As part of Cigna Behavioral Health's contractual obligations to its NJ HMOs, Cigna Behavioral Health shall establish and maintain a system to provide for the presentation and resolution of complaints brought by Participant or by professionals acting on behalf of a Participant and with the Participant's consent, regarding any aspect of Cigna Behavioral Health's services, including, but not limited to, complaints regarding quality of care, choice and accessibility of professionals, and network adequacy. This general complaint system will, at a minimum, incorporate to the satisfaction of the New Jersey Commissioner, the following components:

Written notification to all participants and professionals of the telephone numbers and business addresses of the Cigna Behavioral Health employees responsible for complaint resolution;

A system to record and document the status of all complaints, which shall be maintained for at least three years;

1. Availability of a Cigna Behavioral Health Participant services representative to assist Participants, as requested, with complaint procedures;
2. Establishment of a specified response time for complaints, not to exceed 30 days from receipt thereof by Cigna Behavioral Health
3. A process describing how complaints are processed and resolved;
4. Procedures for follow-up action including the methods to inform the complainant of resolution;
5. Procedures for notifying the continuous quality improvement program of all valid complaints related to quality of care; and
6. A mechanism for notifying Participants and professionals in writing that they may contact the Department, the Department of Banking and Insurance, in the case of Medicaid enrollees, the Division of Medical Assistance and Health Care Services within the Department of Human Services or, in the case of Medicare beneficiaries, the Health Care Financing Administration within the United States Department of Health and Human Services, if dissatisfied with the resolution reached through the HMO's internal complaint system.
   

No professional who exercises the right to file a complaint and/or appeal under this section shall be subject to disenrollment or otherwise penalized solely due to such complaint and/or appeal.

Addition to Section 4, Getting Paid: Timely Filing

In addition to the elements included in Cigna Behavioral Health's definition of 'clean claim,' New Jersey's definition includes the following:

1. The claim is for a service covered by the participant's benefit plan;
2. The claim is submitted with all the information requested by the benefit administrator on the claim form or in other instructions distributed to the professional or participant;
3. The participant to whom the service was provided was covered by the benefit plan on the service date for which the claim was submitted;
4. The benefit administrator does not reasonably believe that the claim has been submitted fraudulently; and
5. The claim does not require special treatment (i.e., unusual claim processing is required to determine whether a service is covered.)

Addition to Section 4, Getting Paid: Overpayment Recovery Procedures

If Cigna Behavioral Health, Inc., for any reason, elects to withhold any compensation amounts from future payments otherwise due to PROVIDER, Cigna Behavioral Health, Inc., shall provide PROVIDER with written notice and full disclosure of the funds withheld prior to such deduction.