Section 4

Timely Filing

The Cigna Behavioral Health, Inc. ("CBH") Participating Provider Agreement requires that claims be submitted within 60 days from the date of covered service. The Agreement permits CBH to deny claims submitted beyond that 60 day time period.

CBH gives providers an additional 30 days to submit claims. Therefore, claims that are not submitted within 90 days of the date of covered service will be denied, unless a longer time is permitted by applicable state law, in which case the claim will be denied in accordance with applicable state law.

When CBH or a payor which is financially responsible to pay for covered services provided to CBH participants, is other than primary under applicable coordination of benefits rules, claims must be submitted within three months (90 days) from the date the primary payor’s explanation of payment was issued.

If proof of timely filing is required to perfect a claim, such proof would include: an Explanation of Benefits (EOB) from another carrier showing the claim was submitted in error, but in good faith, to that carrier; an account ledger showing the original date submitted; or, an original claim form with the original date submitted or mail receipt indicating the claim was received in a Cigna office within the allotted timeframe.

Providers submitting paper claims must use the CMS-1500 form when billing for outpatient services, while facilities must use the UB-04 form for inpatient claims and any other higher level of care. Cigna Behavioral Health defines a 'clean claim' as a claim that has no defect or impropriety, including a lack of substantiating documentation, or particular circumstances requiring special treatment that prevent timely payment from being made on the claim. If additional documentation (i.e., medical records) involves a source outside of Cigna Behavioral Health, the claim is not considered clean.

^{(New Jersey providers: please refer to the Medical Management Program - Provider Guide, Section "New Jersey," for more detailed information.)
(Texas providers: please refer to the Medical Management Program - Provider Guide, Section "Texas," for more detailed information.)}

Claims submitted for services provided in California are not subject to automatic denial if submitted within one (1) year from the date covered services were rendered as mandated.

When Cigna Behavioral Health is not the claims payor, but is responsible for providing and/or arranging for the provision of mental health and substance abuse services, Cigna Behavioral Health will make reasonable efforts to require the payor to make payment to providers within 30 days receipt of a properly completed bill for covered services by Cigna Behavioral Health or its designee. This payment period may be extended if Cigna Behavioral Health or the payor, in good faith, requires additional time to determine responsibility for such billed services.

Cigna Behavioral Health participating providers agree to refrain from duplicate billing within 30 days of submitting a bill for Covered Services to Cigna Behavioral Health or its designee. For additional information, please call Cigna Behavioral Health’s Claim Customer Service:
California HMO Participants California Customer Service 800.753.0540
Participants in East Coast Area Claim Customer Service 800.274.7603

Revision Date: March 2012 22

Participants Patients in Southern States Claim Customer Service 800.283.6226
Participants in West Coast Area Claim Customer Service 800.866.6534

Interactive Response System (IVR)

Cigna Behavioral Health's Interactive Voice Response System (IVR) eliminates the need to speak directly with a representative to obtain routine information. This service is available 24 hours per day, 7 days per week, and allows providers to quickly obtain information about:

• Claim status
• Effective coverage dates for subscribers and/or dependents
• Behavioral care benefits
• Status for authorization of benefits
• Application and contract information

The automated system will quickly and accurately respond to touch-tone key or voice queries.
Cigna Behavioral Health's Provider Service Representatives are available during normal business hours (Monday through Friday:7:30am-7:00pm CT).
Cigna Behavioral Health IVR Refer to above phone numbers
Cigna Behavioral Health COB IVR (for participants to call) 800.472.1680

Electronic Claims

Cigna strongly encourages you to submit claims electronically, including EAP and coordination of benefit (COB) claims. Submitting claims electronically is one of the best ways to simplify and streamline the reimbursement process. Cigna's electronic claims program is:

• Fast-we process, within 15 days, all electronic claims that auto-adjudicate.
• Practical-full integration with your billing procedures. Easy setup and implementation.
• Secure-a higher level of data security than is possible with paper-based process.

Efficient-electronic claims typically have fewer errors than paper claims, so more electronic claims auto-adjudicate

Receive and reconcile your payments faster

Improve your office workflow and productivity, and shorten the payment cycle by enrolling in electronic funds transfer (EFT). When used together, EFT and electronic remittance advice (ERA) can help eliminate claims payment paperwork and improve your cash flow – no more waiting for paper checks to clear. To learn more about EFT and ERA, click these links:

• Electronic Funds Transfer
• Electronic Remittance Advice

Payment Information at your Fingertips

Once you've enrolled in EFT, you can access your remittance reports online the same day you receive your electronic deposit. To learn how to access these reports online, click the link:

• Remittance Reports

National Provider Identifier

The National Provider Identifier (NPI) is a unique identification number for use in standard health care transactions. The NPI is a number issued to providers and covered entities that transmit standard HIPAA electronic transactions (e.g., electronic claims, claim status inquiries). In May 2005, the Centers for Medicare and Medicaid Services (CMS) began issuing NPIs to providers that applied and qualified.
The NPI fulfills a requirement of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), and was required to be used by health plans and health care clearinghouses in HIPAA standard electronic transactions by May 23, 2007. In addition, the NPI:

• Replaces other identifiers previously used by providers and assigned by payers (i.e., UPIN, Medicare/Medicaid numbers)
• Establishes a national standard and unique identifier for all providers
• Helps simplify health care system administration and encourage the electronic transmission of health care information

When you submit claims or encounters electronically, or transmit other electronic transactions, you must include your NPI. Inclusion of the NPI has been a Health Insurance Portability and Accountability Act (HIPAA) requirement since May 2008. Also, the Taxpayer Identification Number (Employee Identification Number or Social Security Number) of the billing provider must be submitted on electronic claims. Cigna is capable of accepting the NPI on standard HIPAA transactions. This approach should not be confused with any guidance specific to Medicare claims requirements. We will notify you when Cigna will no longer accept HIPAA transactions without the NPI.
For general information about the NPI and the NPI application process, visit https://www.cms.gov/Regulations-and-Guidance/Administrative-Simplification/NationalProvIdentStand/, at the Centers for Medicare & Medicaid Services web page. To apply online for an NPI, visit nppes.cms.hhs.gov/NPPES/Welcome.do.

Claim Payment with CMS-1500

The claim submission address and the authorization number for field number 23 on the CMS-1500 form are included in the authorization letter. To ensure timely payment, please complete and submit the CMS claim form to the claim payor as indicated on the authorization letter.
Visit our website at cignaforhcp when submitting claims. No authorization letter is generated for Assessment & Referral model EAP cases; please refer to Section 6 EAP.

Claim Payment with UB-04 (CMS-1450)

The authorization letter with referrals provides the claim submission address and the authorization number for field number 63 on the UB-04 (CMS-1450) form. To ensure timely payment, complete the UB-04 as completely as possible with all required information. Attach an itemization of charges and submit to the claim payor as indicated on the authorization letter.

Using the Correct Procedure Codes

Claims must be submitted with the correct/current procedure codes (CPT, HCPCS, and/or Revenue). Claims submitted with outdated codes will be denied. The provider must then resubmit the claim(s) with the correct code.
For all EAP sessions (including SAP referrals), you should submit your claims utilizing the CPT code 99404.

Using the Correct ICD-10-CM Diagnosis Codes

Claims must be submitted with the correct/current ICD-10-CM Diagnosis codes.
Claims submitted with outdated or incomplete diagnosis codes will be denied. The provider must then resubmit the claim(s) with the correct diagnosis code. A complete ICD-10-CM diagnosis code includes all digits up to two decimal places per the current coding structure in place.

Assignment of Benefits

Cigna Behavioral Health will direct payment to the provider if the participant is a Cigna Behavioral Health participant. Payment is made according to the rate specified in the Cigna Behavioral Health Participating Provider Agreement.
Given that Cigna Behavioral health services has many different types of plans, it is important to remember to obtain an assignment of benefits to receive direct payment from Cigna Behavioral Health or the claims payor. To indicate assignment from your client, include either the participant's signature or the notation “signature on file” on line 13 and check the “yes” box on line 27

Copayment, Coinsurance, and Deductibles

Copayment, coinsurance, and/or deductible amounts to be collected from the participant appear on the Remittance Advice/Explanation of Payment (EOP) form that accompanies the claim payment.
Additional information regarding participant benefits may be obtained either through Cigna Behavioral Health's Claim Customer Service or IVR.
No copayment is collected from EAP participants.

Overdue Copayments, Deductibles, and Coinsurance

The provider may not, under any circumstances, charge interest to participants for overdue copayments, deductibles, or coinsurance.

Eligibility

When Cigna Behavioral Health refers a participant, every effort is made to give providers the correct eligibility information.

Self-Paying Participants

The provider must obtain written approval from the participant, in the form of a Self-Pay Agreement, including full financial disclosure, for any services that were denied by Cigna Behavioral Health, or that were not covered services, in advance of those services being rendered. Services not covered by Cigna Behavioral Health include, but are not limited to:

• Late appointment cancellations
• Court-ordered treatment that is outside the scope of routine outpatient care and is determined by Cigna Behavioral Health to be not medically necessary
• Missed EAP appointments
• Services for which the customer elects to not use their benefit plan

Please see Appendix D, which contains an approved Cigna Behavioral Health Self-Pay Agreement. The provider may use a Self-Pay Agreement of their own design; however, all data elements as described in The Self-Pay Agreement must be contained therein. Self-Pay Agreements signed by the participant either at the time of admission to the facility or at the start of outpatient treatment, that reference the possibility of a self-pay arrangement in the future will not be accepted as proof of a self-pay agreement. In these circumstances, the participant must be financially held harmless as per the terms of the provider agreement

^{(For Maine health, please refer to the Medical Management Program - Provider Guide, Section "Maine")}

The Agreement must include the following:

• That the participant is aware of Cigna Behavioral Health's appeal process and declines to appeal.
• A statement that the Agreement applies only to the specific level of care or services the participant is requesting. If the participant moves to a different level of care, an authorization must be obtained or another Self-Pay Agreement signed.

The Agreement is in effect only from the date the participant signs it, until or unless it is rescinded; the Agreement may never be retroactive. Although by signing the Agreement the participant, in effect, waives his/her right of appeal at that time

Coordination of Benefits (COB)

Whenever another group benefit plan is potentially responsible for a portion of the payment, Cigna Behavioral Health requests other insurance information from the participant. To expedite claim payment, participating providers need to request that the participant complete the 'Coordination of Benefits' form (see Appendix B) and submit it with their first claim submission. Updated COB information must be requested yearly or as information changes.
If Cigna Behavioral Health is a secondary payor, the provider should submit the claim to the primary carrier first, and then enclose a copy of the EOB with their claim submission to Cigna Behavioral Health. Cigna Behavioral Health has an IVR telephone line expressly for policyholder/participant updates for COB. If the policyholder/participant has no other insurance, the policyholder/participant can call 800.472.1680 to automatically update their insurance information. If the policyholder/participant does have other insurance, the COB form should be completed as indicated above.

Delays in Claim Payment

Obtaining complete information from the participant and carefully reviewing claim forms to ensure accuracy and completeness can prevent delays in processing. Some common problems (list not all inclusive) that may create delays may include:

• Failure to obtain prior authorization
• Federal tax ID number not included
• Billing address on claim form does not match information on file with Cigna Behavioral Health
• Visits or days provided exceed the number of visits or days authorized
• Date of service is prior to or after the authorized benefit period
• Provider is billing for unauthorized services
• Insufficient itemization of charges
• Participant has exceeded benefits
• Preexisting conditions not covered, specific to an employer plan
• An unauthorized provider rendered services (for example, Cigna Behavioral Health authorized benefits from a PhD but services were rendered by a social worker)
• Mixed services protocol (charges including both medical and behavioral health treatment)
• Explanation of benefits from primary carrier is not attached to the claim when secondary coverage is requested (often referred to as "Coordination of Benefits" or COB, wherein an individual is covered by more than one benefit plan—under your agreement with Cigna Behavioral health, the total recoverable may not exceed the contracted rate).

Claims lacking information may either be returned to the provider for completion before processing or information may be requested directly from the participant on an EOB. If there is not prompt payment for a claim, it may be pending due to one (or more) of the above reasons. In all instances, Cigna Behavioral Health claim staff will pursue resolution of these issues as quickly as possible

Overpayment Recovery Procedure

^{(New Jersey providers: please refer to the Medical Management Program – Provider Guide, Section "New Jersey," for more specific information.)
(Tennessee providers: please refer to the Medical Management Program – Provider Guide, Section "Tennessee," for more specific information.)}

When an overpayment by Cigna Behavioral Health has been identified, Cigna Behavioral Health obtains a refund in one of two ways: either by offsetting payment from future claims, when applicable, or by requesting a refund from the provider who provided services.
In states where applicable, when Cigna Behavioral Health identifies that a cover payment has been made on a participant's claim, Cigna Behavioral Health will reverse that payment, leaving a negative balance in the provider's account.

Providers are requested to repay overpayments directly to Cigna Behavioral Health as outlined in the overpayment notice sent once overpayment is identified.
Based on banking arrangements for specific clients, as well as state mandates, some claims may offset prior to Cigna Behavioral Health receiving the requested refund. When this occurs, any refund received from the provider is returned to the provider with a letter explaining the offset. Until overpayment is resolved, payment on additional claims may be suspended.

For inquiries about the overpayment process, please call the number on the participant's insurance card.

For ASO accounts and states that allow offset:
If the overpayment on the provider's file has not offset within thirty (30) days, an overpayment letter is sent to the provider requesting the refund. If Cigna Behavioral Health does not receive the refund within sixty (60) days, a second refund request letter is sent advising that if Cigna Behavioral Health does not receive the refund within the next thirty (30) days, a third notice will be sent. If the refund is not received within the next thirty (30) days, Cigna Behavioral Health will again attempt to deduct (offset) the negative balance from future payments to be made to the provider.

If at any time we receive the refund from the provider and the overpayment has already been offset, Cigna Behavioral Health will return the check to the provider with a letter advising that the overpayment has been offset.

Explanation of Payments/Benefits (EOB)

Example of a participants' EOBs is provided in Appendix B. Also attached are definitions of the fields on the EOB.

Non-Cigna Behavioral Health Claims

Please note that in some instances claims are submitted to the medical carrier, not Cigna Behavioral Health. The participant's membership card indicates where to submit claims.

Cigna Debit Card Transactions

The Cigna debit card should be used only for "medical care" expenses as defined in Internal Revenue Code section 213(d). Your patients may use their Cigna debit card to pay for eligible Section 213 medical care expenses through their Flexible Spending Account (FSA) and/or Health Reimbursement Account (HRA).
When a patient presents a Cigna debit card, the card should not be used for non-eligible medical care expenses, such as cosmetic procedures. When Cigna patients use their debit card for their in-network health care visits, substantiating these claims helps to improve their experience and speed up how quickly you get paid by us.
If the transactions are not eligible per IRS regulation, the patient should be asked to provide a separate/additional form of payment. Additional information about eligible transactions can be found at www.cigna.com/expenses or http://www.irs.gov/publications/p969/index.html. You can also call Cigna Customer Service at 1.800.88Cigna.

Telehealth

Cigna Behavioral Health will pay providers that render telehealth services at the same rate it would pay had these services been rendered through in-person contact.