Where does cigna cover

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These providers include doctors, hospitals, clinics, pharmacies and labs. Also, some health plans do not cover services provided by an out-of-network provider, except:. Your health plan does not cover non-emergency services from an out-of-network provider. You will pay a larger part of the cost share for those services than you would for the same services provided by an in-network provider. This may include the deductible, coinsurance and other out-of-pocket amounts.

In addition, you may have to pay the difference between what the plan allows and the amount billed by the provider. This is called Balance Billing. Balance Billing is the difference between the out-of-network provider's charge and Cigna's allowed amount for the service s. An in-network provider may not bill you for the difference between their charge and Cigna's negotiated rate.

When you visit an in-network provider, show your ID card and pay any required copay. After your visit, the provider will send a bill to us. We refer to a bill as a claim.

We will process the claim according to the terms of your insurance plan and any payment due will be made to the provider directly. When you visit an out-of-network provider, show your ID card and ask the provider if they will bill your insurance company. Out-of-network providers may agree to submit a bill on your behalf, but they are not required to.

We will process the claim according to the terms of your insurance plan. If authorized by you, any payment due will be made to the provider. Otherwise, any payment due will be made to you.

If your provider does not agree to submit a bill on your behalf, you must send a completed claim form and an itemized bill to the address listed on your ID card. Or, you can call the Customer Service number on your ID card for information about how to submit a claim.

To pay a claim, Cigna must receive the claim by a certain date. Access the required claim forms for medical, behavioral, pharmacy, vision and dental. Medical Claims: Use the mailing address provided on your ID card. Attn: Claims Service Dept. Box Chattanooga, TN To keep your health insurance coverage in effect, you must pay the monthly bill. We call this the premium payment. If you do not pay the monthly bill, then there is a grace period.

You still have coverage during the grace period. A grace period is a short span of time after the date your premium is due. If you fail to pay premium within the grace period, your coverage may be rescinded or cancelled.

Rescission of your coverage will result in denial of all pending claims and, if claim payments exceed total premiums paid, then claims already paid by Cigna may be retroactively denied. Did you go to a provider and your claim was paid by Cigna, but then later denied? You will receive an Explanation of Benefits detailing how Cigna handled your claim. If your claim was not paid, the Explanation of Benefits will provide the reason why it was denied.

You have the right to appeal when a claim is not paid. Appeal rights and timeframes can vary from state to state. Your policy will include full information on your grievance and appeal rights.

A denied claim means Cigna is not paying for the services you received. A retroactive denial is a claim paid by Cigna and then later denied, requiring you to pay for the services.

Learn more about appeals and grievances. If you overpaid your insurance premium, you may qualify for a refund. If you think you overpaid, Cigna's Billing and Enrollment department can help you. Please call the number on the back of your ID card with questions about your premium payment and possible refund. Do you need approval before a non-emergency hospital stay or having outpatient care? You may need to get Cigna's approval before a hospital stay or outpatient care.

Getting approval is also called prior authorization. Please note: We will review emergency admissions or care after you receive them to determine whether the services were emergent and medically necessary. A service is medically necessary if it is appropriate and necessary to treat your medical condition. The service must also be consistent with sound medical practice. Your health insurance plan has its own list of covered drugs, also called the Prescription Drug List.

The amount covered for your drugs depends on your plan, the drug and the state where you live. To find out what drugs are covered on your plan, use the drug search tool and select the state you live in. Some prescription drugs and related supplies may need prior authorization from Cigna.

This means we have to approve coverage before your doctor can prescribe them. Sometimes our members need access to drugs that are not listed on our drug list. There is a process for requesting a prescription drug exception. How to complete the pharmacy form for a prior authorization or exception request:.

The prescription will be covered at same benefit level as a Participating Pharmacy. The exception request is initially reviewed by Cigna through the formulary exception review process. If you don't like Cigna's decision about your drug claim, you can request that we look at the claim again.

Just submit a written appeal. Tell us in the appeal why the prescription drugs or related supplies should be covered. If you have questions about exceptions or prior authorizations, call Customer Service. Just call the toll-free number on your ID card. Box Chattanooga TN For mail-order pharmacy claims: Express Scripts P. Box St. Louis MO As part of your plan, we're at your service. If you have questions about your medications, contact us. We have information about side effects, and how some medications interact with other medications.

We can let you know how to handle or store them too. Your doctor's office submits a claim for payment to Cigna after you see your doctor or receive other medical care.

If your provider is not submitting a claim on your behalf, you must send a completed claim form and an itemized bill to the address listed on your ID card. It tells you how your claim was paid, including the amount that was paid and to whom it was paid. EOBs are available for you to look at online at www.

You'll also find:. Remember to save your EOBs for tax purposes and as a record of health care dates and services. When two plans cover the same service they may coordinate benefits. This is so that neither plan duplicates the other plan's payment. Coordination of Benefits rules can vary from state to state. Please refer to your policy for more information on "Coordination of Benefits.

If you visit an out-of-network dentist or other provider , you may pay more for services. You may have to pay the difference between what the plan allows and the amount billed by the dentist. Balance Billing is the difference between the out-of-network dentist's charge and Cigna's allowed amount for the service s.

An in-network dentist may not bill you for the difference between their charge and Cigna's negotiated rate. For in-network dental claims, your provider will submit your claim. Cigna will process the claim according to the terms of your insurance plan and any payment due will be made to the provider directly.

For out-of-network dental claims, Cigna must receive your claim within 12 months after the date of service, except in absence of legal capacity.

If your dentist is not submitting a claim on your behalf, you must send a completed claim form and itemized bill to Cigna. View Cigna's dental claim forms. To keep your dental insurance coverage in effect, you must pay the monthly bill.

If you do not pay your monthly bill, then there is a grace period. If you bought your plan from a state or federal marketplace AND you qualify for federal financial assistance and receive an advanced premium tax credit:. Did you go to a dentist and your claim was paid by Cigna, but then later denied?

A denied claim means that Cigna will not pay for the services you received. If you overpaid your insurance premium you may qualify for a refund. A few employers provide coverage for alternative medicine for their employees, and some health plans provide coverage for alternative medicine. Organized medicine has just begun to look at the benefits of certain alternative treatments. The Cigna Medical Technology Assessment Council regularly reviews new treatments and technologies to help ensure that our members have access to effective treatments.

If there is proven effectiveness, and if the local medical director has additional questions, they may consult with an independent medical expert, who provides a complete objective assessment based on medical evidence. Breast Cancer Screening and Treatment We care about the health and well-being of our members and provide access to preventive care and patient education.

It is at the discretion of each woman's doctor to decide, based upon her health history, when or how often she needs a mammogram. There are two types of surgical treatment for breast cancer: lumpectomy, which is the removal of a lump from the breast; and mastectomy, the removal of the entire breast and sometimes the lymph nodes.

A biopsy is a procedure used to detect cancer that involves the removal of a small amount of breast tissue for evaluation. We recognize that each woman enters surgery with a different health history and condition, and each woman recuperates at a different pace. A hospital stay is always a covered benefit for any Cigna member who requires a mastectomy. Medically necessary inpatient care is also covered. Medically necessary home health care services are available following breast surgery procedures.

Following a mastectomy, Cigna medical plans provide coverage for breast reconstruction when appropriate. Health plan members sometimes request coverage for medical treatment associated with a clinical trial. Clinical trials are not without risks, and each trial needs to be evaluated for potential benefits and risks.

Cigna reviews requests for coverage of treatment associated with Phase 3 and 4 clinical trials on a case-by-case basis. Commitment to Quality We promote health by providing:.

We measure the effectiveness of our program activities by seeking external validation of our programs. To learn more about our quality management program or to request a report on our progress in meeting our goals, call Customer Service at the number on the back of your Cigna ID card.

Continuity of Care Continuity of care concerns for participants in our managed care plans Network, POS [Point-of-Service], EPO [Exclusive Provider Organization], or PPO [Preferred Provider Organization] plans can be triggered by several different events—for example, a contract with a provider participating in a network is terminated either by the provider or by the health plan while a member is undergoing a course of treatment from the provider, or a member's employer selects a different health plan to provide coverage to its employees and a provider that an employee is actively receiving treatment from is not in the new network.

This does not apply to Indemnity plans because they are not network-based plans. In an Indemnity plan, members are free to see any provider, so changes in managed care provider networks would not apply.

If a contract with a provider participating in a Cigna network is terminated or an employer selects a Cigna medical plan while an employee is receiving care from a provider who does not participate in a Cigna network, we will work with the member to assure that there is continuity of care. Continuity of care can be accomplished by allowing the member to continue to receive treatment from the current non-participating provider or working to affect the smooth transition of care to a Cigna-participating provider.

We have developed national policies to credential practitioners and facilities that are adopted and managed at the local level by our medical management staff. Before a physician is accepted into the Cigna network, we perform a review of their credentials, which includes:. Cigna accessibility and availability standards also apply to our participating providers. Our medical management staff checks:. After a physician is admitted into a Cigna network, we conduct a review every two years to make sure they continue to meet our standards.

Also, we regularly survey our managed care plan participants on the delivery and quality of services they receive from the doctors participating in the Cigna network.

Each Cigna Network Plan and POS Plan member selects a primary care physician—usually a family practitioner, internist, or pediatrician, who becomes the cornerstone for that member's health care needs.

The primary care physician is familiar with the patient and their health history and helps coordinate care for the member, including the provision of primary and preventive care and referral to specialists when needed except in Cigna HealthCare Network Open Access and POS Access plan—referrals are not required in these plans. The relationship Cigna members establish with their PCP facilitates better use of specialty services. The PCP helps make sure that the member is seeing the appropriate specialist for their condition and confers with the specialist to give details on the member's condition and health history.

For members with complex health conditions, the role of the PCP is essential. The PCP leads the team helping the member to manage multiple health conditions and treatments—often this includes assuring proper access to specialty care and making sure that all of the specialists are keeping one another informed. Under certain circumstances when it is determined that the ongoing needs of a member with chronic or multiple illnesses would be most effectively met by a specialist, that specialist becomes the primary care provider for that member for example, an AIDS patient may use an infectious disease specialist as their PCP.

This decision would be made as part of our case management process, which is an integral part of Cigna health plans. The health care needs of most healthy women at certain stages in their lives are more centered around their reproductive health. Those plans do not require referrals to specialists of any kind and participants are free to see any participating specialists they choose.

Disclosure Disclosure of information to the customer has surfaced as a key issue in the public debate over managed care.

There is a misperception that health plans do not give their members basic information about the plan such as: what is contained in the benefit plan they have selected, how to access services, which providers are in the network, what is the appeal and grievance procedure, etc. Customer advocates and others are interested in requiring health plans to disclose financial information such as: what percentage of each premium dollar goes to the delivery of medical care versus administration of the plan, the specific amount providers are compensated, etc.

We believe that full information disclosure is essential to member satisfaction and in providing access to quality care. Cigna members receive a description of their benefit packages that includes information on: exclusions and limitations, the definition of emergency care, claims, and reimbursement procedures. In addition, participants in our managed care Network, POS, EPO, PPO plans receive instructions on accessing primary and specialty care, away-from-home care, out-of-network benefits POS and PPO plans only , member rights and responsibilities, the Cigna appeal and grievance procedure, a directory of participating providers, and other important information.

Emergency Room Widespread reports of emergency room claim denials by managed care plans have led to calls for legislative solutions.

EMTALA requires hospitals and emergency room physicians to screen and stabilize emergency room patients regardless of whether the patient is in an emergency situation. When a managed care plan participant seeks treatment for a non-emergency condition in the emergency room, they are responsible for the cost of screening and any treatment rendered.

As a result, hospitals and emergency room physicians are often not being paid for these services. They have seized this issue and are seeking legislation that would guarantee payment for all treatment provided in emergency rooms, regardless of the medical necessity of the services. This proposal would remove the financial disincentive for inappropriate use of the emergency room. In effect, it would encourage people to use the most expensive health care setting, the emergency room, rather than their primary care physician or specialists.

Another issue is that emergency room claims are initially being denied because hospitals and emergency room physicians disclose only the final patient diagnosis on claim forms. When the presenting symptoms are disclosed, the claims are often paid. Emergencies should be treated in the emergency room, and patients should get emergency care when they need it at the sudden—and unexpected—onset of a serious injury or life-threatening illness.

In addition, if a managed care plan participant's primary care provider refers them to the emergency room, regardless of the nature or severity of the illness or injury, the claim will be covered. Non-emergency conditions should be treated by a physician in the physician's office.

We encourage all Cigna plan participants to seek treatment for non-emergency conditions as soon as possible. Cigna, by contract, requires participating primary care physicians to maintain hour, seven-day-a-week telephone coverage and to provide an appointment within 24 to 48 hours of a request for urgent medical conditions. When members are unsure whether or not they have a condition that requires immediate medical attention, they should consult with their primary care physicians.

If their symptoms warrant prompt medical attention, the PCP will refer them to the emergency room. This relationship facilitates better treatment in the emergency room because the primary care physician can alert the emergency room that the patient is coming and provide important details on the patient's condition and health history.

Any hour of the day or night, from any phone in the U. The toll-free number is on the back of your Cigna ID card. A Health Information nurse will help you determine if emergency room care is advisable, if you require urgent care, or if self-care followed by a physician office visit is best.

Remember that this is not a call for authorization to seek emergency care. No authorization or referral is required by any Cigna medical plan for emergency care. If you believe life or limb are at risk, don't delay.

Go directly to the nearest emergency facility or notify your local emergency services immediately. The general public is under the false impression that managed care companies do not provide coverage for new treatments, drugs, or devices—often called experimental treatment—because they are expensive and unproven.

This issue has received a great deal of media attention in relation to coverage for autologous bone marrow transplants ABMT for the treatment of breast cancer, as well as coverage for clinical trials. We evaluate requests for coverage for new treatments on a case-by-case basis.

The Cigna coverage review process uses internal and external sources including its Medical Technology Assessment Council, peer-reviewed medical literature, and independent medical experts to assist its medical directors in reaching coverage determinations. With the ethicist's help, we have developed a decision making tool that makes explicit the ethical dimensions of issues that frequently arise in managed care.

The Cigna Medical Ethics Council is a standing committee established to ensure that ethical decision making is an integral part of each health plan's operations. Our Medical Ethics Council includes representation from various departments within the company. Independent Review : The Cigna Expert Review Program assists our medical directors in determining coverage for medically complex cases.

The program provides extensive and objective assessments through a network of credentialed, independent medical experts in all domains of medical care. The medical experts may be local medical experts or from nationally recognized academic medical centers. They render opinions that address the issue of whether the requested technology will specifically benefit the member in question and whether this technology offers advantages over currently proven treatment modalities.

Medical Technology Assessment : The Cigna Medical Technology Assessment process evaluates emerging and evolving technologies to help ensure that our members have access to effective treatments.

The Medical Technology Assessment Council, composed of national and field medical directors, an ethicist, an attorney, and nursing professionals, meets monthly to evaluate independent reports on medical technologies. The council also reviews reports produced by the Technology Assessment Unit research staff at the request of field medical directors.

The actions of the council produce coverage statements that are communicated to all Cigna medical directors. The Medical Technology Assessment process is a central source of scientific, objective, and consistent support for the administration of benefits. We oppose legislative mandates that would require coverage for particular treatments or drugs. Medical science is not static, new treatments are constantly being discovered, and changes are being made to existing treatments on a regular basis.

Government should not be involved in deciding what is the best medical treatment for a particular health condition. Providers unhappy with the changes managed care has made in the way they are paid have raised the issue.

They assert that managed care payment arrangements, particularly capitation, reward physicians for providing less care. Managed care is changing the way that physicians are paid. In many cases they no longer receive a fee for every individual service, procedure, or treatment they perform.

This type of reimbursement encourages overtreatment which, in addition to being expensive, can be dangerous. There is a misperception that managed care offers physicians financial incentives to cut costs and corners when treating patients.

We believe that physicians should direct their efforts toward providing quality health care to Cigna members and that cost reductions can be achieved without affecting quality, simply by eliminating care that is unnecessary or of no proven value. We oppose the use of financial incentives that encourage physicians to withhold necessary care. We do not offer physicians incentives to deny care. Compensation for Cigna-participating and out-of-network providers is determined using one of the following reimbursement methods: Discounted fee for service : Payment for services is based on an agreed upon discounted amount for services provided.

This payment covers physician and, where applicable, hospital or other services covered under the benefit plan. Medical groups and PHOs may in turn compensate providers using a variety of methods. This compensation method applies to Cigna Network plans and the in-network providers in our POS plans. Capitation provides physicians with a predictable income, encourages physicians to keep people well through preventive care, eliminates the financial incentive to provide services which will not benefit the patient, and reduces paperwork for physicians.

Salary : Physicians who are employed to work in a Cigna medical facility are paid a salary. The physician's compensation is based on a dollar amount, decided in advance each year, that is guaranteed regardless of the services provided. Physicians are eligible for a bonus at the end of the year based on quality of care, quality of service, and appropriate use of medical services.

Bonuses and Incentives: Eligible physicians may receive additional payments based on their performance. To determine who qualifies, Cigna evaluates physician performance using criteria that may include quality of care, quality of service, and appropriate use of medical services. Formulary Some patient advocates and independent pharmacists contend that drug formularies limit patient treatment options and can inhibit therapy.

In particular, media attention has focused on certain drugs not being included on formularies. Patient advocacy groups are seeking coverage for all FDA-approved drugs, regardless of whether they are approved for the treatment for which they are being prescribed. Legislative attacks are under way. The Susan Horn Study , concluded that use of formularies increased use of health care services, which resulted in lower quality and increased costs.

The Cigna formulary—a list of drugs covered by a member's benefit plan—was developed to assure quality and cost effective drug therapy. Drugs included in our formulary are carefully selected by physicians and pharmacists for their efficacy, and the formulary is reviewed and updated regularly.

This process allows our members to benefit on an ongoing basis from advances in pharmaceutical science that can dramatically improve the quality of people's lives. Hospitals have used drug formularies in the same way for many years. The Cigna national drug formulary contains 1, FDA-approved brand name and generic drugs.

These drugs are placed on the formulary by the Cigna Pharmacy and Therapeutic Committee, which meets quarterly and is composed of physicians and pharmacists. The Cigna Pharmacy and Therapeutic Committee reviews all FDA-approved drugs, groups them by therapeutic function, and then, within each group, compares their relative therapeutic effectiveness and potential side effects. Only when two or more drugs are determined to be therapeutically equivalent does cost become a consideration.

Cost is an appropriate and necessary consideration, since drug prices have risen three times faster than the rate of inflation over the last decade. We offer a variety of formulary structures, depending on the level of prescription drug coverage your employer chooses to offer.

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Nyse accenture	The prescription will be covered at same benefit level as a Participating Pharmacy. Louis MO As part of your plan, we're at your service. Any hour of the day or night, from any phone in the U. The health care needs of most healthy women at certain stages in their lives are more centered around their reproductive health. Louis MO
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Highmark my direct blue epo 7000b changes for 2019	How to complete the pharmacy form for a prior authorization or exception request: For a timely response to your prior authorization or exception request: Wnere out a Prescription Drug Claim Form completely. Get a free quote Retrieve a Quote. If you visit an out-of-network provider, you may pay more. Providers unhappy with the changes managed care has made in the way ciigna are paid have raised the issue. Medical groups and PHOs may in turn compensate providers using a variety of methods. Learn about the medical, dental, pharmacy, behavioral, and supplemental health benefits your employer may offer. Each Xover Network Plan and POS Plan member selects a primary care physician—usually where does cigna cover family practitioner, internist, or pediatrician, who becomes bleu nuances cornerstone for that member's health care needs.
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