Our case management program includes initiatives specific to this population and our case managers provide support to resolve the special needs of this population. Cigna-HealthSpring is required to provide customers with a notice that informs them of these rights and explains how Cigna-HealthSpring protects the privacy of their health information. For example, customers have the right to look at their medical records, and obtain copies of the records there may be a fee charged for making copies. Timely receipt of clinical information supports the clinical review process. If the customer's condition is unstable and the facility is unable to determine coverage information, Cigna-HealthSpring requests notification as soon as it is determined, including an explanation of the extenuating circumstances.
Medicaid Eligibility for Individuals With Behavioral Health Needs. The customer may be financially responsible for payment if the care rendered is non-emergent. Announcement: Sports Physicals RightCare covers sports physicals as a value-added service. Full delegation allows all activities of a function to be delegated. The statement provides a detailed description of how the claim was processed. The provider may need to keep such proof regarding multiple claims submissions if the provider identifier is pending.
Additional information concerning Medicaid provider participation is available at:. Complete book Individual Chapters - changes to manual arranged by chapter - completed claim forms with sample data. Physicians in the same group practice, but who are in different specialties may bill and be paid without regard to their customer in the same group. Preferred pharmacies are identified using a grey shaded box in the provider directories. Emergency calls must be returned within 30 minutes of the receipt of the telephone call. The damage or destruction of business records or criminal activity exception does not apply to any negligent or intentional act of an employee or agent of the provider because these persons are presumed to be within the control of the provider. If the complaint relates to a medical issue, the Medical Affairs Division staff may assist in resolving the complaint.
Explanations are required for any gaps exceeding six 6 months. If customers need help with communication, such as help from a language interpreter, they should be directed to call Customer Service. Expedited An expedited request can be requested when you as a physician believe that waiting for a decision under the routine time frame could place the customer's life, health, or ability to regain maximum function in serious jeopardy. Provider shall safeguard the privacy and confidentiality of customers and shall ensure the accuracy of the health records of customers. Experimental procedures and items are those items and procedures determined by our plan and the Original Medicare Plan to not be generally accepted by the medical community. Dec 2, 2004 … is provided pursuant to Chapter 9 of the West Virginia Code.
The diagnosis condition established after study to be chiefly responsible for causing the admission of the client to the hospital for care. All stages of reconstruction are covered for a breast after a mastectomy, as well as for the unaffected breast to produce a symmetrical appearance. Cigna-HealthSpring also utilizes urgent care facilities to treat conditions that are non-emergent but require immediate treatment. The right to obtain information about their health care coverage and cost The Evidence of Coverage tells customers what medical services are covered and what they have to pay. Timely filing requirements are not affected or changed by the appeal process or by the appeal outcome. Such amendment shall not require the consent of provider or Cigna-HealthSpring and will be effective immediately on the effective date thereof.
Cigna-HealthSpring employees are not compensated for denial of services. Inpatient admission denials cannot be rebilled as outpatient claims except as noted in subsection 4. Cigna-HealthSpring does require the retro authorization request and applicable clinical information to be submitted to the Health Services department within 1 business day of the start of care. Phone lines are staffed Monday through Friday between the hours of 8:30 a. Sometimes, people become unable to make health care decisions for themselves due to accidents or serious illness. Cigna-HealthSpring Utilization Management staff however does not monitor and retrieve faxed documentation routinely after normal business hours. If both customers have the same date of birth, the plan which covered the customer the longest is considered primary.
In addition to telephonic touch points, the plan regularly sends educational materials to customers in response to identified care gaps and changes in health status. Behavioral health services are interdisciplinary and multidisciplinary: a customer may need one or multiple types of behavioral health providers, and the exchange of information among these providers is essential. Provider acknowledges that Cigna-HealthSpring retains the right to approve, suspend or terminate any medical professionals, as well as any arrangement regarding the credentialing of medical professionals. Cigna-HealthSpring is committed to preserving the confidentiality of its customers and practitioners. Each Cigna-HealthSpring customer is entitled to see a Specialist Physician for certain services required for treatment of a given health condition. No retro-authorizations of referrals will be accepted. Such notice is issued to the provider and the customer, when applicable, documenting the original request that was denied and the alternative approved service, along with the process for appeal.
In addition, this report must include the individual claim that is being appealed. For pre-service requests, Cigna-HealthSpring will approve the request or issue a notice of denial if the request is not medically necessary. North Carolina Providers can submit most requests via our online portal 24 hours per day, 7 days per week at: Providers can fax: 1-855-500-2774 Providers can call: Fax and Portal are available 24 hours per day, 7 days per week. This affidavit or statement must be made by the person with personal knowledge of the facts. The hospital is notified in writing of the decision.