Case Management Program

Section 3

Identifying the Cigna Behavioral Health Participant

Establishing participant eligibility for benefits prior to initiating treatment is essential to ensure claim payment. Participants are not required to obtain prior benefit authorization for routine outpatient care, including diagnostic or initial treatment sessions. Participants can visit the online Provider Directory at www.cigna.com to search for practitioners or can contact us through the mental health and substance use telephone number on their medical identification card. However, coverage for any higher level of care must be preauthorized. Practitioners are responsible for obtaining prior authorization for non-routine outpatient care as well as for all higher levels of care. The practitioner may not bill the participant for care for which prior authorization was not obtained, beyond applicable coinsurance/copayment and/or deductible.

Not verifying eligibility and benefit coverage can result in an Administrative Denial, whereby the practitioner must hold the participant financially harmless if the practitioner was aware of or failed to determine the participant's coverage. If a participant does not have a health care identification card, ask the participant for the information below, then log in to Cigna for Health Care Professionals (CignaforHCP.com) to verify eligibility and benefits for the participant, or call Cigna Behavioral Health.


Participant Information Participant Name
ZIP Code
Date of Birth
Subscriber ID #
Plan Subscriber Information Name
Participant Number
Subscriber ID #
Date of Birth
ZIP Code

Participants enrolled in PPO, OAP, and HMO plans may select a practitioner from a network Provider Directory and are not required to secure prior benefit authorization from Cigna Behavioral Health for routine outpatient services. Preauthorization of coverage and case management of inpatient and residential services for PPO, OAP, and HMO participants are still required and must be obtained by the practitioner. Preauthorization for partial and intensive outpatient programs (IOP) is dependent upon the individual's policy. The implementation of federal parity laws in 2010 has resulted in some policies not requiring authorization for partial or IOP. A Cigna Behavioral Health representative can help you determine if preauthorization is required for your patient's benefit plan. Benefits, coinsurance, claim information, and the claims filing address are prominently listed on the participant card.

A practitioner contracted with Cigna Behavioral Health must treat all Cigna Behavioral Health participants equally, and must behave as contracted, regardless of service location. You may not require that Cigna Behavioral Health participants sign self-pay agreements prior to providing covered services to them, unless you specifically set forth in detail to the participant and the participant agrees to pay for those specified behavioral care services in writing prior to the delivery of those behavioral care services. Nor may you charge Cigna Behavioral Health participants out-of-network rates. Please refer to your Cigna Behavioral Health Participating Provider Agreement for additional information.

Scheduling Appointments

Cigna Behavioral Health has adopted the below access standards based on industry standards, and our appointment access standards now include office wait times. In addition, participants should be seen within the timeframes listed below based on the severity of their clinical presentation.
  • Post-discharge from inpatient care – Within 7 calendar days
  • Emergent – Life threatening – appointment to be within six hours
  • Urgent non-life threatening – As soon as possible but not to exceed 48 hours
  • Initial routine – Within 10 business days
  • Follow-up routine care within 30 calendar days
  • EAP standard – Within 2 business days
  • Office wait time – 15 minutes or less

Practitioners are asked to make every effort to ensure compliance by seeing participants within these access standard timeframes.* Practitioners who are unable to schedule a participant visit within the access standard timeframes should immediately refer the participant to the online practitioner directory or contact Cigna Behavioral Health through the mental health and substance abuse telephone number on their card for alternative referral.

Answering machine/voicemail greetings

It is expected that network practitioners have the capability of 24-hour access for participants in crisis and that answering machine greetings contain clear instructions for accessing care in the event of a crisis. General referrals to emergency room settings for all access standards other than non-life threatening and life-threatening emergencies are not considered to be evidence of appropriate crisis coverage.

It is also expected that your outward greeting communicate message response time frames, e.g. all calls will be returned within 24-48 hours.

*State and/or Federal requirements will override these standards when applicable.

Case Management Process

You can review a list of procedures requiring prior authorization and submit for prior authorization using the appropriate form on the Cigna for Health Care Professionals website, or by calling the number on the back of your patient's ID card. Additional clinical information may be requested before authorization can be given. All documentation should be submitted immediately to help avoid delays. If all necessary information is not provided, Cigna may deny the coverage request for authorization of an admission, procedure, or service.

Outpatient Care

Participants are not required to obtain prior benefit authorization for routine outpatient care services. Routine outpatient services should include an evaluation for individual, couple, family and/or group therapy, plus a medication evaluation. When participants access providers directly, it is important to ensure benefit coverage and to verify eligibility prior to administering services to participants in plans managed by Cigna Behavioral Health, since practitioners are contractually prohibited from billing participants. Eligibility and benefits may be verified by logging in to CignaforHCP.com. The participant's health care identification card lists the appropriate Cigna Behavioral Health telephone number (Customer Service at 800.926.2273 can provide information in the event of uncertainty regarding the appropriate number to call for benefit eligibility.)

Practitioners are contractually prohibited from billing participants for non-authorized care.

The clinical Case Management staff is trained to assess disease states and to coordinate care between the participants' employee assistance program, disability management vendor, and medical plan. We work to focus on the whole picture so that we may have the greatest positive impact on the clinical outcome ensuring, through utilization management activities, that continued authorization is based on the appropriateness of care provided. To understand our Case Management process and philosophy, it is important to recognize the intrinsic role of the Triage Clinicians, Care Coordinators, and Personal Advocates.

Triage

Cigna Behavioral Health believes that any triage assessment must, at a very minimum, include an evaluation of risk and lethality as well as the possible use and/or abuse of alcohol and other substances, including prescribed medications. The triage function focuses on interventions that will address the immediate crisis. Our triage team is centralized, providing 24/7 service.

Facility-Based Treatment

Requests for benefit authorization for inpatient or other levels of facility-based treatment are considered within a patient's available benefit coverage and in the context of the MCG Behavioral Health Guidelines or The ASAM Criteria®. Preauthorization of coverage by the practitioner is required for all facility-based services, with the exception of partial hospitalization and intensive outpatient programs, when applicable. Depending upon the individual's benefit plan, preauthorization of partial hospitalization and intensive outpatient program service may or may not be required. Cigna Behavioral Health's clinical staff is available 24 hours per day, 7 days per week to review and authorize coverage. If it is determined that medical necessity is met for the requested level of care, Cigna Behavioral Health will arrange admission to a participating facility and specify the participating physician to treat the participant.


The Care Advocacy Program philosophy is to marshal resources and to advocate for participants, with a goal of returning them to the highest possible level of functioning as soon as clinically indicated. Designated Case Management interventions are designed to add value to each case. The Case Manager's ability to manage each case with varying levels of appropriate clinical intensity is one of our greatest strengths.

Emergency Admissions

If the acuity of the participant's condition does not allow for preauthorization of coverage, contact Cigna Behavioral Health as soon as possible. Please be prepared to provide the following information to the Cigna Behavioral Health staff:
  • Participant's name, age, and participant identification number.
  • History, diagnosis, indications, and nature of the immediate crisis.
  • Alternative treatment provided or considered.
  • Treatment goals, estimated length of stay, and discharge plans.

If the clinical indicators for hospitalization are unclear based on prudent layperson guidelines or the MCG Behavioral Health Guidelines or The ASAM Criteria®, staff may request additional information or consult a Physician Reviewer. If coverage for hospitalization is then authorized, the staff will arrange the admission. A Case Manager will then conduct regular, ongoing reviews with the hospital staff.


Referrals

Occasionally, it may be necessary for a practitioner to refer a participant outside of his or her practice. A practitioner should search the provider directory or contact a Cigna Behavioral Health Case Manager for referral to an appropriate Cigna Behavioral Health participating practitioner.

Medication

Non-prescribing practitioners who believe medication should be considered can search the provider directory or contact a Cigna Behavioral Health Case Manager for referral to an appropriate Cigna Behavioral Health practitioner. The practitioner can offer the participant the name and phone number of an appropriate prescriber. The participant may then contact the prescriber for an appointment. When medication is prescribed, health plan participants should have prescriptions filled at an authorized health plan pharmacy.

Coaching and Support Programs

Cigna offers six Coaching and Support (C&S) programs to help individuals initiate and engage in behavioral treatment.

The six programs are; C&S-Substance Use, C&S- Opioid and Pain Management, C&S-Autism, C&S-Parent and Families, C&S-Eating Disorder, and C&S- Intensive Behavioral Case Management.

Cigna Case Managers, specially trained in coaching individuals with mental health and substance use disorders, utilize a motivational interviewing approach focused on decreasing both internal and external barriers that may be preventing the individual from initiating and/or engaging in treatment or recovery activities. This approach allows for each program to meet the individual’s unique needs

A unique program we offer is Changing Lives by Integrating Mind & Body (CLIMB).This program provides individual and group coaching services to participants who are struggling to cope when living with a chronic physical or emotional condition. The program uses a cognitive behavioral approach based on identifying and improving thinking patterns which cause unhealthy behavior and negative emotions.

Buprenorphine Treatment

Buprenorphine treatment is a modality for outpatient office based Medication Assisted Treatment of opiate use disorders. We have Cigna Case Managers that are able to partner with individuals on MAT in order to enhance adherence to this treatment. Cigna Behavioral Health considers outpatient opiate treatment with Buprenorphine to be potentially eligible for benefit. Both the induction phase of treatment and ongoing medication management are considered to be routine services and do not typically require prior authorization by Cigna Behavioral Health.

Testing

Generally, clinical review for psychological/neuropsychological testing for covered diagnoses will not be required. There may be certain situations where a review will be required such as for a specific customer/account benefit plan. Testing related to custody evaluations, rehabilitation, vocational counseling, or school evaluations are generally not covered. Please call the number on the back of your patient's ID card prior to confirm benefits and eligibility.

Autism Spectrum Disorder and Applied Behavior Analysis

Prior authorization is typically required for the assessment and treatment of applied behavior analysis (ABA). If you are treating a participant with Autism spectrum disorder please call the number on the back of the participant's plan identification card to confirm eligibility and benefits. Benefit coverage for Autism spectrum disorder and ABA varies by benefit plan and due to state mandates. In most cases your request will be referred to the autism-Coaching and Support Team for discussion of a customized treatment plan. To learn more about our autism team and how to make a request for ABA services, refer to our Autism Information and Resources page. Please refer to your Participating Provider Agreement, Exhibit A for your fee schedule and a listing of autism spectrum disorder-related services eligible for reimbursement. Please refer to Appendix F for information about Cigna Behavioral Health's Specialty Networks, including autism assessment and treatment.

Cigna Behavioral Health's Compensation Promotes Quality of Care and Utilization Management*

(New Jersey practitioners, please refer to the Medical Management Program – Provider Guide, Section "New Jersey" for state-specific information.)

Cigna Behavioral Health compensates health care practitioners in a manner intended to emphasize preventive care, promote quality of care, and assure the most appropriate use of medical services. Cigna Behavioral Health reinforces this philosophy through utilization management decisions by its Medical Directors, Physician Advisors, and Case Management staff. Cigna Behavioral Health employees are encouraged to promote appropriate utilization rather than under-utilization of health care services.
The same criterion applies for staff eligible to receive additional payments based on their performance. Cigna Behavioral Health employees and consultants receive no financial incentives or rewards to deny coverage of medically necessary care. Cigna Behavioral Health offers no incentives for UM decision-makers for underutilization of care.

Coverage Denials*

(California practitioners: please refer to the Medical Management Program – Provider Guide, Section "California" for Coverage Denial information.)

For clinical cases under review resulting in an adverse determination (coverage denial) following the peer-to-peer review, a review of the decision is available with a physician not previously involved in the case. The appeal review is with a Cigna Behavioral Health-contracted, board certified psychiatrist or doctoral-level psychologist, and may be done on an expedited basis, if the situation is deemed urgent and the participant is still in that level of care, or on a standard basis, where more information such as the medical record or a summary of treatment may be made available. An appeal must be submitted within 180 calendar days from the claim denial.

A participant, the participant's delegate, or provider on behalf of a participant, who is dissatisfied with the outcome of the appeals determination, may file an appeal by following the health plan's, or, in some instances, the state's, external appeals process. Many states offer an expedited process if the participant feels the situation is urgent and the participant is still in that level of care. The Case Manager assigned to the case is able to provide information regarding the extent of appeals available.

All appeals are reviewed and determinations made by board certified psychiatrists or board certified PhD-level psychologists. If an appeal subsequently overturns an earlier decision, Cigna Behavioral Health will implement the appeal decision and/or process the authorization or claim for payment of services. Decisions are communicated in writing with all adverse determinations and contain the following information:
  • The specific guideline on which the determination is based, including the MCG Behavioral Health Guidelines or The ASAM Criteria®;
  • The facts and evidence considered; and
  • The clinical rationale for the determination

Appeals of Coverage Denials

For clinical cases under review resulting in an adverse determination (coverage denial) following the peer-to-peer review, a review of the decision is available with a physician not previously involved in the case. This first level appeal review is with a Cigna Behavioral Health-contracted, board certified psychiatrist or doctoral-level psychologist, and may be done on an expedited basis, if the situation is deemed urgent and the participant is still in that level of care, or on a standard basis, where more information such as the medical record or a summary of treatment may be made available. A first level appeal must be submitted within 180 calendar days from the claim denial. A second level appeal review may be available to the participant, the participant's delegate or practitioner on behalf of the participant, in those instances when the denial is upheld at first level appeal. For health plan participants, the standard appeal is filed through the health plan's Appeals Committee. For non-health plan participants, the appeal is filed through the Cigna Behavioral Health Central Appeals Unit. It is important to note that Appeals Committees are for the purpose of resolving participant issues. Payment disputes where the participant is held harmless are not eligible for review by the Appeals Committee, unless the practitioner, with a participant's written authorization, requests an appeal on behalf of a participant. A second level appeal must be submitted within 60 days from the receipt of the first level appeal decision letter.

A participant, the participant's delegate, or practitioner on behalf of a participant, who is dissatisfied with the outcome of the Appeals Committee determination, may file an appeal by following the health plan, or in some instances, the state's external appeals process. Many states offer an expedited process if the participant feels the situation is urgent and the participant is still in that level of care. The Case Manager assigned to the case is able to provide information regarding the extent of appeals available.

All levels of appeals are reviewed and determinations made by board certified psychiatrists or board certified PhD-level psychologists. If an appeal subsequently overturns an earlier decision, Cigna Behavioral Health will implement the appeal decision and/or process the authorization or claim for payment of services. Decisions are communicated in writing with all adverse determinations and contain the following information:
  • The specific guideline on which the determination is based, including the MCG Behavioral Health Guidelines or The ASAM Criteria®;
  • The facts and evidence considered; and
  • The clinical rationale for the determination.

Administrative Denial and Appeal

Administrative denials may be issued for a number of reasons, including exhausted benefits, services not covered under the participant's benefit plan, lack of prior benefit authorization for services, and/or benefits exhausted for the contract year. Participants, or providers on behalf of participants, are entitled to appeal administrative denials.

The appeal review of an administrative denial occurs at Cigna Behavioral Health by a Central Appeals Unit Appeals Coordinator.

Practitioner Concerns Related to Administrative Processes

(New Jersey practitioners, please refer to the Medical Management Program – Provider Guide, Section "New Jersey" for more state-specific information.)

Cigna Behavioral Health has a practitioner concern process separate from the administrative or clinical treatment denial and appeal process discussed immediately above. The purpose of this process is to resolve administrative issues. For administrative concerns, please contact Cigna Behavioral Health as follows:
  • Call Claim Customer Service (800.926.2273) with any claim-related issues. For California Practitioners, please see Appendix A
  • Call the appropriate Regional Care Center for Appeals of Administrative Denials (the telephone number will be in the denial letter).
  • Call the appropriate Provider Relations department with any provider agreement or fee schedule-related issues (see Appendix A)
It is the practitioner's responsibility to present supporting documentation to the appropriate Cigna Behavioral Health office. It is Cigna Behavioral Health's responsibility to investigate all issues presented and to respond to the practitioner in a timely manner. Practitioners who are dissatisfied with the resolution of their issue may write to the Director of Health Operations Business Unit, the Regional Care Center Director or the Director of Network Operations, as appropriate to the issue, for a final determination. Practitioners may contact the Provider Advocate team for the correct location to address their concern. Practitioners who continue to be dissatisfied may pursue arbitration as outlined in the section entitled Dispute Resolution Procedure in the Participating Provider Agreement.

If a participant complains to Cigna Behavioral Health about some aspect of care from a practitioner, the practitioner is required to participate in the internal Cigna Behavioral Health complaint resolution process.
If a participant complains to the provider about an administrative issue, the participant should be directed to call the telephone number listed on the participant's health care identification card. For participants residing in California, please refer to Appendix A

Referrals to all Non-Participating Providers and Ancillary Services Including Attending MD Services, Residential Care Facilities and Free-Standing Laboratories

Patients whose benefit plans are administered by Cigna Behavioral Health generally expect that when they choose to seek care from a Cigna Behavioral network participating provider, charges for all related care will be processed at the in-network benefit level. For this to occur, the patient must be referred to Cigna and/or Cigna Behavioral participating providers, including other practitioners, laboratories and/or facilities. When a patient is referred to a non-participating provider, the patient may incur unexpected financial liability. Patients whose plans include out-of-network benefits are free to choose to use these benefits for services covered under their plan; however, in doing so, these patients will generally incur higher out-of-pocket costs. To ensure that Cigna Behavioral customers are making informed choices when accessing care, you must fully disclose the financial effect of referrals to participating or non-participating providers under their benefit plan, including the referring practitioner financial interests, if any.

Practitioner's Responsibility to Transition Participant Care

Further, for practitioners who are treating participants under a Preferred Provider Organization arrangement, it is Cigna Behavioral Health's expectation that the practitioner will communicate sufficient advance notice of their termination as necessary to promote transition of care, and that they will apprise the participant of the right to continued treatment with the terminated practitioner for up to 90 days post-termination.

In the event of suspension, additional referrals to the practitioner are halted and, depending on the reason for suspension, Cigna Behavioral Health may reassign the practitioner's current participants.

In those states where there are laws regulating the appeal process, the state law supersedes this procedure.