NETWORK NEWS. How Cigna-HealthSpring s 24-Hour Health Information Line (HIL) benefits members SPRING Inside

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1 SPRING 2014 NETWORK NEWS Inside 1 How Cigna-Healthspring s 24-Hour Health Information Line (HIL) benefits members 2 A prescription for healthier patients Cigna Home Delivery PharmacySM 2 Provider Call Center Hours of Operation Update 2 New Star Measures 2 Retired Star Measures 2 Tips for Stars Success in Introduction to ICD-10 Basics for Health Care Professionals 4 Clinical Spotlight Stroke, CVA, or Brain Attack 5 Access and Availability Standards for Providers Cigna-HealthSpring Clinical Guidelines 8 Member Rights and Responsibilities 11 New! Cigna-HealthSpring recommends that Providers begin reporting Anatomical Modifiers to facilitate correctcoding for Claims Processing 11 Nashville Public Television Reports How Cigna-HealthSpring s 24-Hour Health Information Line (HIL) benefits members The 24-Hour Health Information Line (HIL) is a valuable resource for Cigna-HealthSpring members who need immediate answers to health questions when: The PCP is unavailable The PCP office is closed or it s the middle of the night The member needs information about benefits or services The HIL is open 24 hours a day, 7 days a week. When a member calls, they talk directly with a professional such as a: Registered nurse Physician s assistant Nurse practitioner Nurse-trained specialist The professionals that staff the HIL are trained to provide help for a variety of issues, such as: Instructions on self-help and home care Referrals to case management and health advocacy programs Recommending the most appropriate level and source of care Navigating the health care systems Access to a range of online services, including hundreds of different health Podcasts The HIL helps provide peace of mind. Members don t have to wonder or wait to get important information about their health care needs. Cigna-HealthSpring members can get personal, one-on-one help by calling (TTY 711) 24 hours a day, 7 days a week. Note: Members are encouraged to call their PCP and tell them about their health issue within 24 hours of calling the 24-Hour Health Information Line. INT_14_ Cigna

2 A prescription for healthier patients Cigna Home Delivery Pharmacy SM One of the most important ways to improve the health of your patients is to make certain they receive and take their medications as prescribed. Cigna Home Delivery can help. We send a 3 month supply in one fill, making it simpler by only having to fill four times a year Many patient plans offer a lower cost incentive when prescriptions are filled at home delivery Our customers achieve up to a 15 point improvement in adherence rates when compared to those that use a retail pharmacy It s easy to get your patients started with Cigna Home Delivery Pharmacy. You can send prescriptions by: 1. Using your e-prescribing software. Select Pharmacy Name: Cigna Home Delivery Pharmacy 2. Faxed prescriptions can be sent to Talk to your patients today about Cigna Home Delivery Pharmacy for better health and health care spending. Questions? Doctors and staff call (Press option 3). Provider Call Center Hours of Operation Update Please note that as of December 2013, the Provider Call Center hours of operation changed to 8:00 a.m.- 6:00 p.m. CST, Monday through Friday. The call center will be closed from 11:30 a.m. 12:30 p.m. CST daily. New Star Measures CMS added the following measure to the 2015 (2013 DOS) Star Rating calculation: 1. Special Needs Plan (SNP) Care Management (Self - Reported - Part C) Percentage of new SNP members that have completed an HRA within 90 days and returning SNP members that have completed an annual HRA within 365 days of the last HRA An HRA can be downloaded from the Cigna-HealthSpring website at for members to complete when there is a change in health status. Providers can then fax the completed HRA to Retired Star Measures 1. CMS moved the Glaucoma Testing (HEDIS - Part C) measure from the 2015 (2013 DOS) Star Ratings and going forward. This is due to the U.S. Preventive Services Task Force s recent conclusion that the current evidence is insufficient to assess the balance of benefits and harms of screening for primary open-angle glaucoma in adults. 2. CMS also moved the Breast Cancer Screening (HEDIS Part C ) to the display page in 2015 (2013 DOS) before returning it as a Star Rating measure in 2016 (2014 DOS). This is to phase-in the new methodology changes. Tips for Stars Success in 2014 Diabetic Measures See diabetic patients at least 4 times per year. Ensure annual completion of the following screenings: A1c, LDL, kidney function, retinal eye exam. Encourage completion of lab work prior to office so that medication adjustments and disease control can be topics of discussion. Continue to emphasize adherence to medications at every visit as a tool to achieve cholesterol and blood sugar control. Controlling Blood Pressure Create a process to ensure that a second reading is obtained before check-out if initial reading is not <139/89. Use manual cuffs appropriate for patient s arm size for blood pressure rechecks. Continue to emphasize adherence to medications at every visit as a tool to achieve cholesterol and blood sugar control. 2 CIGNA-HEALTHSPRING NETWORK NEWS SPRING 2014

3 Introduction to ICD-10 Basics for Health Care Professionals To assist our health care professionals with the upcoming transition to ICD-10, Cigna-HealthSpring has published five training modules on our website that cover the basics for ICD-10: Module A: ICD-10 Dates & Deadlines Module B: ICD-9 & ICD-10 Claim Submission Guidelines Module C: Reasons for Adopting ICD-10 Module D: Basic Differences Between ICD-9 & ICD-10 Module E: Anticipated Questions & Benefits for ICD-10 You can access the training modules and the additional training documents on the Cigna-HealthSpring provider website (ICD-10 Information page) at: Note: To view these modules and documents, you must install the free Adobe Reader. ICD-10 Training Discount Cigna has partnered with HealthStream / Precyse University to provide a discount to our health care professionals for their ICD-10 online learning platform. HealthStream / Precyse University provides expansive and one-of-a-kind content on ICD-10. Together they offer a powerful and unique ICD-10 education. To obtain the discount, go to and type Cigna as the coupon code. ICD-10 Benefits Accommodates newly developed diagnoses and procedures Adds laterality (right vs. left) Allows for greater specificity Allows flexibility for adding new codes Better measures quality of care Includes new health care terminology and medical treatment Tracks disease trends and makes it easier to share data globally Additional ICD-10 Information You can find additional ICD-10 information on the website: ICD-10 Claims Processing Guidance How Can You Prepare for ICD-10? Improve Your Clinical Documentation Now to Help Prepare for ICD-10 ICD-10 Delay Announced The President signed the Protecting Access to Medicare Act of 2014 which prevents steep cuts to Medicare physician payments and delays the transition to ICD-10 diagnostic and procedure codes to at least October 1, For now, there is not a new ICD-10 implementation date. We expect the industry to continue to support the clean cut over to ICD-10 based on date of service or date of discharge. We will not accept ICD-10 codes until the new compliance date. For now, Cigna-HealthSpring expects this delay to have little or no impact on our ICD-10 project delivery and testing deliverables. This could change as we receive further direction from CMS or HHS. Your ICD-10 remediation and training efforts should continue as scheduled. Do not put off these efforts until next year. Focus on better clinical documentation to prepare for ICD-10. ICD-9 vs. ICD-10 Type of code Diagnosis Codes Procedure Codes Number of ICD-9 codes Number of ICD-10 codes 14,000 68,000 3,000 87,000 ICD X X X. X X category etiology, anatomic site, manifestation ICD-10 S A X X X. X X X X category etiology, extension anatomic site, severity Closed fracture of neck of radius Displaced fracture of neck of right radius, initial encounter for closed fracture CIGNA-HEALTHSPRING NETWORK NEWS SPRING

4 Clinical Spotlight Stroke, CVA, or Brain Attack Each year, approximately 795,000 people in the U.S. have a stroke and 130,000 of those result in death from stroke. Strokes in the U.S. account for almost $39 billion each year in health care services, medications, and lost productivity1. Strokes, cerebral vascular accidents (CVAs), or brain attacks include two basic types, hemorrhagic and ischemic events. Hemorrhagic strokes are extra vascular bleeds in the intracerebral or subarachnoid spaces. Ischemic strokes are caused by thrombosis, embolism and/ or systemic hypoperfusion. Approximately 87% of strokes are ischemic1. Both types of stroke are associated with sequelae or late effects that can evolve as the patient recovers from the acute event. Table 1 outlines the deficits seen 6 months after stroke in a sample of adults aged 65 years or older2. Table 1: Late effects associated with stroke Deficit or Disability Percentage (n=220) Hemiparesis 50% Cognitive deficits 46% Depression symptoms 35% Unable to walk unassisted 31% Social disability 30% Institutionalization 26% Urinary incontinence 22% Hemianopsia 20% Aphasia 19% Sensory deficit 15% Clinicians documentation practices strongly influence coding, which in turn effects CMS remuneration to Medicare Advantage plans and the services they provide patients. Clinicians in a variety of health care settings must accurately document and code acute stroke and associated findings, history of stroke without residuals, and the late effects found after stroke. Key Clinical Documentation Features If a suspected stroke is cause for an encounter in the physician s office, the assessment should be documented as probable or suspected CVA. The clinician should include the acute signs or symptoms and physical exam findings. Please note outpatient coding guidelines do not allow coding of probable or suspected conditions. Per coding guidelines, the clinician s documentation of the signs, symptoms and physical exam findings should be coded. If the clinician believes the clinical presentation is consistent with a stroke, the clinician can document an impending stroke in her/his impressions based upon her/his clinical judgment. The word impending needs to be included in the impression and supported by the clinical documentation. Until further testing is available to confirm the etiology or site of an acute stroke, the current CVA (acute event) codes cannot be assigned. In the community setting, most clinicians will assess and monitor the late effects associated with stroke including neurological and cognitive impairments, subsequent psychiatric/mental health conditions, and motor deficits. Motor deficits documentation includes: dominant/non-dominant side affected, specific limbs or muscle groups affected, and if the patient is experiencing weakness versus mono/ hemiplegia or paresis. Additionally, clinicians should document the artificial openings for feeding or elimination that are associated with late effects from a previous stroke. Finally, clinicians should clearly document treatment plans (e.g., medications, monitoring, labs/studies, or referrals) for all stroke late effects. Key Coding Issues Coding CVAs can be confusing. The trick to correctly coding stroke-related diagnoses is two-fold: Properly document the CVA status (acute or past history) Note if residuals or late effects remain from previous CVA(s) First tip: Acute CVA codes are most frequently captured during the inpatient hospital admission. Once the patient has been discharged, the acute CVA code can no longer be assigned! The FY 2014 ICD-9 diagnostic codes associated with acute stroke include: Hemorrhagic strokes 430 to 432 series Ischemic or unspecified strokes 433 and 434 series In the community, non-acute setting clinicians are advised to code the sign/symptoms and physical exam findings associated with a suspected stroke. If the clinician documents impending stroke or TIA in their impression, code (Impending CVA, TIA, or intermittent cerebral ischemia) is appropriate. If impending is not documented in the impressions then codes associated with specific signs, symptoms and physical exam findings are more appropriate. In 2004 coding guidelines changed and the 436 code for acute, but ill defined, cerebrovascular disease is not appropriate because more specific codes differentiating hemorrhagic and ischemic stroke were developed. Second tip: Properly linking a remaining late effect or residual to a previous CVA is necessary throughout the patient s lifetime. Linking late effects from previous CVA activates the 438 codes. These codes are commonly assigned in the physician office, outpatient, rehab, or long-term care settings. Patients that do not exhibit any neurological deficits from a prior CVA are coded to a History of CVA code or V CIGNA-HEALTHSPRING NETWORK NEWS SPRING 2014

5 Finally, the V44 series codes associated with artificial openings subsequent or incidental to a stroke should be coded. The American Hospital Association (AHA) coding clinic guidelines outline the coding rules for coding of acute CVAs. Note that this coding advice carries over to other outpatient settings (physician office or outpatient) once the patient is discharged from the inpatient setting AHA Coding Guidelines Third Quarter 2006: Rehabilitation Hospital Coding Question: Could you please provide guidelines to apply for ICD-9-CM coding of acute conditions in which treatment carries over into the rehab stay, e.g., follow-up treatment for pneumonia, UTI, or sepsis with oral antibiotics? Answer: If the patient has an active condition that is still being treated, the condition may be coded. The condition may be reported for as long as the patient receives treatment. The medical record documentation must be reviewed in its entirety to determine whether it is appropriate to assign the code for the acute condition. When further clarification is needed, please query the physician so that the most appropriate code assignment may be reported. However, this advice does not apply to acute cerebrovascular accidents (CVAs) or strokes after the initial episode of care in the acute care facility. In the case of acute CVA/stroke, the sequelae or late effect would be coded. After the initial treatment and the patient is discharged from acute care, codes from category 438, Late effects of cerebrovascular disease, should be assigned to describe the sequelae of the stroke (i.e., residual neurologic deficits). The sequelae may occur immediately after the onset of the stroke, either subside over time or remain for a lifetime. Please see Coding Clinic Fourth Quarter 1999, pages 6-8, for similar examples. Copyright , American Hospital Association( AHA ), Chicago, Illinois Access and Availability Standards for Providers A Primary Care Physician (PCP) must have their primary office open to receive Cigna-HealthSpring Members five (5) days and for at least 20 hours per week. The PCP must ensure that coverage is available 24 hours a day, seven days a week. PCP offices must be able to schedule appointments for Cigna-HealthSpring Members at least two (2) months in advance of the appointment. A PCP must arrange for coverage during absences with another Cigna-HealthSpring Participating Provider in an appropriate specialty which is documented on the Provider Application and agreed upon in the Provider Agreement. Primary Care Access Standards Appointment Type Urgent Non-Urgent/Non-Emergent Routine and Preventative Waiting Time in Office Specialist Access Standards Appointment Type Urgent Non-Urgent/Non-Emergent Elective High Index of Suspicion of Malignancy Waiting Time in Office Behavioral Health Access Standards Access Standard Immediately Within one (1) week Within thirty (30) business days Thirty (30) minutes or less Access Standard Immediately Within one (1) week Within thirty (30) Days Less than one (1) week Thirty (30) minutes or less Appointment Type Access Standard Emergency Within six (6) hours of the referral Urgent/Symptomatic Within forty-eight (48) hours of the referral Routine Within ten (10) business days of the referral Waiting Time in Office Thirty (30) minutes or less After-Hours Access Standards 1 Centers for Disease Control (2013) Stroke Facts. Retrieved 10/18/ Kelly-Hayes M, Beiser A, Kase CS, Scaramucci A, D Agostino RB, Wolf PA (2003). The influence of gender and age on disability following ischemic stroke: the Framingham study. Journal of Stroke and Cerebrovascular Disease 12(3): All Participating Providers must return telephone calls related to medical issues. Emergency calls must be returned within 30 minutes of the receipt of the telephone call. Non-emergency calls should be returned within a 24-hour time period. A reliable 24 hours a day/7 days a week answering service with a beeper or paging system and on-call coverage arranged with another Participating Provider of the same specialty is preferred. CIGNA-HEALTHSPRING NETWORK NEWS SPRING

6 2014 Cigna-HealthSpring Clinical Guidelines Cigna-HealthSpring has adopted evidence based clinical practice guidelines as road maps for healthcare decision-making targeting specific clinical circumstances. Cigna-HealthSpring promotes the use of clinical practice guidelines to: Define clear goals of care based on the best available scientific evidence Reduce variation in care and outcomes Provide a more rational basis for clinical management of some conditions Comply with accreditation standards and regulatory expectations The table below contains the clinical practice guidelines approved by Cigna-HealthSpring s Clinical Guidelines Steering Committee. The table also contains links to the websites with the most current version of the guideline. Topic Name of Guideline Organization / Web Address Acute Stress Disorder or Post Traumatic Stress Disorder APA Practice Guideline for the Treatment of Patients with Acute Stress Disorder or Post Traumatic Stress Disorder, Second Edition(2004) American Psychiatric Association Bipolar Disorder Cholesterol Management in Adults Chronic Heart Failure in Adults Chronic Obstructive Pulmonary Disease in Adults Communityacquired Pneumonia in Adults Depression APA Practice Guideline Watch for the for the Practice Guideline for the Treatment of Patients with Patients with Acute Stress Disorder or Post Traumatic Stress Disorder, 2009 APA Practice Guideline for the Treatment of Patients with Bipolar Disorder, Second Edition (2002) APA Practice Guideline Watch for the for the Practice Guideline for the Treatment of Patients with Bipolar Disorder, (2009) ICSI Health Care Guideline: Lipid Management in Adults; Eleventh Edition 2009 Focused Update Incorporated Into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults Primary Care Management of Chronic Stable Angina and Asymptomatic Suspected or Known Coronary Artery Disease: Ann Intern Med. 5 October 2004;141(7): Chronic Obstructive Pulmonary Disease: Management of chronic obstructive pulmonary disease in adults in primary and secondary care Infectious Diseases Society of America/ American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults Treatment of Patients With Major Depressive Disorder, Third Edition, May &sectionid= &sectionid= American Psychiatric Association 28&sectionid= &sectionid= Agency for Healthcare Research and Quality &search=lipid+management#top American College of Cardiology American College of Physicians 141&issue=7&page=562 Agency for Healthcare Research and Quality &search=copd Infectious Diseases Society of America/ American Thoracic Society Supplement_2/S27.full.pdf+html American Psychiatric Association 28&sectionid= CIGNA-HEALTHSPRING NETWORK NEWS SPRING 2014

7 Topic Name of Guideline Organization / Web Address Diabetes Standards of medical care in diabetes. Diabetes Care, Volume 35, Supplement 1, January 2012 American Diabetes Association (ADA) Supplement_1/S11.full.pdf+html Fall Prevention Hypertension Prevention of Falls in Community-Dwelling Older Adults Recommendation Statement May The Seventh Report on the Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure 2011 Expert Consensus on Hypertension in the Elderly: Executive Summary US Preventative Services Task Force uspstf/uspsfalls.htm National Heart, Lung and Blood Institute Journal of the American College of Cardiology /4/25/j.jacc v1.pdf Osteoporosis Schizophrenia Preventive Services Guideline Medical Guidelines for Clinical Practice for the Diagnosis and Treatment of Postmenopausal Osteoporosis, 2010 Practice Guideline for the Treatment of Patients With Schizophrenia, Second Edition Guideline Watch (September 2009): Practice Guideline for the Treatment of Patients with Schizophrenia Guide to Clinical Preventive Services 2012 Preventive Services Task Force (USPSTF) American Association of Clinical Endocrinologists American Psychiatric Association 28&sectionid= &sectionid= Agency for Healthcare Research and Quality guidelines-recommendations/guide/index.html adult/mmwr-adult-schedule.pdf hcp/child-adolescent.html Approved by Clinical Guideline Steering Committee January 2014 This information is provided for general reference and not intended to address every clinical situation associated with the conditions and diseases addressed by these guidelines. Physicians and health care professionals must exercise clinical discretion in interpreting and applying this information to individual patients. We hope you will consider this information and use it, when it is appropriate for your eligible members. CIGNA-HEALTHSPRING NETWORK NEWS SPRING

8 Member Rights and Responsibilities Cigna-HealthSpring Members have the following rights: The right to be treated with dignity and respect The right to the privacy of medical records and personal health information The right to see Participating Providers, get covered services, and get prescriptions filled within a reasonable period of time The right to know treatment choices and participate in decisions about their health care The right to use advance directives (such as a living will or a power of attorney) The right to make complaints The right to get information about their health care coverage and cost The right to get information about Cigna-HealthSpring, plan Providers, drug coverage, and costs The right to get more information about Members rights The right to take action if a Member thinks they have been treated unfairly or their rights are not being respected The right to be treated with dignity and respect Members have the right to be treated with dignity, respect, and fairness at all times. Cigna-HealthSpring must obey laws against discrimination that protect Members from unfair treatment. These laws say that Cigna-HealthSpring cannot discriminate against Members (treat Members unfairly) because of a person s race, disability, religion, gender, sexual orientation, health, ethnicity, creed, age, or national origin. If Members need help with communication, such as help from a language interpreter, they should be directed to call Member Services. Member Services can also help Members in filing complaints about access to facilities (such as wheel chair access). Members can also call the Office for Civil Rights at or TTY/TDD , or the Office for Civil Rights in their area for assistance. The right to the privacy of medical records and personal health information There are federal and state laws that protect the privacy of Member medical records and personal health information. Cigna-HealthSpring keeps Members personal health information private as required under these laws. Any personal information that a Member gives Cigna-HealthSpring is protected. Cigna- HealthSpring staff will make sure that unauthorized people do not see or change Member records. Generally, we will get written permission from the Member (or from someone the Member has given legal authority to make decisions on their behalf) before we can give Member health information to anyone who is not providing the Member s medical care. There are exceptions allowed or required by law, such as release of health information to government agencies that are checking on quality of care. The laws that protect Member privacy give them rights related to getting information and controlling how their health information is used. Cigna-HealthSpring is required to provide Members with a notice that tells them about these rights and explains how Cigna-HealthSpring protects the privacy of their health information. For example, Members have the right to look at their medical records, and to get copies of the records (there may be a fee charged for making copies). Members also have the right to ask plan Providers to make additions or corrections to their medical records (if Members ask plan Providers to do this, they will review Member requests and figure out whether the changes are appropriate). Members have the right to know how their health information has been given out and used for routine and nonroutine purposes. If Members have questions or concerns about privacy of their personal information and medical records, they should be directed to call Member Services. Cigna-HealthSpring will release a Member s information, including prescription drug event data, to Medicare, which may release it for research and other purposes that follow all applicable Federal statutes and regulations. The right to see Participating Providers, get covered services, and get prescriptions filled within a reasonable period of time Members will get most or all of their health care from Participating Providers, that is, from doctors and other health Providers who are part of Cigna-HealthSpring. Members have the right to choose a Participating Provider (Cigna-HealthSpring will tell Members which doctors are accepting new patients). Members have the right to go to a women s health specialist (such as a gynecologist) without a referral. Members have the right to timely access to their Providers and to see specialists when care from a specialist is needed. Members also have the right to timely access to their prescriptions at any network pharmacy. Timely access means that Members can get appointments and services within a reasonable amount of time. The Evidence of Coverage explains how Members access Participating Providers to get the care and services they need. It also explains their rights to get care for a medical emergency and urgently needed care. 8 CIGNA-HEALTHSPRING NETWORK NEWS SPRING 2014

9 The right to know treatment choices and participate in decisions about their health care Members have the right to get full information from their Providers when they receive medical care, and the right to participate fully in treatment planning and decisions about their health care. Cigna-HealthSpring Providers must explain things in a way that Members can understand. Members have the right to know about all of the treatment choices that are recommended for their condition including all appropriate and medically necessary treatment options, no matter what their cost or whether they are covered by Cigna-HealthSpring. This includes the right to know about the different Medication Management Treatment Programs Cigna-HealthSpring offers and those in which Members may participate. Members have the right to be told about any risks involved in their care. Members must be told in advance if any proposed medical care or treatment is part of a research experiment and be given the choice of refusing experimental treatments. Members have the right to receive a detailed explanation from Cigna-HealthSpring if they believe that a plan Provider has denied care that they believe they are entitled to receive or care they believe they should continue to receive. In these cases, Members must request an initial decision. Initial decisions are discussed in the Members Evidence of Coverage. Members have the right to refuse treatment. This includes the right to leave a hospital or other medical facility, even if their doctor advises them not to leave. This also includes the right to stop taking their medication. If Members refuse treatment, they accept responsibility for what happens as a result of refusing treatment. The right to use advance directives (such as a living will or a power of attorney) Members have the right to ask someone such as a family member or friend to help them with decisions about their health care. Sometimes, people become unable to make health care decisions for themselves due to accidents or serious illness. If a Member wants to, he/she can use a special form to give someone they trust the legal authority to make decisions for them if they ever become unable to make decisions for themselves. Members also have the right to give their doctors written instructions about how they want them to handle their medical care if they become unable to make decisions for themselves. The legal documents that Members can use to give their directions in advance of these situations are called advance directives. There are different types of advance directives and different names for them. Documents called living wills and powers of attorney for health care are examples of advance directives. If Members decide that they want to have an advance directive, there are several ways to get this type of legal form. Members can get a form from their lawyer, from a social worker, from Cigna- HealthSpring, or from some office supply stores. Members can sometimes get advance directive forms from organizations that give people information about Medicare. Regardless of where they get this form, keep in mind that it is a legal document. Members should consider having a lawyer help them prepare it. It is important to sign this form and keep a copy at home. Members should give a copy of the form to their doctor and to the person they name on the form as the one to make decisions for them if they can t. Members may want to give copies to close friends or family members as well. If Members know ahead of time that they are going to be hospitalized and they have signed an advance directive, they should take a copy with them to the hospital. If Members are admitted to the hospital, the hospital will ask them whether they have signed an advance directive form and whether they have it with them. If Members have not signed an advance directive form or does not have a copy available during admission, the hospital has forms available and will ask if the Member wants to sign one. Remember, it is a Member s choice whether he/she wants to fill out an advance directive (including whether they want to sign one if they are in the hospital). According to law, no one can deny them care or discriminate against them based on whether or not they have signed an advance directive. If Members have signed an advance directive and they believe that a doctor or hospital has not followed the instructions in it, Members may file a complaint with their State Board of Medicine or appropriate state agency (this information can be found in the Member s Evidence of Coverage). The right to make complaints Members have the right to make a complaint if they have concerns or problems related to their coverage or care. Members or an appointed/authorized representative may file Appeals, grievances,concerns and coverage determinations If Members make a complaint or file an appeal or coverage determination, Cigna-HealthSpring must treat them fairly (i.e., not discriminate against them) because they made a complaint or filed an appeal or coverage determination. To obtain information relative to appeals, grievances, concerns and/or coverage determinations, Members should be directed to call Member Services. The right to get information about their health care coverage and cost The Evidence of Coverage tells Members what medical services are covered and what they have to pay. If they need more information, they should be directed to call Member Services. Members have the right to an explanation from Cigna-HealthSpring about any bills they may get for services not covered by Cigna-HealthSpring. Cigna-HealthSpring must tell Members in writing why Cigna- HealthSpring will not pay for or allow them to get a service and how they can file an appeal to ask Cigna-HealthSpring to change this decision. Staff should inform Members on how to file an appeal, if asked, and should direct Members to review their Evidence of Coverage for more information about filing an appeal. continued CIGNA-HEALTHSPRING NETWORK NEWS SPRING

10 continued The right to get information about Cigna-HealthSpring, plan Providers, drug coverage, and costs Members have the right to get information from us about our plan and operations. This includes information about our financial condition, about the services we provide, and about our health care Providers and their qualifications. Members have the right to find out from us how we pay our doctors. To get any of this information, Members should be directed to call Member Services. Members have the right to get information from us about their Part D prescription coverage. This includes information about our financial condition and about our network pharmacies. To get any of this information, staff should direct Members to call Member Services. The right to get more information about Members rights Members have the right to receive information about their rights and responsibilities. If Members have questions or concerns about their rights and protections, they should be directed to call Member Services. Members can also get free help and information from their State Health Insurance Assistance Program (SHIP). In addition, the Medicare program has written a booklet called Members Medicare Rights and Protections. To get a free copy, Members should be directed to call MEDICARE ( ). TTY users should call Members can call 24 hours a day, 7 days a week. Or, Members can visit on the web to order this booklet or print it directly from their computer. The right to take action if a Member thinks they have been treated unfairly or their rights are not being respected If Members think they have been treated unfairly or their rights have not been respected, there are options for what they can do. If Members think they have been treated unfairly due to their race, color, national origin, disability, age, or religion, we must encourage them to let us know immediately. They can also call the Office for Civil Rights in their area. For any other kind of concern or problem related to their Medicare rights and protections described in this section, Members should be encouraged to call Member Services. Members can also get help from their State Health Insurance Assistance Program (SHIP). Cigna-HealthSpring Members have the following responsibilities: Along with certain rights, there are also responsibilities associated with being a Member of Cigna-HealthSpring. Members are responsible for the following: To become familiar with their Cigna-HealthSpring coverage and the rules they must follow to get care as a Member. Members can use their Cigna-HealthSpring Evidence of Coverage and other information that we provide them to learn about their coverage, what we have to pay, and the rules they need to follow. Members should always be encouraged to call Member Services if they have any questions or complaints. To advise Cigna-HealthSpring if they have other insurance coverage. To notify Providers when seeking care (unless it is an emergency) that they are enrolled with Cigna-HealthSpring and present their plan enrollment card to the Provider. To give their doctors and other Providers the information they need to provide care for them and to follow the treatment plans and instructions that they and their doctors agree upon. Members must be encouraged to ask questions of their doctors and other Providers whenever the Member has them. To act in a way that supports the care given to other patients and helps the smooth running of their doctor s office, hospitals, and other offices. To pay their plan premiums and any co-payments or coinsurances they may have for the Covered Services they receive. Members must also meet their other financial responsibilities that are described in their Evidence of Coverage. To let Cigna-HealthSpring know if they have any questions, concerns, problems, or suggestions regarding their rights, responsibilities, coverage, and/or Cigna-HealthSpring operations. To notify Cigna-HealthSpring Member Services and their Providers of any address and/or phone number changes as soon as possible. To use their Cigna-HealthSpring plan only to access services, medications and other benefits for themselves. 10 CIGNA-HEALTHSPRING NETWORK NEWS SPRING 2014

11 New! Cigna-HealthSpring recommends that Providers begin reporting Anatomical Modifiers to facilitate correct-coding for Claims Processing At Cigna-HealthSpring, we strive to continually update our policies and claims payment systems to align with: Correct-coding initiatives The Centers for Medicare & Medicaid Services (CMS) guidelines National benchmarks Industry standards such as the: American Medical Association (AMA) Current Procedural Terminology (CPT ) Healthcare Common Procedure Coding System (HCPCS) International Classification of Diseases, 9th Edition/ Revision (ICD-9) code sets on physician/health care provider claims and facility claims In July of 2014, Cigna-HealthSpring will start to implement coding policies based on national correct-coding initiatives to: Control improper coding that leads to inappropriate payment Support the use of anatomical modifiers to validate the part of the body on which a procedure is performed. Procedures that require an anatomical modifier may be denied when: An anatomical modifier is not appended A modifier is appended to a procedure code that does not match the anatomical site indicated by the modifier CMS has identified the following set of anatomical modifiers to facilitate correct coding for claims processing: E1 E4 FA, F1 F9 TA, T1 T9 LC LD LM LT RI RC RT eyelids fingers toes left circumflex, coronary artery left anterior descending coronary artery left main coronary artery left ramus intermedius right coronary artery right Cigna-HealthSpring recommends that providers begin reporting anatomical modifiers to accurately define service encounters. This recent update supports Cigna-HealthSpring s continuing efforts to process claims accurately without having to request additional documentation to rule out duplicate or other inappropriate billing. Nashville Public Television Reports Nashville Public Television Reports: Aging Matters is a Cigna-HealthSpring sponsored documentary that focuses on issues impacting the aging population. The first episode weaves personal stories of families alongside interviews with scholars, doctors and medical ethicists to explore the complicated experience of dying, and why so few live the death they say they want. For more information, or to watch the previous episodes visit Cigna-HealthSpring is a proud sponsor of NPT Reports: Aging Matters Initiative. Our goal is the public finds the program helpful and educational and that it informs and inspires our community to discuss senior health issues. CIGNA-HEALTHSPRING NETWORK NEWS SPRING

12 SPRING 2014 NETWORK NEWS NETWORK NEWS 3601 O Donnell Street Baltimore, MD SPRING 2014 <Name> <Address>