Cigna Behavioral Health's Quality Management Program supports our goal of continuous improvement in the quality of care and services delivered to participants.
Cigna Behavioral Health is accredited by the National Committee for Quality Assurance (NCQA) as a Managed Behavioral Health Organization (MBHO).
Additionally, the Quality Management Program is designed to fulfill Managed Care Organization (MCO) standards and to support health plan customers in their accreditation through the NCQA.
Cigna Behavioral Health values the input and involvement of our practitioners in our Quality Management Program, and we communicate program results annually in our national practitioner and provider newsletter. If you would like to receive more information, become more involved, or offer feedback and suggestions concerning Cigna Behavioral Health's Quality Management Program, please contact us at 800.926.2273.
Creating Opportunities for Quality Improvement
Through Cigna Behavioral Health's Quality Management Program, data about many aspects of our operations is reviewed and monitored quarterly or annually to assess performance and create improvements in care and service for participants. Data reviewed and monitored include:
- Practitioner satisfaction surveys
- Participant satisfaction surveys
- Practitioner medical record audits
- Complaint and appeal analysis and trending
- Utilization data
- Compliance with Cigna Behavioral Health's appointment access, practitioner and practitioner geographical availability, and telephone access standards
- HEDIS® (Healthcare Effectiveness Data and Information Set) metrics
- Follow-up after hospitalization. Typically, all discharged participants should be seen within seven working days of discharge
Coordination of Behavioral Health and General Medical Care
It is the policy of Cigna Behavioral Health that behavioral health services must be closely coordinated with general medical care and between behavioral care providers when care is delivered simultaneously by more than one provider, program or facility. To enable the sharing of information between providers as treatment proceeds, Cigna Behavioral Health suggests that providers request a required Release of Information signature from the participant during the treatment process, even if the participant initially declines permission for communication between professionals. For the coordination of medical and behavioral care especially, this policy reflects Cigna Behavioral Health's understanding of the complex interrelationship between emotional and physical factors, and its appreciation for the fact that psychiatric problems often complicate or present as medical illnesses. Conversely, medical problems may present with psychiatric symptoms.
Appendix G includes a sample release form and a draft letter for structured communication with PCPs. You are welcome to use these tools to support your communication with PCPs.
For each consenting participant in simultaneous medical and behavioral treatment, Cigna Behavioral Health practitioners are expected to:
- Obtain and document the Medical Care Practitioner's/Primary Care Physician's (PCP's) name, address, telephone, and facsimile (if available) numbers.
- Obtain and document a Release of Information, as required by law, to exchange information between you and the Medical Care Practitioner/Primary Care Physician. If the participant refuses to sign a release for communication with the Medical Care Practitioner/Primary Care Physician, the reason for refusal should be documented.
- Exchange appropriate clinical information directly with Primary Care Physicians in an effective and timely manner throughout the treatment regimen. With proper consent, facilities may contact Primary Care Physicians upon admission and discharge. Outpatient practitioners are expected to exchange appropriate clinical information directly with PCPs in an effective and timely manner throughout treatment, and at a minimum, communication should occur:
- After the initial assessment, to include diagnosis, medication, initial treatment plan, and diagnostic tests recommended or ordered.
- When a participant is not compliant with treatment recommendations.
- When a participant's condition is unstable.
- When there are clinically significant changes in a participant's condition and/or level of care, including but not limited to, inpatient, partial hospitalization, intensive outpatient treatment, comorbid medical and behavioral conditions, new, or substantial medication changes.
- At the completion of behavioral treatment.
- Document verbal and written communication with PCPs.
Cigna Behavioral Health monitors a healthcare professional's compliance coordinating behavioral care with medical care through medical record reviews and Care Management reviews as part of the recredentialing process and the quality management program.
Cigna Behavioral Health believes well-documented treatment records, whether electronic or paper, facilitate communication, coordination, and continuity of care; and promote the efficiency and effectiveness of treatment. The health practitioner is responsible for maintaining an adequate clinical record for each participant and furnishing Cigna Behavioral Health with clinical data as necessary for utilization review or quality management. Cigna Behavioral Health's record-keeping standards require the participant name and identification number on each page in the record. Treatment record entries should be legible, signed with the clinician's name and credentials, in ink, dated, and maintained in a consistent chronological order within each file. Records should be easily and readily retrievable in a secure environment that protects participant confidentiality.
Treatment Record Review (TRR) standards are based on state mandates, when applicable, and Centers for Medicare & Medicaid Services (CMS) requirements regarding treatment of Medicare participants.
The practitioner's treatment records should include documentation of all contacts regarding the participant. Documentation in the record should include, but is not limited to:
- Key demographic data.
- The presenting problem (reason for visit).
- A full psychological and medical history.
- A mental status evaluation including assessment of suicidal and homicidal ideation.
- ICD-10 diagnosis.
- Treatment plan with measurable goals.
- All diagnostic and treatment services ordered or provided, directly or through referral.
- With participant consent, evidence of coordination of care with the PCPs and other involved clinicians, in addition to other record-keeping requirements outlined in the Behavioral Treatment Record Review Tool (Appendix D).
- Centers for Medicare & Medicaid Services (CMS) requirements on whether:
- Were Advanced Directives executed?
- Does the Primary Care Provider have a copy of the Advanced Directives?
To support your efforts in documentation, behavioral providers are encouraged to document in the treatment record:
- Your attempts to coordinate care with the client's PCP.
- Discussions in which you encourage clients without a PCP to choose a PCP.
To assess compliance with its medical record standards, the medical record-keeping practices of selected high volume practitioners are audited by Cigna Behavioral Health. As high volume practitioners near recredentialing, participants seen by them in the prior twelve (12) months are identified. A letter is sent to selected practitioners professionals, soliciting blinded copies of three (3) clinical records. Audit results are used to give practitioners feedback (particularly when results are below the 80% performance goal) and to drive organizational quality improvement. Cigna Behavioral Health has also found that effective treatment record documentation supports treatment outcomes through improved treatment planning, the monitoring of participant progress towards goals, and improved communication in the case management process.
Quality clinical record-keeping may also reduce risk management difficulties for practitioners by providing a record of the treatment progress along with documentation of informed consent, participant's understanding of their rights and responsibilities and participant's understanding of the treatment plan. Please see Appendix D, which is a sample ‘Informed Consent Form’ you are welcome to use.
In states where there are laws regulating the record-keeping process, these laws shall prevail if greater than Cigna Behavioral Health's minimum standards; if not, Cigna Behavioral Health standards shall apply.
Participant Rights and Responsibilities
Cigna Behavioral Health supports informing patients of their rights and responsibilities related to the provision of care and service. As a Cigna Behavioral Health practitioner, you should:
- Facilitate the participant's awareness of the Cigna Behavioral Health Participant Rights and Responsibilities statement at their first appointment. This can be accomplished by providing a copy to the participant or display of the document. The information in Appendix C can be copied for this purpose.
- Offer to help the participant get more information about any of the items in the statement.
- Notify the participant how to access services, including service outside of normal business hours.
- Discuss the services available to the participant and possible charges for those services.
Please note there are states with specific participant notification requirements applicable to mental health and/or substance abuse services, and/or to HIV status. The Cigna Behavioral Health Participant Rights and Responsibilities do not necessarily meet all state-specific requirements. State laws vary on participant, access to records, and duty to warn. Therefore, an addendum with required language must be attached to this document to comply with your state specific regulations. Please consult your legal advisor for guidance.
EAP participants should be provided an EAP Statement of Understanding see Appendix E.
Cigna Behavioral Health is committed to maintaining and protecting the confidentiality of patient's personal and sensitive information. To better understand our handling of personal health information, refer to the statement located in Appendix C.
Improving Participant Safety
The Institute of Medicine emphasized the safety of health care in the public spotlight by publication of their report, "To Err is Human: Building a Safer Health System." As a result, safety catapulted to a national health care issue. Every health care practitioner should be evaluating:
- What is my role in preventing potential errors or safety risks?
- What barriers exist to improving participant safety?
- What strategies can be implemented in my practice to reduce errors or improve safety?
While there are many steps needed to reduce error in America's complex health care system, a few steps practitioners can consider include:
- With approved consent, communicate and coordinate care with other behavioral health, primary care, or other health care practitioners who are involved in the participant's care.
- Gather information on all prescription and over-the-counter medications and dietary supplements the participant is on.
- Inquire about any known allergies or adverse medication reactions.
- Educate the participant on how and when to take medication and how to manage possible side effects.
- Evaluate how computerized records and other technology may contribute to improved safety.
Through the Quality Management Program, Cigna Behavioral Health evaluates data on various measures to identify opportunities for improving safety for our participants.
Health Promotion/Preventive Health Services
Cigna Behavioral Health encourages participating practitioners to educate participants about their diagnosis along with treatment information and suitable health promotion strategies. This may also include providing literature, suggesting books, or informing the participant of other educational resources and self-help groups. As appropriate, the practitioner should recommend the use of preventive strategies that may include relapse prevention, stress management, wellness programs and lifestyle changes. In addition, be sure to document your efforts in your medical record.
Cigna Behavioral Health offers a Preventive Health Program for Attention-Deficit/Hyperactivity Disorder (ADHD) as well as consumer oriented educational materials on a variety of topics.
The intent of our Attention-Deficit/Hyperactivity Disorder (ADHD) program is to educate and empower caregivers, to reduce the impact of problems commonly associated with the disorder and to encourage early detection of ADHD in siblings.
Automated rules in our claims processing system identify each new case of ADHD. Educational information and tools are mailed to parents and guardians to improve their understanding of, and their ability to manage their child's condition and to encourage coordination and consistency of response across medical, behavioral, educational, family, and other social settings.
Initial and annual screening for depression, stress, and anxiety is now routine within Cigna HealthCare's Medical Disease Management Programs, encouraging the identification and treatment of behavioral health disorders that may occur as a coexisting condition with a medical disease. Those who screen positive are provided intensive care management and ongoing standardized protocols for assessment and intervention are applied until the behavioral health condition remits. Where consent is provided, additional materials and support are made available to their medical practitioner or a referral for treatment with a qualified behavioral health practitioner can be arranged.
Educational Opportunities for Practitioners
You are encouraged to participate in educational programs focusing on clinical practice issues pertinent to service delivery systems.
Medical Necessity Criteria
Cigna Behavioral Health uses objective guidelines for medical necessity decisions and seeks and documents input from practitioners in reviewing or developing these guidelines. They are based on sound clinical evidence and are applied based on individual need and an assessment of the availability of services in the delivery system.
The Cigna Behavioral Medical Necessity Criteria are available, free of charge, at Resources > Behavioral Resources > Medical Necessity Criteria. If you are unable to access the Internet and would like to request a copy or to provide feedback, suggestions or input regarding Cigna Behavioral Health's Medical Necessity Criteria, you can contact us at 800.926.2273.
Clinical Practice Guidelines
Cigna Behavioral Health has adopted Clinical Practice Guidelines from professional societies and other recognized sources such as the American Psychiatric Association, the American Academy of Pediatrics, or the National Institute of Alcohol Abuse and Alcoholism. Our Care Management staff use these in their work with practitioners to guide decisions about the appropriate type of treatment for common behavioral disorders. The conclusions expressed within these guidelines are based on scientific, evidence-based research. A full list of guidelines currently approved for use and instructions on where the full-text source documents can be obtained through a link on the Resources > Clinical Practice Tools > Clinical Practice Guidelines.
Through the Quality Management Program, Cigna Behavioral Health monitors whether treatment is consistent with selected guidelines that Cigna Behavioral Health Guidelines have adopted. Feedback, suggestions, and input regarding Clinical Practice Guidelines are always welcome and can be provided to Cigna Behavioral Health by contacting a Provider Relations representative at the Cigna Behavioral Health Operating Unit with which you generally work, or by calling Cigna Behavioral Health at 800.926.2273.
Clinical Screening Tools and Treatment Support Toolkits
Cigna Behavioral Health has assembled a number of validated screening and assessment tools and, where necessary, obtained permissions from copyright holders for distribution to our network for use. These can be found at: Clinical Screening Tools.
Additionally, patient and provider toolkits, containing educational and treatment support tools, are available for download and use at: Primary Physician Tool.
Integration with Chronic Condition/Disease Management
Cigna's chronic condition programs (Your Health First SM) are supported by Cigna Behavioral Health via an integrated approach to help program participants manage chronic health conditions. Your Health First addresses the health of the whole person rather than focusing on a single disease that triggers program participation.
Supported by evidence-based medical guidelines and influential behavioral techniques, the integrated multidisciplinary approach helps participants fully manage their personal health, including adherence to medications, understanding and managing risk factors, maintaining up-to-date screenings and more.
For details regarding Cigna's chronic condition programs, including practitioner rights and responsibilities, see Chronic Condition Management section of the Medical Resources found on CignaforHCP.com, or contact us at 855.246.1873.