STAR+PLUS IN-SERVICE NURSING FACILITY - Cigna

STAR+PLUS IN-SERVICE NURSING FACILITY

H8423_MCDTX_18_64904_PR Approved

AGENDA

• Cigna-HealthSpring’s Company Overview

• STAR+PLUS Nursing Facility Program Overview

• STAR+PLUS Nursing Facility Benefits and Eligibility

• Authorizations

• Skilled vs. Non-Skilled Services

• Non-Emergent Ambulance Services

• Interacting with Cigna-HealthSpring STAR+PLUS

• Claims Process

• Payment Dispute Form

• Appeals

• Electronic Funds Transfer

• Electronic Remittance Advice

• Cigna-HealthSpring Website & Secure Provider Portal

• Fraud, Waste and Abuse

• Important Phone Numbers

• Questions and Answers

• STAR+PLUS Nursing Facility Program Overview

• STAR+PLUS Nursing Facility Benefits and Eligibility

• Interacting with Cigna-HealthSpring STAR+PLUS

• Cigna-HealthSpring Website & Secure Provider PortalConfidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © Copyright 2018 Cigna. 2

CIGNA-HEALTHSPRING COMPANY OVERVIEW

Based in Nashville, Tennessee, Cigna-HealthSpring got its start in 2000 and is now one of the country’s largest and fastest-growing coordinated care plans whose primary focus is Medicare Advantage plans. Cigna-HealthSpring currently owns and operates Medicare Advantage plans in Alabama, Arkansas, Delaware, Florida, Georgia, Illinois, Indiana, Kansas, Maryland, Mississippi, Missouri, North Carolina, Pennsylvania, South Carolina, Tennessee, Texas, and Washington, D.C. , as well as a national stand-alone prescription drug plan.

Our Mission Statement

Cigna-HealthSpring is dedicated to improving the health of the communities we serve by delivering the highest quality and greatest value in healthcare benefits and services.

Confidential, unpublished property of Cigna. Do not duplicate or distribute. Use and distribution limited solely to authorized personnel. © Copyright 2018 Cigna. 3

CIGNA-HEALTHSPRING COMPANY OVERVIEW (CONT.)

• Cigna-HealthSpring currently offers STAR+PLUS services in the Tarrant SDA,Hidalgo SDA and MRSA Northeast.

• Combined, Cigna-HealthSpring serves Members in 50 counties across the State ofTexas for all three service delivery areas.

• March 1st, 2015, Cigna-HealthSpring began serving all three Service Delivery Areasfor Nursing Facility services.


CIGNA-HEALTHSPRING COMPANY OVERVIEW (CONT.)STAR+PLUS COUNTY COVERAGE

Tarrant SDA

May 1, 2011 – (6 Counties)

Hidalgo SDA

March 1, 2012 (10 Counties)

MRSA Northeast SDA

September 1, 2014 (34 Counties)

Denton, Hood, Johnson, Parker,

Tarrant and Wise.

Cameron, Duval, Hidalgo, Jim Hogg,

Maverick, McMullen, Starr, Webb,

Willacy, and Zapata.

Anderson, Angelina, Bowie, Camp,

Cass, Cherokee, Cooke, Delta, Fannin,

Franklin, Grayson, Gregg, Harrison,

Henderson, Hopkins, Houston, Lamar,

Marion, Montague, Morris,

Nacogdoches, Panola, Rains, Red

River, Rusk, Sabine, San Augustine,

Shelby, Smith, Titus, Trinity, Upshur,

Van Zandt and Wood.


• STAR+PLUS is a Texas Medicaid managed care program designed to coordinateand provide preventive, primary, and acute care, Long-Term Services and Supports(LTSS) to community-based and Nursing Facility residents through a managed caredelivery system.

• Health and Human Services Commission (HHSC) has carved in custodial NursingFacility services to the Managed Care Organizations (MCO). The expectation is toimprove the quality of care, and to better coordinate services and healthcare needs.

STAR+PLUS NURSING FACILITY PROGRAM OVERVIEW


• Assess Member’s health risks and functional needs.

• Assist Nursing Facility Members wanting to return to the community.

• Provide competent service coordination, which includes service planning, andmonitoring and coordinating acute care for members with complex or chronic healthcare needs.

• Improve cost effectiveness by reducing unnecessary hospitalizations and providingappropriate medical services.

STAR+PLUS NURSING FACILITY PROGRAM OVERVIEW (cont.)Program Objectives


STAR+PLUS NURSING FACILITY BENEFITS AND ELIGIBILITYEligibility

• To be eligible for Nursing Facility services, a STAR+PLUS Member must meet all ofthe following criteria:

• A physician certifies the Member’s medical condition.

• The Member’s medical condition meets Medical Necessity (MN) requirements.

• The Member has received a Level 1 Pre-admission Screening and Resident Review

(PASRR).

• Once a Member is admitted to the facility they will receive a Minimum Data Set (MDS)

evaluation by the nursing facility to determine the Member’s Resource Utilization

Group (RUG).


Enrollment is required for Medicaid recipients who live in a STAR+PLUS service area and fit one or more of the following criteria:

– People who are have a physical or mental disability and qualify for supplementalsecurity income (SSI) benefits or for elderly individuals who have Medicaid due tolow income.

– People who qualify for Community-Based Alternatives (CBA) HCBS STAR+PLUSwaiver services.

– People age 21 or older who can receive Medicaid because they are in a SocialSecurity Exclusion program and meet financial criteria for HCBS STAR+PLUSwaiver services.

– People age 21 or older who are receiving SSI.

STAR+PLUS NURSING FACILITY PROGRAM OVERVIEW (cont.)Program Qualifications


• Once a Medicaid client is determined by HHSC to be eligible forSTAR+PLUS, he/she will receive an enrollment packet in the mail fromHHSC's administrative services contractor, MAXIMUS.

• The packet contains information about the STAR+PLUS program,instructions for completing the enrollment form, and information about theMCOs available in his/her service area.

• MAXIMUS processes STAR+PLUS applications, assists Members who aretransitioning from traditional, fee-for-service Medicaid into the STAR+PLUSProgram, and assists Members in selecting a MCO and process planchanges.

• Members who need assistance can contact an enrollment counselor bycalling the MAXIMUS Helpline at 1-877-782-6440.

• If the member enrolls before the 15th of the month he/she will be effectivethe 1st of the next month. If the member enrolls after the 15th of the monthhe/she becomes effective the 1st of the following month (e.g. 45 days).

STAR+PLUS NURSING FACILITY PROGRAM OVERVIEW (cont.)Member Enrollment Process


• The Nursing Facility will continue to provide services under the Unit Rate services.

• This applies to the types of services historically included in the DADS daily rate fornursing facility providers, such as room and board, medical supplies and equipment,personal needs items, social services and over-the-counter drugs.

• The Nursing Facility Unit Rate payment from MCOs also includes applicable nursingfacility rate enhancements and professional and general liability insurance.

• Nursing Facility Unit Rates excludes Nursing Facility Add-on Services.

• Add-On services, provided by either qualified Nursing Facility employees orcontracted/certified individuals, are reimbursed separately by the MCO.

• Nursing Facilities will complete and submit the Minimum Data Set (MDS) and LongTerm Care Medicaid Information (LTCMI) electronically on the LTC Online Portalsystem at TMHP.

STAR+PLUS NURSING FACILITY PROGRAM OVERVIEW (cont.)Unit Rate Services


• Nursing Facility Add-on Services are the services that are provided in the facility settingby the provider or another network provider. They are not included in the NursingFacility Unit Rate, and are including but not limited to:

– emergency dental services– physician-ordered rehabilitative services– customized power wheel chairs– augmentative communication devices

• Providers billing for add-on services must be in-network with Cigna-HealthSpring;contracting and credentialing may be required for the respective entity. NursingFacilities may bill claims on behalf of employed or contracted providers for therapy add-on services only.

Other Services– Physicians and other professional provider services are covered for NF residents.– Physicians need to be contracted and credentialed with Cigna-HealthSpring.– Pharmacies are contracted through OptumRX.

STAR+PLUS NURSING FACILITY PROGRAM OVERVIEW (cont.)Add-on Services


• In order to establish medical necessity for therapy requests, clinical informationsupporting a new onset of issues is necessary to make a determination.

• Services can be acute due to injury, illness or an exacerbation of a chronic condition,but the clinical documentation needs to demonstrate that.

• Treatment Plan indicating the frequency and length of the request.

• Documentation demonstrating if the member can progress and respond appropriately tothe therapy.

• One of the most frequent reasons for denials is lack of medical information.

STAR+PLUS NURSING FACILITY PROGRAM OVERVIEW Key Elements From Clinical Notes for Add-on Services


What are the turnaround times for an authorization, and how can I escalate the authorization request?

• Our standard turnaround time (TAT) is 3 business days.

• TAT is calculated from the date and time of the receipt of call/fax/portal.

• If the auth request comes in on Tuesday at 1pm, it is due for a determination to theprovider no later than Friday at 1pm.

• 3 business days includes time obtaining the clinical, the UM nurse reviewing theinformation, determining if it meets criteria and if not, sending the case to the medicaldirector for review.

• We monitor TAT closely and if a TAT is missed, the manager has to explain why it wasmissed to the director.

• In life-threatening cases where a member is at risk, you can call UM and request theservice be expedited. The TAT is then 1 business day.

– *Life-threatening such as swallowing issues, stroke, apnea, etc…

– True emergencies can be reported to UM the next business day.

AUTHORIZATION TURNAROUND TIMES


What documentation is required for Inpatient Medical/Surgery?

• Complete ER record

• Admitting orders

• History and Physical

• Physician Treatment Plan

• OR report (if applicable)

• Clinical information

• Labs and imaging results

• Consultations and evaluations

AUTHORIZATION REQUEST FOR INFORMATION


• Physician’s treatment plan

• OR Report (if applicable)

• History and Physical/progress notes

• Treatment plan, physicians orders

• Nutritional assessment, current weights

• Laboratory and radiology reports

• Therapy evaluation and weekly progress notes

• Wound care assessment and treatment sheets

• Discharge plan

• Any other pertinent clinical information such as abnormal lab results, imaging results,IV medications, consults, evaluations, etc.


What documentation is required for Skilled Nursing Facility services?


What documentation is required for Outpatient services?

– Recent Office Visit Notes

– Applicable labs and Imaging

– Current orders

– Current treatment plan

• Specifics are necessary in order to meet InterQual® standards

• UM Milliman and/or InterQual notes only are not acceptable. Initial clinical must betime stamped with physicians name, date and time.



What is required for discharge planning as a client transitions from a facility?

– Home health

– DME

– Infusion therapy

– Physical therapy

– Occupational therapy

– Outpatient speech therapy

If discharge planning is provided by the Social Worker

– Provide Social Workers full name and phone number to:

– Fax: 877-809-0787

– Additional notes as needed

Note: Discharge planning is critical to ensuring the member has services they need as they transition home. We can assist in the process and supply names of in-network providers and begin the authorization process for services.



• For STAR+PLUS, the benefit allowed for our members is a non-skilled bed oftenknown as custodial. A STAR+PLUS member can only be in a non-skilled bed.

• Under the Medicare-Medicaid Plan, skilled nursing facility bed is a benefit just as anyother Medicare recipient is.

• A MMP member can be in a non- skilled bed or a skilled bed.

• If a MMP member is going to be admitted to a skilled bed, an authorization is needed.

• If a STAR+PLUS member is going to be admitted, the actual admission is notauthorized, but any “add-on” services are such as therapies and customizedwheelchairs.

• For Dual Eligible members needing therapies in a non-skilled bed, it is helpful for us ifyou note whether or not you are billing Medicare Part B or Medicaid.

SKILLED VS NON-SKILLED


STAR+PLUS NURSING FACILITY PROGRAM OVERVIEW (CONT.)NON-EMERGENT AMBULANCE SERVICES

Requests for prior authorization for non-emergent ambulance transports are submitted by the Nursing Facility. An ambulance provider may NOT request a prior authorization for non-emergent ambulance transports. The ambulance provider is ultimately responsible for ensuring that a prior authorization has been obtained prior to transport. Non-payment may result for services provided without a prior authorization or when the authorization request is denied by the MCO.


Unit Rate

Claims billed to Cigna-HealthSpring by Nursing Facility

Billing Provider: Complete and submit Cigna-HealthSpring Authorization Form• emergency dental services• physician-ordered rehabilitative

services• customized power wheel chairs• augmentative communication devices

Add-on Services

Complete the 3618 or 3619 forms with MDS Assessments and submit to TMHP LTC Online portal• Room and board• medical supplies and equipment• personal needs items• social services• over-the-counter drugs

Claims billed to Cigna-HealthSpring for services provided by Nursing Facility or their subcontractors.

Claims billed to Cigna-HealthSpring for services provided by a Cigna-HealthSpring in-network provider


• Pre-admission Screening and Resident Review

– All people who are planning to move to a partially federally funded nursing facility mustundergo a Level 1 Pre-admission Screening and Resident Review (PASSR). If theperson is suspected of having a mental illness, or a diagnosis of an intellectualdisability or a related condition. This includes private pay individuals. Note: If the Level1 Screening has a positive indication of conditions for MI and/or IDD a Level 2 PASRRAssessment (face-to-face) must be conducted by the Local Authority to confirm ordeny these conditions by the Local Authority.

– People are assessed to see if they need specialized services. People who are notsatisfied with their PASRR determination have the right to a fair hearing to appeal thedetermination.

• What services are provided by Local Authority or Local Mental Health Authority?

– Alternate placement services

– Customized manual wheelchairs and specialized durable medical equipment

– Determination of intellectual disability

– Specialized therapies

– Service coordination

– Vocational training

STAR+PLUS NURSING FACILITY PROGRAM OVERVIEW (cont.)Texas Medicaid Program Benefits (Behavioral)


Value-Added Services (VAS)• Initially, Cigna-HealthSpring notifies new members in the Welcome Kit regarding the available value-

added services and how to access them. Thereafter, Cigna-HealthSpring sends benefit education materials to members annually, outlining the available value-added services and how to access them. Additional details about value-added services are available at http://starplus.mycignahealthspring.com/. Cigna-HealthSpring members can get assistance accessing value-added services from their Service Coordinator by calling 1-877-725-2688 or by calling Member Service at 1-877-653-0327.

• Note: ALL services must be obtained through a in-network provider. VAS are provided to members, one per year.

• *Value Added Service effective September 1, 2017.

Medicaid ONLY Members ALL Members

Dental ServicesAdults, age 21 and over

Cigna‐HealthSpring Fitness Plus‐ Active & Fit Home Fitness Kit

Enhanced Vision ServicesAdults, age 21 and over

Fleece Blanket

*Good Health Reward Gift Card ‐ $30 gift card for getting an annual well visit and certain labs or immunizations

Limit one gift card per Member per year.

Clip‐on Lamp

Reacher/Grabber

*Bedside Caddy

*Lumbar Pillow

NURSING FACILITY ADDITONAL BENEFITSCigna-HealthSpring Value Added Services


NEW Texas Medicaid STAR+PLUS ID Card:

• Medicaid providers should be prepared to verify a person’s Medicaid eligibility with thenew Your Texas Benefits Identification Card.

– The front of the card shows the person’s unique Medicaid ID#

– That same number is embedded in a magnetic strip on the back

– Accessible with a basic swipe-style card reader; if Provider has a

card reader in his/her office

INTERACTING WITH CIGNA-HEALTHSPRING STAR+PLUSMember/Provider Services-Eligibility Verification


INTERACTING WITH CIGNA-HEALTHSPRING STAR+PLUSTexas Medicaid “Your Texas Benefits” Card

*Please note the STAR+PLUS MCO will not be listed on the card*


STAR+PLUS NURSING FACILITY BENEFITS AND ELIGIBILITY (cont.)Cigna-HealthSpring STAR+PLUS Example ID Card for Medicaid Only Eligible Member


STAR+PLUS NURSING FACILITY BENEFITS AND ELIGIBILITY (cont.)Cigna-HealthSpring STAR+PLUS Example ID Card for Dual Eligible Member


3 Ways to Verify Eligibility with Cigna-HealthSpring:

1. The Cigna-HealthSpring Provider/Member Services Department by calling1-877-653-0331.

2. TexMedConnect - The State’s eligibility verification system.

3. The Cigna-HealthSpring secure Provider Portal accessible through theCigna-HealthSpring website.

*Member eligibility can change each month. Please verify eligibility the 1st ofevery month.

INTERACTING WITH CIGNA-HEALTHSPRING STAR+PLUSMember/Provider Services – Eligibility Verification


Responsibilities of Cigna-HealthSpring’s Service Coordinator:

• Provide support to the Nursing Facility in obtaining add-on services.

• Collaborate in the creation of a plan of care.

• Participate in care plan and IDT's meetings to provide feedback on possibleservices with discharge planning and community placement.

• Monitor progress toward Member’s individual health goals.

• Assist the Nursing Facility with discharge planning or changes in levels of care.

• Assist the Nursing Facility by reminding members, as needed, of requirements toremit applied income to the facility.

• Assist Member or family members in transitioning our Member to a Hospiceprovider.

Service Coordinator contact number: 1-877-725-2688

INTERACTING WITH CIGNA-HEALTHSPRING STAR+PLUS (cont.)Service Coordination



• NF Members will be categorized as Level 1 Members and all Members within an NFwill have the same assigned SC, who will perform a minimum of four (4) face-to-facevisits yearly.

• The assigned SC will take referrals from NF Members wanting to return to thecommunity and, when appropriate Members are identified, will develop a plan of careto transition the Member back into the community. SCs must contact the NF within 14days once they are notified.

• Person-Centered Care is promoting a new way of thinking relating to people living innursing facilities from task-oriented and schedule driven to focus on the person livingin the facility and building relationships.


Responsibilities of the Nursing Facility:

• Inviting the MCO SC to provide input for the development of the NF care plan,subject to the member's right to refuse, by notifying the MCO SC when theinterdisciplinary team is scheduled to meet

• Notifying the MCO SC within one business day of unplanned admission ordischarge to a hospital or other acute facility, skilled bed, or another nursing home

• Notifying the MCO SC if a member moves into hospice care

• Notifying the MCO SC within one business day of an adverse change in amember's physical or mental condition or environment that could potentially lead tohospitalization

• When resident wants to transition from a NF to community or Section Q is marked“Yes” on the MDS

• Notifying the MCO SC within one business day of an emergency room visit

• Notifying the MCO SC within 72 hours of a member's death

• Notifying the MCO SC of any other important circumstances such as the relocationof residents due to a natural disaster

• Providing the MCO SC access to the facility, NF staff, and members' medicalinformation and records



• Member/Provider Services provides customer service for providers, Member’sauthorized personal representatives as well as vendors, etc.

Services provided include:

– Verify eligibility, benefits and prior authorizations on file

– Assist providers to connect to the appropriate departments

– Verify claims receipt or review claims status

– Process demographic changes such as PCP on file or Member addresschanges

– Provide assistance with Cigna-HealthSpring’s public website & secureProvider Portal

Contact Provider/Member Services Department at 1-877-653-0331

INTERACTING WITH CIGNA-HEALTHSPRING STAR+PLUS (cont.)Member/Provider Services


The Contracting and Provider Relations functions includes:

– Responsibility for maintaining the provider network, ensuring a sufficient number ofproviders are available in each County to serve the healthcare needs of Membersenrolled in Cigna-HealthSpring’s STAR+PLUS Program.

– Distribute contracting documents to Providers as well as respond to any inquiriesrelated to contracting and credentialing requirements.

– Serve as the primary liaison with participating providers to resolve any operationalchallenges between the Provider and Cigna-HealthSpring. The Nursing Facility Representative is proficient in Nursing Facility billing matters and is able to resolvebilling and payment inquiries by working directly with the Cigna-HealthSpringclaims department. Providers will be notified within 10 days of any changes toyour Nursing Facility Provider Representative.

INTERACTING WITH CIGNA-HEALTHSPRING STAR+PLUS (cont.)Contracting & Provider Relations


Claims Filing Deadline

• Cigna-HealthSpring's claim filing deadline for daily unit rates is the same as traditional,fee-for-service Medicaid. Providers must submit Unit Rate and Medicare co-insuranceclaims to Cigna-HealthSpring within three hundred sixty-five (365) days from the datethe covered service was rendered. If the claim is not filed with Cigna-HealthSpringwithin 365 days from the date of service, the claim will be denied. The required dataelements for Medicaid claims must be present for a claim to be considered a cleanclaim and are the same as fee-for-service clean claim requirements.

• Cigna-HealthSpring is required to process Nursing Facility Unit Rate clean claimswithin 10 days of receipt.

• Add-on Services claims must be sent to Cigna-HealthSpring within ninety-five (95) daysfrom the date the covered service was rendered.

• Providers should not collect payment from or bill Cigna-HealthSpring Membersfor any covered services, with exception of applied income.

INTERACTING WITH CIGNA-HEALTHSPRING STAR+PLUS (cont.)Claims


Member CoverageVision Care

Responsibility

Dental Care Responsibility

(except emergency dental, see page 12)

If Primary Payer Is … And secondary payer is…

Cigna-HealthSpring STAR+PLUS

n/aValue Added through Cigna-HealthSpring STAR+PLUS

Value Added through Cigna-HealthSpring STAR+PLUS

Cigna-HealthSpring MA-PD (Medicare)

Cigna-HealthSpring STAR+PLUS

Cigna-HealthSpring MA-PD

Cigna-HealthSpring MA-PD

Other Payer MA-PDCigna-HealthSpring STAR+PLUS

Other Payer MA-PD Other Payer MA-PD

Traditional MedicareCigna-HealthSpring STAR+PLUS

Medicare Medicare

CLAIMS RESPONSIBILITY FOR VISION AND DENTAL SERVICESClaims


3 ways to file a claim with Cigna-HealthSpring

1. Electronically – (Payer ID# 52192) – via 1 of the following 3 Cigna-HealthSpring claims clearinghouses; (1) Emdeon, (2) PayerPath, or(3) Availity.

2. Via secure Provider Portal – Submit CMS 1500 and UB04;individual claims or by batch.

3. Via TMHP State’s website – Visit the website http://www.tmhp.com/and click on ‘Providers’ in the top header. Then Click ‘Go toTexMedConnect’ in the upper right corner. TMHP claims areforwarded to Cigna-HealthSpring.

INTERACTING WITH CIGNA-HEALTHSPRING STAR+PLUS (cont.)Claims


Type of Service Claims Address

Add-on Services(Provided by the Nursing Facility or a Cigna-HealthSpring subcontracted Provider)

Cigna-HealthSpringP.O. Box 981709 – STAR+PLUSEl Paso, TX 79998-1709

Dental Services, including Emergency Dental ServicesElectronic Claims:Emdeon/Availity Payer ID: CX014

DentaQuest-Claims12121 North Corporate ParkwayMequon, WI 53092

Vision Serviceswww.superiorvision.com1-800-879-6901

Superior Vision939 Elkridge Landing Road, Suite 200Linthicum, MD 21090

INTERACTING WITH CIGNA-HEALTHSPRING STAR+PLUS Claims


INTERACTING WITH CIGNA-HEALTHSPRINGPayment Disputes

A payment dispute is a written communication (i.e. a letter) from the Provider about a disagreement with the manner in which a claim was processed, but does not require a claim to be corrected and does not require medical records.

The Payment Dispute From can be found on our website: http://starplus.cignahealthspring.com.

Examples of when to use the payment dispute form: (this is not a complete list)

• Denial for “timely filing”, but provider has proof of timely• Denial for incorrect applied income • Denial for “RUG Level Changes” affecting payments previously

made by Cigna-HealthSpring• Denial for “no coverage”, but member was active during the Date

of Service (DOS)• Provider not being paid at correct reimbursement rate, paid

incorrectly• Denial for incorrect modifier, CPT code, National Drug Code

(NDC) number, NPI/TIN/TPI, Place of Service (POS), Date ofService (DOS), Type of Bill (TOB), Diagnosis (DX) code, etc. and denied incorrectly

• Denial for “no active provider contract” and provider does havean active contract listed

• Denial for insufficient units, per authorization on file there’s units available, or there’s no units available due to error on our end


• 3 ways a Provider may appeal a previously processed claim:

1. Fax the request to Cigna-HealthSpring at 1-877-809-0783.

2. Electronically via HSConnect Provider Portal.

3. Mail the request to:

Cigna-HealthSpringAppeals and Complaints DepartmentPO Box 211088Bedford, TX 76095

– Requests for reconsideration must be made within 120 days from the date ofremittance of the Explanation of Payment (EOP).

– Acknowledgement letter sent within 5 business days of receipt; appealresolved within thirty (30) calendar days.

INTERACTING WITH CIGNA-HEALTHSPRING STAR+PLUSAppeals & Complaints


The Difference Between a Corrected Claim and an Appeal

• Claim Appeal – An appealed claim is a claim that has been previouslyadjudicated as a Clean Claim and the provider is appealing the dispositionthrough written notification to the Managed Care Organization. e.g., an appealbased on a discrepancy with the amount paid to a provider; a written notificationappealing the disposition on a previously adjudicated clean claim.

• Corrected Claim – A corrected claim is a claim that has already beenadjudicated, whether paid or denied. A provider would submit a corrected claim ifthe original claim adjudicated needs to be changed. e.g., provider billed with anincorrect date of service/incorrect number of units:

– Corrected claims can be resubmitted via HSConnect, or via paper, by enteringa “7” for the Resubmission code, and the original claim number as your OriginalReference No on box 22 of the CMS 1500 form. The original claim number canbe found on the original EOP. Follow UB04 corrected claim code as stated inthe Nursing Facility Provider Manual.

– Corrected claims are considered claims reconsiderations and are notconsidered claims appeals.

INTERACTING WITH CIGNA-HEALTHSPRING STAR+PLUS Appeals & Complaints


Electronic Funds Transfer (EFT)

• Cigna-HealthSpring contracts with Emdeon to deliver electronic funds transferservices. If you are an existing EFT customer with Emdeon and wish to addCigna-HealthSpring to your service, please call 1-866-506-2830, and selectOption 1 to speak with an Emdeon Enrollment Representative.

– There is no cost for providers to enroll in EFT.

– If you would like to learn more or sign up for EFT, please visit Emdeon’sePayment Web site at www.emdeonepayment.com.

INTERACTING WITH CIGNA-HEALTHSPRING STAR+PLUS (cont.)EFT


Electronic Remittance Advice (ERA)

• Providers who are able to automatically post 835 remittance data will save posting timeand eliminate keying errors by taking advantage of 835 ERA file service.

ERA Enrollment Process• Download Emdeon Provider ERA Enrollment Form at the following location:

http://www.emdeon.com/resourcepdfs/ERAPSF.pdf

• Complete and submit ERA Enrollment Form via Email or Fax to Emdeon ERA Group:

– Email: [email protected]

– Fax: 1-615-885-3713

• Any questions related to ERA Enrollment or the ERA process in general, please callEmdeon ePayment Solutions at 1-866-506-2830 for assistance.

• NOTE: ERA enrollment for all Cigna-HealthSpring health plans must be enrolled underCigna-HealthSpring Payer ID “52192”.

INTERACTING WITH CIGNA-HEALTHSPRING STAR+PLUS (cont.)ERA


How to Complete a CMS 1500 Form

• The following slides list theminimum data required toprocess a claim on a CMS 1500form.

• Providers can view a sampleCMS 1500 form in Appendix Jof their provider manual.However, photocopies of theform should not be used to fileclaims with Cigna-HealthSpring.

*Used for add-on services

CMS 1500 Overview


How to Complete a CMS UB04 Form

• The following slides list theminimum data required toprocess a claim on a CMSUB04 form.

• Providers can view a sampleCMS UB04 form in Appendix I of their provider manual.However, photocopies of theform should not be used to fileclaims with Cigna-HealthSpring.

UB04 Overview


CLAIM FILING TIPS

• Participating Providers must submit claims within three hundred and sixty-five (365)days from the date the services were rendered for Nursing Facility unit rate services.

• Add-on Services claims must be sent to Cigna-HealthSpring within ninety-five (95)days from the date the covered service was rendered.

• Cigna-HealthSpring is required to process clean claims within 10 days of receipt forNursing Facility unit rate services. Add-On Service claims are paid within 30 days.

• Providers should not collect payment from or bill Cigna-HealthSpring members forcovered services, with the exception of applied income.

• Submit claims for one Member and one Provider per claim form. Unit rate billedseparate from Add-on services.

• Multiple visits rendered over several days should be itemized by date of service. Ifthere is a break in consecutive days, bill the dates as rendered on a separate line.

• Avoid using unlisted procedure codes when possible. Submit unlisted codes only afterreceiving prior authorization for the specific code.


• The Cigna-HealthSpring TexasMedicaid STAR+PLUS website isavailable at:http://starplus.cignahealthspring.com/sptxnursingclaims

• The website includes much of theinformation included in today’spresentation and allows providers todownload numerous additional, moreinformative resources as well, such as:

– Nursing Facility Provider RepresentativeContact information

– HSConnect and Change HealthcareNursing Facility Portal Guide

– Nursing Facility Quick Reference Guide

– Nursing Facility Presentation

– Nursing Facility Provider Manual

CIGNA-HEALTHSPRING STAR+PLUS PROVIDER WEBSITE


• Cigna-HealthSpring’s secure ProviderPortal is available to participatingproviders only.

• Providers must have a User ID &Password to access the ProviderPortal. New Providers must register aUser ID & Password online whenaccessing the Provider Portal.

• The Provider Portal allows 24-houraccess and is an interactive site whereparticipating Providers are allowed to:

– Verify Member eligibility and PCP onfile

– Verify Member’s Service Coordinator

– Check claim status

– Request authorizations

– Check authorization status

– MESAVE - RUG Level & AppliedIncome

Providers can seek assistance with the Provider Portal by calling 1-866-952-7596.

CIGNA-HEALTHSPRING’S PROVIDER PORTAL


CIGNA-HEALTHSPRING’S PROVIDER PORTAL


FRAUD, WASTE AND ABUSEDefinitions

Fraud: Intentional deception or misrepresentation to obtain money or products of a health care benefit program by false or fraudulent pretenses/representation.

Waste: The over-utilization of services that result in unnecessary costs.

Abuse: Obtaining payment for items or services when there is no legal entitlement to that payment, but without knowing and/or intentional misrepresentation of facts to obtain payments, resulting in unnecessary costs to the Medicare program or improper payment for services that fail to meet professionally recognized standards of care or that are medically necessary.

What are the differences between Fraud, Waste and Abuse?

One of the primary differences is intent and knowledge. Fraud requires the person to have intent to obtain payment and the knowledge that his or her actions are wrong. Waste and abuse may involve obtaining an improper payment, but does not require the same intent and knowledge as Fraud.


FRAUD, WASTE AND ABUSE CONTINUED Lines of Communication

Via Cigna-HealthSpring

To report suspected or detected Medicare or Medicaid program non-compliance, please contact Cigna-HealthSpring's Compliance Department . To report potential fraud, waste, or abuse please contact Cigna-HealthSpring's Benefit Integrity Unit.

Cigna-HealthSpring Cigna-HealthSpring

Attn: Compliance Department Attn: Benefit Integrity Unit

530 Great Circle Rd 500 Great Circle Road

Nashville, TN 37228 Nashville, TN 37228

– By phone: 1-800-230-6138, Monday through Friday, 8:00 AM to 6:00 PM CST

Via HHSC Office of Inspector General

– Visit http://oig.hhsc.state.tx.us/. Under the box labeled “I WANT TO” click “Report Waste,Abuse and Fraud” to complete the online form. The site tells you about the types of waste,abuse and fraud to report.

– If you would rather talk to a person, call the HHSC Office of Inspector General FraudHotline (OIG) at 1-800-436-6184


INTERNAL CONTACTS Phone Number

Behavioral Health Substance Abuse Services 1-877-725-2539

Behavioral Health Crisis Hotline- Hidalgo 1-888-843-1315

Behavioral Health Crisis Hotline- Tarrant and MRSA-Northeast 1-877-562-4397

Claims Status Request 1-877-653-0331

Compliance Hotline 1-877-653-0331

Cigna-HealthSpring Automated Eligibility Verification Line 1-866-467-3126

Provider/Member Services Department 1-877-653-0331

Utilization Management – Service Coordination 1-877-725-2688

Utilization Management – Concurrent Review & Skilled Nursing Facility 1-877-725-2688

Utilization Management – Home Health 1-877-725-2688

Utilization Management – Inpatient Intake 1-877-725-2688

Utilization Management – Prior Authorization 1-877-725-2688

INTERNAL CONTACTS


EXTERNAL CONTACTS Phone Number

Automated Inquiry System (AIS), Eligibility Verification 1-800-925-9126

Cigna-HealthSpring Pharmacy 1-877-653-0331

Comprehensive Care Program (CCP) 1-800-846-7470

Dental (DentaQuest) – Provider Services 1-888-308-9345

Dental (DentaQuest) – Member Services 1-855-418-1628Change Healthcare (formerly know as Emdeon) 1-800-845-6592

Long-term Care Ombudsman 1-800-252-2412

MAXIMUS (Medicaid Managed Care Helpline) 1-877-782-6440

Medicaid Managed Care Helpline 1-866-566-8989

Medicaid Managed Care Helpline TDD 1-866-222-4306

Medical Transportation Organization (MTO) – Tarrant SDA 1-855-687-3255Medical Transportation Organization (MTO) – Hidalgo SDA and MRSA Northeast SDA 1-877-633-8747

Texas Department of Family & Protective Services (TDFPS) 1-800-252-5400

Vision (Superior Vision) 1-800-879-6901

EXTERNAL CONTACTS


All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including HealthSpring Life & Health Insurance Company, Inc. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. Cigna-HealthSpring CarePlan is a health plan that contracts with both Medicare and Texas Medicaid to provide benefits of both programs to enrollees. © 2018 Cigna

© 2018 Cigna. Some content provided under license.

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