Cigna modifier reimbursement policy

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When a surgery involves more than one surgical procedure covered under a customer's plan, reimbursement policies apply. Procedures performed during the same operative session by the same provider known as "multiple procedures" are reimbursed following these guidelines:. Procedures requiring a separate incision performed during the same operative session known as "bilateral procedures" are reimbursed following these guidelines:.

Back to Coverage and Claims. All rights reserved. All insurance policies and group benefit plans contain exclusions and limitations. For availability, costs and complete details of coverage, contact a licensed agent or Cigna sales representative.

This website is not intended for residents of New Mexico. After a physician is admitted into a Cigna network, we conduct a review every two years to make sure they continue to meet our standards. Also, we regularly survey our managed care plan participants on the delivery and quality of services they receive from the doctors participating in the Cigna network.

Each Cigna Network Plan and POS Plan member selects a primary care physician—usually a family practitioner, internist, or pediatrician, who becomes the cornerstone for that member's health care needs. The primary care physician is familiar with the patient and their health history and helps coordinate care for the member, including the provision of primary and preventive care and referral to specialists when needed except in Cigna HealthCare Network Open Access and POS Access plan—referrals are not required in these plans.

The relationship Cigna members establish with their PCP facilitates better use of specialty services. The PCP helps make sure that the member is seeing the appropriate specialist for their condition and confers with the specialist to give details on the member's condition and health history.

For members with complex health conditions, the role of the PCP is essential. The PCP leads the team helping the member to manage multiple health conditions and treatments—often this includes assuring proper access to specialty care and making sure that all of the specialists are keeping one another informed. Under certain circumstances when it is determined that the ongoing needs of a member with chronic or multiple illnesses would be most effectively met by a specialist, that specialist becomes the primary care provider for that member for example, an AIDS patient may use an infectious disease specialist as their PCP.

This decision would be made as part of our case management process, which is an integral part of Cigna health plans. The health care needs of most healthy women at certain stages in their lives are more centered around their reproductive health.

Those plans do not require referrals to specialists of any kind and participants are free to see any participating specialists they choose.

Disclosure Disclosure of information to the customer has surfaced as a key issue in the public debate over managed care. There is a misperception that health plans do not give their members basic information about the plan such as: what is contained in the benefit plan they have selected, how to access services, which providers are in the network, what is the appeal and grievance procedure, etc.

Customer advocates and others are interested in requiring health plans to disclose financial information such as: what percentage of each premium dollar goes to the delivery of medical care versus administration of the plan, the specific amount providers are compensated, etc.

We believe that full information disclosure is essential to member satisfaction and in providing access to quality care. Cigna members receive a description of their benefit packages that includes information on: exclusions and limitations, the definition of emergency care, claims, and reimbursement procedures. In addition, participants in our managed care Network, POS, EPO, PPO plans receive instructions on accessing primary and specialty care, away-from-home care, out-of-network benefits POS and PPO plans only , member rights and responsibilities, the Cigna appeal and grievance procedure, a directory of participating providers, and other important information.

Emergency Room Widespread reports of emergency room claim denials by managed care plans have led to calls for legislative solutions.

EMTALA requires hospitals and emergency room physicians to screen and stabilize emergency room patients regardless of whether the patient is in an emergency situation. When a managed care plan participant seeks treatment for a non-emergency condition in the emergency room, they are responsible for the cost of screening and any treatment rendered.

As a result, hospitals and emergency room physicians are often not being paid for these services. They have seized this issue and are seeking legislation that would guarantee payment for all treatment provided in emergency rooms, regardless of the medical necessity of the services. This proposal would remove the financial disincentive for inappropriate use of the emergency room.

In effect, it would encourage people to use the most expensive health care setting, the emergency room, rather than their primary care physician or specialists.

Another issue is that emergency room claims are initially being denied because hospitals and emergency room physicians disclose only the final patient diagnosis on claim forms. When the presenting symptoms are disclosed, the claims are often paid. Emergencies should be treated in the emergency room, and patients should get emergency care when they need it at the sudden—and unexpected—onset of a serious injury or life-threatening illness.

In addition, if a managed care plan participant's primary care provider refers them to the emergency room, regardless of the nature or severity of the illness or injury, the claim will be covered. Non-emergency conditions should be treated by a physician in the physician's office. We encourage all Cigna plan participants to seek treatment for non-emergency conditions as soon as possible. Cigna, by contract, requires participating primary care physicians to maintain hour, seven-day-a-week telephone coverage and to provide an appointment within 24 to 48 hours of a request for urgent medical conditions.

When members are unsure whether or not they have a condition that requires immediate medical attention, they should consult with their primary care physicians. If their symptoms warrant prompt medical attention, the PCP will refer them to the emergency room. This relationship facilitates better treatment in the emergency room because the primary care physician can alert the emergency room that the patient is coming and provide important details on the patient's condition and health history.

Any hour of the day or night, from any phone in the U. The toll-free number is on the back of your Cigna ID card. A Health Information nurse will help you determine if emergency room care is advisable, if you require urgent care, or if self-care followed by a physician office visit is best.

Remember that this is not a call for authorization to seek emergency care. No authorization or referral is required by any Cigna medical plan for emergency care. If you believe life or limb are at risk, don't delay. Go directly to the nearest emergency facility or notify your local emergency services immediately. The general public is under the false impression that managed care companies do not provide coverage for new treatments, drugs, or devices—often called experimental treatment—because they are expensive and unproven.

This issue has received a great deal of media attention in relation to coverage for autologous bone marrow transplants ABMT for the treatment of breast cancer, as well as coverage for clinical trials. We evaluate requests for coverage for new treatments on a case-by-case basis. The Cigna coverage review process uses internal and external sources including its Medical Technology Assessment Council, peer-reviewed medical literature, and independent medical experts to assist its medical directors in reaching coverage determinations.

With the ethicist's help, we have developed a decision making tool that makes explicit the ethical dimensions of issues that frequently arise in managed care. The Cigna Medical Ethics Council is a standing committee established to ensure that ethical decision making is an integral part of each health plan's operations.

Our Medical Ethics Council includes representation from various departments within the company. Independent Review : The Cigna Expert Review Program assists our medical directors in determining coverage for medically complex cases.

The program provides extensive and objective assessments through a network of credentialed, independent medical experts in all domains of medical care. The medical experts may be local medical experts or from nationally recognized academic medical centers. They render opinions that address the issue of whether the requested technology will specifically benefit the member in question and whether this technology offers advantages over currently proven treatment modalities.

Medical Technology Assessment : The Cigna Medical Technology Assessment process evaluates emerging and evolving technologies to help ensure that our members have access to effective treatments. The Medical Technology Assessment Council, composed of national and field medical directors, an ethicist, an attorney, and nursing professionals, meets monthly to evaluate independent reports on medical technologies.

The council also reviews reports produced by the Technology Assessment Unit research staff at the request of field medical directors. The actions of the council produce coverage statements that are communicated to all Cigna medical directors.

The Medical Technology Assessment process is a central source of scientific, objective, and consistent support for the administration of benefits. We oppose legislative mandates that would require coverage for particular treatments or drugs. Medical science is not static, new treatments are constantly being discovered, and changes are being made to existing treatments on a regular basis. Government should not be involved in deciding what is the best medical treatment for a particular health condition.

Providers unhappy with the changes managed care has made in the way they are paid have raised the issue. They assert that managed care payment arrangements, particularly capitation, reward physicians for providing less care. Managed care is changing the way that physicians are paid. In many cases they no longer receive a fee for every individual service, procedure, or treatment they perform. This type of reimbursement encourages overtreatment which, in addition to being expensive, can be dangerous.

There is a misperception that managed care offers physicians financial incentives to cut costs and corners when treating patients. We believe that physicians should direct their efforts toward providing quality health care to Cigna members and that cost reductions can be achieved without affecting quality, simply by eliminating care that is unnecessary or of no proven value.

We oppose the use of financial incentives that encourage physicians to withhold necessary care. We do not offer physicians incentives to deny care. Compensation for Cigna-participating and out-of-network providers is determined using one of the following reimbursement methods: Discounted fee for service : Payment for services is based on an agreed upon discounted amount for services provided.

This payment covers physician and, where applicable, hospital or other services covered under the benefit plan. Medical groups and PHOs may in turn compensate providers using a variety of methods. This compensation method applies to Cigna Network plans and the in-network providers in our POS plans.

Capitation provides physicians with a predictable income, encourages physicians to keep people well through preventive care, eliminates the financial incentive to provide services which will not benefit the patient, and reduces paperwork for physicians. Salary : Physicians who are employed to work in a Cigna medical facility are paid a salary. The physician's compensation is based on a dollar amount, decided in advance each year, that is guaranteed regardless of the services provided. Physicians are eligible for a bonus at the end of the year based on quality of care, quality of service, and appropriate use of medical services.

Bonuses and Incentives: Eligible physicians may receive additional payments based on their performance. To determine who qualifies, Cigna evaluates physician performance using criteria that may include quality of care, quality of service, and appropriate use of medical services.

Formulary Some patient advocates and independent pharmacists contend that drug formularies limit patient treatment options and can inhibit therapy. In particular, media attention has focused on certain drugs not being included on formularies. Patient advocacy groups are seeking coverage for all FDA-approved drugs, regardless of whether they are approved for the treatment for which they are being prescribed.

Legislative attacks are under way. The Susan Horn Study , concluded that use of formularies increased use of health care services, which resulted in lower quality and increased costs.

The Cigna formulary—a list of drugs covered by a member's benefit plan—was developed to assure quality and cost effective drug therapy. Drugs included in our formulary are carefully selected by physicians and pharmacists for their efficacy, and the formulary is reviewed and updated regularly. This process allows our members to benefit on an ongoing basis from advances in pharmaceutical science that can dramatically improve the quality of people's lives.

Hospitals have used drug formularies in the same way for many years. The Cigna national drug formulary contains 1, FDA-approved brand name and generic drugs. These drugs are placed on the formulary by the Cigna Pharmacy and Therapeutic Committee, which meets quarterly and is composed of physicians and pharmacists. The Cigna Pharmacy and Therapeutic Committee reviews all FDA-approved drugs, groups them by therapeutic function, and then, within each group, compares their relative therapeutic effectiveness and potential side effects.

Only when two or more drugs are determined to be therapeutically equivalent does cost become a consideration. Cost is an appropriate and necessary consideration, since drug prices have risen three times faster than the rate of inflation over the last decade. We offer a variety of formulary structures, depending on the level of prescription drug coverage your employer chooses to offer.

Our Two-Tier Formulary covers generic drugs and preferred brand-name drugs that do not have generic equivalents slightly higher copayment required. Our Three-Tier Formulary covers generics, preferred-brand, and non-preferred brand drugs medications that have generic equivalents or one or more preferred-brand options available at a higher copayment level. Your employer can tell you which formulary program you participate in or you can call Member Services.

You can also review your specific formulary for covered medications online. Local Cigna plans may modify the national formulary to take into consideration local prescribing practices. If a physician wishes to prescribe a drug that is not on the formulary, the physician or a member may seek an exception to the formulary for coverage of a non-formulary drug.

It has resurfaced again in several state legislatures and at the federal level. Critics of managed care are making the argument that when a health plan denies coverage for a treatment or procedure, it is a medical decision—because the health plan is deciding what treatment it will cover—and should be subject to medical malpractice liability. The underlying assumption is that treatment will not be given unless the health plan will pay for it. Health plan medical professionals make coverage determinations based on the terms of a member's particular benefit plan.

Health plan medical directors use utilization management guidelines to assist in making such coverage determinations, but they are used as just that—guidelines—and are not a substitute for a clinician's judgment. The utilization management guidelines are a set of optimal clinical practice benchmarks for a given treatment with no complications and are based solely on sound clinical practices.

The Cigna utilization management guidelines are reviewed by each local health plan's quality committee, composed of Cigna-participating physicians practicing in the area, and are modified to reflect local practice. The guidelines are applied on a case-by-case basis. Mandated Benefits Mandated benefits require managed care companies and insurers by law to provide coverage for specific treatments and procedures and may set durational limits on coverage e. These laws, typically enacted by state legislatures, apply only to HMOs and insured plans, and do not apply to self-insured plans.

Federal mandates, however, apply to all employer-provided plans, whether insured or self-insured. One of the biggest concerns with mandated benefits is that they increase the cost of health care coverage. Some recent examples of mandated benefits include coverage for diabetic supplies, equipment and education, prostate screening antigen PSA testing for prostate cancer, bone densitometry for osteoporosis, breast reconstructive surgery following a mastectomy, and mastectomy length-of-stay requirements.

We are opposed to the government determining specific benefits to be included in managed care and insurance contracts. We believe that the marketplace should determine the benefits available to health plan participants. Mandatory Point-of-Service Legislative mandates that would require all HMOs to offer a point-of-service plan—a plan that offers participants the option to choose out-of-network providers for covered services—have been introduced in several states and have been enacted in several others.

Legislators are attempting to guarantee that consumers are offered a health care coverage option other than a traditional HMO. We oppose legislative mandates that would require all HMOs to offer an out-of-network benefit. This mandate would increase costs for employers and members and would eliminate traditional HMOs as a product offering in the marketplace. Point-of-service plans are already an option widely available in the marketplace.

Maternity Care We care about the health and well-being of our members. We also provide expectant mothers with educational materials, including a handbook on pregnancy and infancy.