claims Filing Deadline . 38Claim Filing Formats. 39National Provider Identification (NPI) Numbers . 39FQHC Claim Filing Instructions . 42RHC Claim Filing Instructions . 42Coordination of Benefits . 58Prior Authorization . 58Claims Payment . 58Electronic Funds Transfer . 58Claim Status and Resolution of Claims Issues . 59Claims Appeals. 59Payment Disputes . 59Balance Billing . 60Private Pay Agreement. 60Claim Filing Tips . 61Sample of Explanation of Payment (EOP). 62PROVIDER RESPONSIBILITIES . 63Communication Among Providers . 63Provider Access and Availability Standards . 63Demographic Changes . 64Advanced Medical Directives. 64Coordination with Texas Department of Family and Protective Services (TDFPS) . 65Termination of Provider Contracts . 65Attendant Care Enhancement Program (ACEP) . 65Community First Choice Provider Responsibilities . 66Electronic Visit Verification (EVV) . 67Cigna-HealthSpring Provider Compliance and Waste, Abuse, and Fraud Policy . 70Provider Complaint and Appeal Process . 71REPORTING ABUSE, NEGLECT, OR EXPLOITATION (ANE) . 72QUALITY MANAGEMENT . 73Overview. 73QI Department Functions . 73Quality Improvement Committee (QIC) . 73Clinical Practice Guidelines . 74Healthcare Plan Effectiveness Data and Information Set (HEDIS ) . 74On-Site Assessments . 74Medical Record Requirements . 75Credentialing . 77Direct Access to a Specialty Care Provider for Members with Special Health Care Needs . 84Member Rights and Responsibilities . 84Member’s Right to Designate an OB/GYN . 86Member Complaint and Appeal Process . 86Hospital Discharge Appeals. 89APPENDICES . 90Appendix A, Cigna-HealthSpring Member Identification Card . 91Appendix B, Sample Texas Benefits Medicaid Card . 92Appendix C, Sample Form 1027-A Temporary Medicaid Identification . 93Appendix D, Authorization Requirements . 94Appendix D, Authorization Requirements . 95Appendix D, Authorization Requirements . 96Appendix E, Prior Authorization Request Form . 97Appendix F, Inpatient Authorization Form . 983
Appendix G, Outpatient Authorization Form . 99Appendix H, Sample UB-04 Claim Form . 100Appendix I, Sample CMS 1500 Claim form . 101Appendix J, Sample of Claims Appeal Form . 102Appendix K, Payment Dispute Form. 103Appendix L, Member Acknowledgement Statement . 104Appendix M, Private Pay Agreement . 105Appendix N, Clinical Practice Guidelines. 1064
IMPORTANT PHONENUMBERSExternal Contacts Clinical PathologyFor quick reference information about Cigna-HealthSpring andthe Medicare-Medicaid Plan, providers can visit our website edicaidplan/index.html or our Provider Portal athttps://starplus.hsconnectonline.com.Note: Users should not enter "www" prior to entering the webaddress for the Provider Portal. Also, providers can call thefollowing resources for more information:Cigna-HealthSpring 1-800-959-49411-877-653-03311-877-653-0331Provider Services DepartmentMember Service DepartmentBehavioral Health ServicesBehavioral Health Crisis HotlineClaims Status RequestCompliance HotlineCigna-HealthSpring AutomatedEligibility Verification LineService CoordinationUtilization Management Concurrent ReviewUtilization Management – HomeHealth / Long-Term Services andSupportsUtilization Management - InpatientIntake Prior AuthorizationUtilization Management –Outpatient Prior ernal Contacts24-Hour Health InformationLineTMHP AutomatedInquiry System (AIS),Eligibility VerificationComprehensive CareProgram (CCP)Dental DentaQuestProviders:Members:Change Healthcare (formerlyEmdeon) (EDI)Quest 66-697-8378Laboratories (CPL) Laboratory Services(Labcorp) ProPathMAXIMUS (MedicaidManaged Care Helpline)Medicaid Managed CareHelplineMedicaid Managed CareHelpline TDDMedical TransportationProgram (MTP) - HidalgoTexas Department Of FamilyAnd Protective RODUCTIONWelcome to Cigna-HealthSpring CarePlan (Medicare-MedicaidPlan). Cigna-HealthSpring, Inc. (Cigna-HealthSpring) and itssubsidiaries are wholly-owned by Cigna Corporation (Cigna), apublicly-traded global health service company and the fourthlargest insurer in the United States based on enrollment. Cignais listed on the New York Stock Exchange (NYSE: CI) and is acomponent of the S&P 500 Stock Index.Cigna was formed in 1982 by the merger of the ConnecticutGeneral Life Insurance Company and the Insurance Companyof North America (INA). In 1792, a group of prominent citizensin Philadelphia formed the Insurance Company of NorthAmerica (INA), the first marine insurance company in theUnited States. In 1865, the Governor of Connecticut signed aspecial act of the General Assembly incorporating theConnecticut General Life Insurance Company (CG). Cignaacquired HealthSpring and its subsidiaries on January 31,2012.Cigna-HealthSpring is focused on delivering coordinated careplans to Medicare beneficiaries, with a special focus onimproving health care for low-income beneficiaries that qualifyfor Medicare-Medicaid (dual eligible). Cigna-HealthSpring andCigna combined have over 402,000 Medicare-MedicaidEnrollees and over 1.25 million Prescription Drug Plan (PDP)Enrollees. Nationwide, we are the: 4th largest Medicare-Medicaid MCO plan 3rd largest Special Needs Plan (SNP) (includingDual, Chronic, and Institutional) 4th largest Special Needs Plan for InstitutionalEnrollees (those residing in a Nursing Home) (ISNP)
4th largest Special Needs Plan for Dual Eligibles (D-SNP) 4th largest Special Needs Plan for MedicareBeneficiaries with Chronic Conditions (CignaHealthSpring covers individuals with Diabetes) 6th largest Prescription Drug PlanCigna-HealthSpring’s history officially began in 1996 whenhealthcare entrepreneur Herb Fritch saw an opportunity in astruggling Nashville health plan called Health Net, whichoffered Medicare and some commercial group plans. This wasa time of unprecedented downturn in the Medicare industrydue to falling government reimbursements, and most planswere pulling out of the business altogether. Mr. Fritchpersonally carried 15% of the original funding. Herb tookownership of the plan in September 2000, and within a fewmonths, he and a new management team had halted andreversed its losses. In October 2001, the plan’s name waschanged to HealthSpring to reflect its new direction andgrowth.Herb’s approach was two-pronged: 1) a focus on the specifichealthcare needs of people on Medicare and the dual eligiblepopulation, and 2) engaging physicians in a model thatestablished the primary care physician (PCP) as the Providerthat is responsible for the coordination of care with anemphasis on preventive care. He committed to this course at atime when most health plans were leaving the Medicaremarket and had given up attempting meaningful partnershipswith physicians.Medicare-Medicaid Plan ProgramOverviewWe are pleased to announce that, beginning March 1, 2015,Cigna-HealthSpring will be participating in the MedicareMedicaid Alignment Initiative. The goal of this initiative is tobetter serve both community and institutional based individualswho are eligible for both Medicare and Medicaid (dual-eligibleenrollees). The initiative is to develop a service delivery modelthat improves care coordination of services, improves quality ofcare, and reduces cost.Providers should use this provider manual in conjunction withthe Cigna-HealthSpring participating provider agreement tounderstand important participation requirements such as: Services that are covered under Cigna-HealthSpring How to determine Member eligibility How to access health care services within Cigna 6HealthSpring’s networkHow to file claims with Cigna-HealthSpringProvider roles and responsibilitiesCigna-HealthSpring’s Quality Management programMember roles and responsibilitiesThis provider manual is current as of its publication date.Cigna-HealthSpring reserves the right to make updates asnecessary and will make updates available to providerspromptly.Cigna-HealthSpring conducts its business affairs inaccordance with Federal and State laws.Cigna-HealthSpring takes the privacy and confidentiality ofMembers’ health information seriously. Cigna-HealthSpringcomplies with the Health Insurance Portability andAccountability Act of 1996 (HIPAA) and Texas regulatoryrequirements.Objectives of the MMP ProgramThe objective of the MMP Program is to: Make it easier for clients to get care Promote independence in the community Eliminate cost shifting between Medicare andMedicaid Achieve cost savings for the State and Federalgovernment through improvements in care andcoordination Require one health plan to be responsible for the fullarray of service.Member ConfidentialityAt Cigna‑HealthSpring, we know our members’ privacy isextremely important to them, and we respect their right toprivacy when it comes to their personal information and healthcare. We are committed to protecting our members’ personalinformation. Cigna‑HealthSpring does not disclose memberinformation to anyone without obtaining consent from anauthorized person(s), unless we are permitted to do so by law.When a member joins a Cigna-HealthSpring plan, we want youto know the steps we have taken to protect the privacy of ourmembers. This includes how we gather and use their personalinformation. Cigna-HealthSpring’s privacy practices apply to allof Cigna-HealthSpring’s past, present, and future members.When a member joins the Cigna‑HealthSpringMedicare‑Medicaid Plan, the member agrees to giveCigna‑HealthSpring access to Protected Health Information.Protected Health Information (“PHI”), as defined by the HealthInsurance Portability and Accountability Act of 1996 (“HIPAA”),is information created or received by a health care provider,health plan, employer or health care clearinghouse, that: (i)relates to the past, present, or future physical or behavioralhealth or condition of an individual, the provision of healthcareto the individual, or the past, present or future payment forprovision of health care to the individual; (ii) identifies theindividual, or with respect to which there is a reasonable basisto believe the information can be used to identify the individual;and (iii) is transmitted or maintained in an electronic medium,
or in any form or medium. Access to PHI allowsCigna‑HealthSpring to work with providers, like yourself, todecide whether a service is a covered service and pay yourclean claims for covered services using the members’ medicalrecords. Medical records and claims are generally used toreview treatment and to do
Cigna-HealthSpring CarePlan (Medicare-Medicaid Plan) Dear Valued Provider and Staff: I would like to extend a warm welcome and thank you for participating with Ci
