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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

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Cigna funds overview
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


Additional information on cigna claims submission
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


Additional information on cigna claims submission timeframe
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


Additional information on cigna claims submission category a
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)


Additional information on cigna claims submission category one
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


Additional information on cigna claims submission category two
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


Additional information on cigna claims submission category two1
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


Additional information on cigna claims submission category two2
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


Additional information on cigna claims submission medical necessity
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


Cigna claims submission
CIGNA Claims Submission Necessity

  • 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


North carolina managed care patient assistance program
North Carolina Managed Care Patient Assistance Program Necessity

  • 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 @ [email protected]


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