Payer Solutions

Active Accounts
Updated June 2024

When it comes to providing health benefits for their employees, some employer groups require a high level of customization and flexibility. Therefore, the employer group may choose to align with the capabilities of a combination of third-party administrators (TPAs), business process outsourcers (BPOs), and health insurers to meet their needs. Evernorth Payer Solutions provides a breadth of complementary product solutions, including access to Cigna Healthcare medical networks and Evernorth Behavioral Networks. In addition to network access, some employer groups may also access the Cigna Dental SAR PPO network, Cigna LifeSOURCE Transplant Network®, pharmacy benefit management, case management, out-of-network savings program, as well as other Evernorth and Cigna Healthcare affordability and clinical solutions, such as Embarc Benefit Protection®.

In these relationships, Evernorth Payer Solutions:

  • Provides access to a medical and behavioral network.
  • Performs utilization reviews for medical necessity of services.
  • Re-prices claims according to our contracted rates and claims logic.
  • Provides clinical appeals management.
  • Provides contract dispute resolution.

TPAs, BPOs, and insurers:

  • Maintain eligibility.
  • Administer benefits.
  • Pay claims for these shared accounts using their own systems and vendors.
  • Provide customer service to customers.
  • Issue ID cards.

Important information: How TPA-administered plans are managed:

  • We complete a business review to ensure TPAs and payers meet established standards for claim payment accuracy, payment response time, and customer call statistics (e.g., speed of answer). Adherence to these standards is contractually required and audited on a regular basis.
  • Our staff and provider service partners support health care providers and resolve claim inquiries or issues.
  • We administer the contractual relationship with health care providers to resolve contract language and intent differences.
  • Payers often use clearinghouse vendors to process payments.
  • Typically, smaller groups use stop loss coverage at a much higher rate to fund claims.
  • These scenarios may add to the time it takes to get the explanation of payment (EOP) to you. Standard turnaround time is 30-45 days.
  • We require TPAs, BPOs, and insurers to provide eligibility information. This can help minimize late identification of non-covered individuals.
  • Plan designs generally require in-network and out-of-network benefit differentials to encourage plan participants to use health care providers who participate in our network.

Additional Information

  • ID cards:
    • Contain the Cigna Healthcare logo and the words “Shared Administration” on the front of the card. This designates that Cigna shares the administration of the plan with a third party. Older ID cards may include an “S” instead of the words “Shared Administration.”
    • Include the paper and electronic claims submission addresses.
    • Include the TPA or insurer's telephone number and address(es) for inquiries about eligibility, benefits, claim status, and payment. Please contact the TPA with questions about these topics.
  • Cigna Healthcare medical utilization management includes precertification, concurrent care review, and discharge planning.
  • The Payer Solutions Active Accounts list, updated in June 2024, begins on the next page.

View the recent list of active Payer Solutions accounts.