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Published byPercival Hudson Modified over 9 years ago
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CIGNA Funds Overview Category A Settlement Fund* (No Documentation): $30 million OR/ Claim Distribution Fund* (No Limitation/Cap) Category 1 Compensation: Specific Code List Category 2 Compensation: Other Codes Medical Necessity Claims Compensation Foundation Fund: $15 million * Physician may contribute to Foundation Fund
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Additional Information on CIGNA Claims Submission Timeframe: 180 Days from Notification Covers HMO, PPO and Indemnity Patients Physician Groups/Organizations May File for Physicians Working for them at the time claims were made, without signatures. Must be same provider ID number. Physicians may file for Category A regardless of whether they submitted claims to CIGNA HealthCare
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Additional Information on CIGNA Claims Submission: Timeframe September 2, 2003: Preliminary Approval Hearing & Order December 18, 2003: Fairness Hearing October 2003: First Settlement Notice Mailed February 12, 2004: Appeals Filed April 22, 2004: Appeals Dismissed Week of May 3, 2004: Extensions to be Filed to Resolve Several Issues (Electronic Filings, etc.) June 15, 2004 (Estimated) Second Settlement Notice Mailed June 15-December 15, 2004: 180 Days to Submit Claims to Settlement Administrator
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Additional Information on CIGNA Claims Submission: Category A –Formula No. of Retired Physicians, plus No. of Deceased Physicians (Times Two); Plus No. of Active Physicians Sending in Category A Form= No. Physicians No. Physicians Divided by$30,000,000 = Result Result = Amount Paid Per Physician –Comment: The Amount Per Physician will vary significantly depending on number of physicians applying for Category A Funds (Estimated Range: $50-$400)
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Additional Information on CIGNA Claims Submission: Category One CPT Codes and Code Sets Underpaid, Bundled or Downcoded Specified Time Periods from 1/1/96-12/31/03 Paid at Amounts Specified on Category One List Specific Documentation and Certification Requirements Found in Draft Notice Category One Code List: Exhibit 1 of the CIGNA Settlement Agreement
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Additional Information on CIGNA Claims Submission: Category Two All Other CPT Codes Improperly Denied, Reduced Also Includes Code Sets Outside of the Specified Time Periods in Category 1 Failure to recognize Modifiers 50, 51, RT, LT, FA-F9 and TA-T9 HCPCS Level II “J” codes translated into an incorrect or overbroad CPT Code
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Additional Information on CIGNA Claims Submission: Category Two Paid at 100% of June 1, 2001 Medicare Rates Request/Obtain Your Facilitation List from Settlement Administrator Specific Documentation and Certification Requirements Found in Draft Notice May require: HCFA 1500, EOB & Medical Records
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Additional Information on CIGNA Claims Submission: Category Two Claims Submission –Cover Sheet –Certification –Documentation Notified of Inadequate Documentation within 14 Days: 30 Days to Resubmit External Review of Re-Denials
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Additional Information on CIGNA Claims Submission: Medical Necessity Resubmit if Improperly Denied Based On: –Medically Necessity –Experimental or Investigational Does not include Coverage Determinations If Re-Denied, CIGNA Must Submit to External Reviewer
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CIGNA Claims Submission Read Claim Notice Form Carefully Outstanding Issues: –Electronic vs. Manual Submission –Documentation Requirements: Facilitation List –Vendors: Certification Find Settlement Agreement and All Forms: http://www.hmosettlements.com
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North Carolina Managed Care Patient Assistance Program Created by NC Patient’s Bill of Rights (2001) Located in Attorney General Roy Cooper’s Office Patient Assistance Specialists “provide advice to consumers, caregivers, and providers about insurance and managed care issues including benefits, grievances, appeals, and external review processes.” (919) 733-MCPA (6272) or toll free (866) 867- MCPA (6272) or via email @ MCPA@mail.jus.state.nc.us.
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