2021 OUT-OF-NETWORK PROVIDER MANUAL MEDICARE ADVANTAGE
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2021 OUT-OF-NETWORK PROVIDER MANUAL MEDICARE ADVANTAGE PCOMM-2021-1082 8/21
Table of Contents
Medicare overview ........................................................................................................................ 3
Introduction and New 2021 Plan Offerings ................................................................................. 3
2021 ID Card Examples ................................................................................................................ 4
Medicare Advantage - HMO .............................................................................................................. 4
Medicare Advantage - PPO............................................................................................................... 4
Medicare Advantage Employer Group – HMO .................................................................................. 4
Medicare Advantage Employer Group - PPO .................................................................................... 4
Medicare Advantage Prescription Drug - HMO.................................................................................. 5
Medicare Advantage Prescription Drug - PPO .................................................................................. 5
Verify Customer Eligibility and Benefits ..................................................................................... 5
Referrals and Prior Authorizations .............................................................................................. 6
Referrals vs. Prior Authorizations ...................................................................................................... 6
Quick Reference Referral Guide ....................................................................................................... 6
Requesting an HMO Referral ............................................................................................................ 7
Request for Prior Authorizations to Non-Participating Providers ........................................................ 7
HMO plans .............................................................................................................................. 7
PPO plans ................................................................................................................................ 7
Billing............................................................................................................................................. 7
Claims Submission ........................................................................................................................... 7
Electronic Submission .............................................................................................................. 7
Electronic Remittance Advice (ERA)/Electronic Funds Transfer (EFT) Process ........................... 7
ERA/EFT Support (after enrollment) ............................................................................................ 8
Paper Claims Submission ........................................................................................................ 8
Timely Filing ............................................................................................................................. 8
Questions? ............................................................................................................................... 9
Exchange of Electronic Data........................................................................................................ 9
Information Protection Requirements and Guidance ......................................................................... 9
Reimbursement of Out-of-Network Providers ............................................................................ 9
CMS Preclusion List ................................................................................................................... 10
Why is this important? ..................................................................................................................... 10
Who is on the list?........................................................................................................................... 10
Are providers notified when they are placed on the Preclusion List? ............................................... 10
Vendor-Specific Networks.......................................................................................................... 10
Join Cigna's Network.................................................................................................................. 11
Provider Notification ........................................................................................................................ 11
Key Contacts ............................................................................................................................... 12
Medicare Advantage PPO Flyer................................................................................................... 13
Page 2 of 12
Medicare overview
Cigna contracts with the Centers for Medicare & Medicaid Services (CMS) to offer Medicare
Advantage (MA) plans. Customers are able to select one of several plans offered based on their
location, budget and health care needs.
Cigna Medicare Advantage Health Maintenance Organization (HMO) Plans: Generally,
customers are required to select a PCP and must receive all covered services by utilizing in-
network providers, except in the case of emergency. Select service areas do not require the use of
referrals. See the Referrals and Prior Authorizations section for further information.
HMO plans:
• Cigna Traditions Medicare (HMO I-SNP*)
• Cigna TotalCare (HMO D-SNP**)
• Cigna Achieve Medicare (HMO C-SNP***)
• Cigna Preferred Medicare
• Cigna Alliance Medicare
* Institutional special needs plan ** Dual-eligible special needs plan *** Chronic condition special needs plan
Cigna Medicare Advantage Preferred Provider Organization (PPO) Plan: Generally, customers
are not required, but encouraged to select a PCP and referrals are not required to see Medicare-
accepting providers in or out of the network. Customers are not limited to their home service area
for routine care.
PPO plans:
• Cigna True Choice Plus Medicare
Introduction and New 2021 Plan Offerings
Cigna continues to expand by offering new product offerings for 2021 in select markets. We are
excited to introduce these plans to better improve the health of our customers. As a result, non-
participating providers are likely to see more patients with these new plans.
This out-of-network provider manual has been created to assist you and your office when providing
care to Cigna customers who may have an out of network benefit. It is not a binding legal
document but it contains important information concerning our policies and procedures
including claims payment and submission requirements, prior authorization and referral
requirements and other helpful information. This manual is intended to help non-participating
providers more effectively do business with Cigna Medicare. As a non-participating provider, note
the following:
• Referrals are not required to see customers enrolled in select plans (check
customer ID card). See the Referrals and Prior Authorizations section for further
information.
• No contract is required to see members enrolled in PPO plans, however you must
be eligible for reimbursement under CMS rules and regulations.
• Cigna will reimburse out of network providers who provide Covered Services to its
Medicare Advantage PPO plan members in accord with CMS regulations and the
member’s Benefit Plan design.
• Customer Identification Cards provide high-level product/network information and
indicate the customer’s plan, referral requirements and out-of-network benefits. Contact
numbers are located on the back of the card for further assistance.
Page 3 of 12
2021 ID Card Examples
Customer Identification Cards provide high-level product/network information. Remember to contact the
phone numbers on the card for assistance and follow guidance in order to verify eligibility, referral/no
referral and authorization guidance.
Medicare Advantage - HMO
Medicare Advantage - PPO
INT 21 89716
Medicare Advantage Employer Group – HMO
Medicare Advantage Employer Group - PPO
Page 4 of 12
Medicare Advantage Prescription Drug - HMO
Medicare Advantage Prescription Drug - PPO
Verify Customer Eligibility and Benefits
To verify customer eligibility and benefits:
1. Ask to see the customer’s Identification Card (ID card). Each customer is provided
with an ID Card. Noted on the ID card is the customer’s Cigna identification number,
plan code, copayment and effective date. Since changes do occur with eligibility, the
card alone does not guarantee the customer is eligible.*
2. Call Cigna Medicare Provider Customer Services at 800-230-6138. An automated
Interactive Voice Response (IVR) system is available 24 hours a day, 7 days a week, or
you can speak with a Provider Customer Service Representative Monday-Friday, 8 am
– 5 pm CST.
*Customer data is subject to change. CMS retroactively terminates customers for various reasons. When this occurs,
Cigna’s claim recovery unit will request a refund from the provider. The provider must then contact CMS Eligibility to
determine the customer’s actual benefit coverage for the date of service in question, typically the customer has moved to
another plan.
Page 5 of 12
Referrals and Prior Authorizations
Referrals vs. Prior Authorizations
Referrals Prior Authorizations
HMO: A benefit tool that allows an HMO: An HMO customer needs a prior
HMO customer to see a specialist. authorization review for any in-network service
on the Cigna Medicare prior authorization grid
PPO: PPO customers do not need and for all out-of-network care.
a referral to see a specialist.
However, before receiving
PPO: A prior authorization is recommended for
services from out-of-network
providers, the customer may want any out-of-network care to confirm that
to ask for a pre-visit coverage services are covered and are medically
determination. necessary.
Quick Reference Referral Guide
Specialist referrals
HMO plan HMO POS plan PPO plan
Market required for this HMO
offered offered * offered
plan **
Alabama
Arizona
Arkansas
Central Florida
Colorado
Delaware
Georgia
Illinois
Kansas City
Maryland
New Jersey
New Mexico
North Carolina
North Florida
Ohio
Oklahoma
Pennsylvania
South Carolina
South Florida
Southern Mississippi
Tennessee
Texas
Utah
Virginia
Washington, DC
* HMO point-of-service plan
** Select markets with HMO plans only. PPO plans do not require referrals.
Page 6 of 12
Requesting an HMO Referral
For select markets with HMO plans that require specialist referrals only
(AZ, CO, Central & South FL, IL, TX, OK)
Referrals can be requested through several methods, such as:
• Fax
• Phone
• Mail
Remember: A referral does not guarantee payment – services must be a covered benefit. To verify benefits
before providing services, call 800-230-6138.
Request for Prior Authorizations to Non-Participating Providers
HMO plans
Prior authorizations to a non-participating provider are reviewed to determine if there is a
continuity of care issue, a network gap has been identified, or in medically necessary
circumstances in which the customer’s need cannot be met in network, (e.g., a service or
procedure is not provided in-network; delivery of services closer or sooner than provided or
allowed by the organization’s access or availability standards). Prior authorization is required for
non-participating providers and requests are reviewed for specific criteria. It is recommended that
a PCP initiate requests for authorizations to non-participating providers, customers or their
authorized representatives may request on their own behalf.
PPO plans
Prior authorizations are recommended, but not required, in the following scenarios:
• A continuity of care issue
• A network gap has been identified
• In medically necessary circumstances in which the customer’s need cannot be met in network
(e.g., a service or procedure is not provided in-network; delivery of services closer or sooner
than provided or allowed by the organization’s access or availability standards)
• To confirm that services are covered and are medically necessary.
Billing
Claims Submission
Cigna prefers electronic submission of claims; however, both electronic and paper claims
are accepted.
Electronic Submission
Electronic claims may be submitted through:
• Change Healthcare / Availity (Payer ID: 63092 or 52192)
• SSI Group /Proxymed/Medassets/Zirmed/Office Ally/Gateway EDI (Payer ID: 63092)
• Relay Health (Professional claims CPID: 2795 or 3839 Institutional claims CPID: 1556 or
1978)
Electronic Remittance Advice (ERA)/Electronic Funds Transfer (EFT) Process
1. Access the Enrollment forms for ERA and EFT via
Changehealthcare.com/support/customer-resources/enrollment-services.
2. Select ERA Enrollment Forms to receive ERA files.
a. In Section ERA Payer Enrollment Forms select institutional or professional and
Page 7 of 12input 52192 in the search bar, click enter.
b. This will show the form for Cigna.
3. Click on the form and complete. You can send directly via email to Change Healthcare on
the bottom of the form.
4. Select EFT Enrollment Forms to receive payments electronically.
5. To set-up an EFT or change an existing EFT banking or payer select the EPayment
Request Forms.
6. Complete the form per instructions and email to eftenrollment@changehealthcare.com or fax
to 615-238-9615.
7. To change a contact on an existing EFT select Epayment Contact Change Form.
a. Complete the form.
b. Email to eftenrollment@changehealthcare.com or fax to 615-238-9615.
ERA/EFT Support (after enrollment)
1. EFT support requests after enrollment, contact 866-506-2830 Option 2 .
2. ERA/Claims support requests after enrollment, contact 866-742-4355 Option 1.
3. If a Provider is setup for EFT they can view electronic payments and electronic
remittances (ERA) via the Payment Manager portal:
https://cda.changehealthcare.com/Portal/
a. To request a login, contact 866-506-2830
b. To access the user guide to the Payment Manager portal:
https://cda.changehealthcare.com/ext/Manuals/Payment_Manager_SVP_NEW_G
UI_4.2.pdf
4. If not setup for EFT or only set up for ERA, contact Change HealthCare at 866-369-8805
to request a paid version of Payment Manager.
5. Alternately, if a Provider is not set up to receive EFTs, they may request access to the
Vision Tool by submitting an ON 24/7 request to view claims, EFTs or ERAs.
a. To submit a request through CHC ON 24/7: https://client-
support.changehealthcare.com
6. For additional support, view the Provider Quick Reference User Guide at
Changehealthcare.com > Support > Enrollment > Provider Quick Reference User Guide
Paper Claims Submission
Cigna
Claims PO Box 981706
El Paso, TX 79998
Supporting claim documents (i.e. medical records, itemized bills, EOBs, etc. should be faxed
to 615-401-4642 or mailed to:
Cigna
Claims Intake PO Box 20002
Nashville, TN 37228
Timely Filing
According to Medicare standards, claims from out-of-network providers are to be submitted
within 365 days from the date of service. Claims received after 365 days will be denied for
timely filing.
Page 8 of 12Questions?
If you have claims questions, see the Key Contacts section.
Exchange of Electronic Data
Information Protection Requirements and Guidance
Cigna follows all applicable laws, rules and regulations regarding the electronic transmittal
and reception of customer and provider information. If an electronic connection is made to
facilitate such data transfer, all applicable laws must be followed. At all times, a provider must
be able to track disclosures, provide details of data protections and respond to requests made
by Cigna regarding information protection.
Cigna will engage with a provider’s staff to appropriately implement the connection. Any files
placed for receipt by provider staff must be downloaded in 24 hours, as all data is deleted on
a fixed schedule. If the files are unable to be downloaded, then alternate arrangements for
retransmission must be made. The provider and provider’s staff will work collaboratively with
Cigna to ensure information is adequately protected and secure during transmission.
Reimbursement of Out-of-Network Providers
Cigna Medicare Advantage (MA) PPO plans follow CMS rules and regulations when
reimbursing out-of-network providers for Covered Services rendered to our Customers.
Depending on your Medicare-participation status, you are paid as followed for covered plan
services:
• If you are not contracted with Cigna, but are a Medicare-participating provider (you
always accept assignment), then you will be reimbursed the Medicare allowed
amount (minus any applicable patient cost-share). Per CMS requirements, you must
accept Cigna’s payment and any associated cost-share as payment in full. Under a
Cigna MA PPO plan, you may only bill patients for their cost-share amounts and for
any non-covered services. You may not balance bill patients or Cigna MA PPO for
covered plan services in excess of the original Medicare rate.
• If you are not contracted with Cigna and are not a Medicare-participating provider
(you accept assignment on a case-by-case basis), then you will be reimbursed as
follows:
o If you accepted assignment for the services and affirmatively indicated
acceptance on the submitted claim, you will be reimbursed the Medicare
allowed amount (minus any applicable patient cost-share). You must
accept Cigna’s payment and any associated cost-share as payment in full.
Under a Cigna MA PPO plan, you may bill patients for their cost-share
amounts, and for any non-covered services. You may not balance bill
patients or Cigna MA PPO for covered plan services in excess of the
original Medicare rate.
o If you did not accept assignment for the services, you will be reimbursed up
to the original Medicare limiting charge minus any applicable patient cost-share
amount. Under a Cigna MA PPO plan, you may bill patients for their cost-share
amounts, and for any non-covered services. You may not balance bill patients
for covered plan services in excess of the plan cost- share. Cigna MA PPO
plan is responsible for paying you the difference between the patients’ cost-
sharing and the original Medicare limiting charge.
MA HMO plans do not have out-of-network benefits. However, if any of the following apply, a prior
authorization can be submitted and reviewed. If the prior authorization has been approved, Cigna will
Page 9 of 12reimburse the provider at the Medicare reimbursement rate.
• A continuity of care issue
• A network gap has been identified
• In medically necessary circumstances in which the customer’s need cannot be met in network,
(e.g., a service or procedure is not provided in-network; delivery of services closer or sooner
than provided or allowed by the organization’s access or availability standards)
CMS Preclusion List
CMS publishes a Preclusion List that lists providers and prescribers who are precluded from receiving
payment for Medicare Advantage (MA) items and services or Part D drugs.
Why is this important?
CMS makes the Preclusion List available to Part D sponsors and the MA plans on a monthly
basis. The preclusion list requirements are:
• MA plans must deny payment for a health care item or service furnished by an individual
or entity on the Preclusion List.
• Part D sponsors must reject pharmacy claims (or deny a beneficiary request for
reimbursement) for a Part D drug that is prescribed by an individual on the Preclusion
List.
Who is on the list?
• Individuals or entities who meet the following criteria:
• Are currently revoked from Medicare, are under an active reenrollment bar, and CMS has
determined that the underlying conduct that led to the revocation is detrimental to the best
interests of the Medicare program.
• Have engaged in behavior for which CMS could have revoked the individual or entity to the
extent applicable if they had been enrolled in Medicare, and CMS determines that the underlying
conduct that would have led to the revocation is detrimental to the best interests of the Medicare
Program.
Are providers notified when they are placed on the Preclusion List?
Yes. CMS sends an email and letter to the provider or entity in advance of their inclusion on the
Preclusion List. The email and letter are sent to the Provider Enrollment Chain and Ownership
System (PECOS) address or National Plan and Provider Enumeration System (NPPES) mailing
address. The letter includes the reason for the preclusion, the effective date of the preclusion, and
applicable rights to appeal. For more information on the preclusion list, visit:
https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/Preclusion-List
Vendor-Specific Networks
Cigna may elect to offer or obtain certain Covered Services exclusively through arrangements with
national or regional vendor networks. It is important for participating providers to be aware of these
vendor-specific networks to avoid potential claims issues and customer confusion.
Cigna currently utilizes two vendor-specific networks:
• Hearing Care Solutions (for routine hearing-related benefits and supplies) and
• Superior Vision (for routine vision services and supplies in all markets except Alabama,
Southern Mississippi and Northern Florida (Panhandle) and medical vision coverage in our
Maryland, Delaware, District of Columbia, Pennsylvania, New Jersey, Northern Virginia and
Kansas City markets).
In our HMO plans, these hearing and vision services may be covered only when they are supplied by
providers that participate in the Hearing Care Solutions or Superior Vision networks. In our PPO plans,
Page 10 of 12they may be covered at in-network benefit and cost-sharing levels only when they are supplied by
providers that participate in the Hearing Care Solutions or Superior Vision networks. Providers are
encouraged to call the customer service number on the customer’s ID card with any questions around
services that may or may not be covered.
Providers should inform customers whether they participate in either of these vendor-specific
networks before providing any related services.
Join Cigna's Network
To join Cigna's network, visit Medicareproviders.cigna.com > Provider Resources > Forms and
Practice Support and complete the applicable form(s) specific to a market:
1. Facility/Ancillary Network Interest Form, or
2. Medical Practitioner Interest Form
All practitioner and organizational applicants to Cigna must meet basic eligibility requirements
and complete the credentialing process prior to becoming a Participating Provider. Every
provider undergoes a rigorous verification process that includes primary and secondary source
verifications of all applicable information for the contracted specialty(s).
Cigna does not discriminate in terms of participation, reimbursement, or based on the population
of customers serviced, against any health care professional who is acting within the scope of
his or her license or certification under state law.
Provider Notification
All initial applicants who successfully complete the credentialing process are notified in writing
of their plan effective date. Providers can accept Cigna Medicare Advantage PPO plan
customers and bill Cigna. An authorization is recommended but not required to confirm that
services are covered and are medically necessary, Applicants who are denied by the
Credentialing Committee will be notified in writing within 60 sixty (60) days of the decision
detailing the reason(s) for the denial.
Page 11 of 12Key Contacts
Key Contacts
Claims questions: 800-230-6138
Electronic Claims may be submitted through:
• Change Healthcare/Availity (Payor ID: 63092 or 52192)
• SSIGroup/Proxymed/Medassests/Zirmed/ OfficeAlly/Gateway
EDI (Payor ID: 63092)
• Relay Health (Professional claims CPID: 2795 or 3839 |
Institutional claims CPID: 1556 or 1978)
Claims Processing
Mail Paper Claims to:
Cigna
PO Box 981706
El Paso, TX 79998
Mail Reconsideration Requests to:
Cigna Reconsiderations
PO Box 20002
Nashville, TN 37202
EFT support requests after enrollment, contact 866-506-2830 Option 2
Electronic Remittance Advice
(ERA)/Electronic Funds
Transfer (EFT) ERA/Claims support requests after enrollment, contact 866-742-4355
Option 1
Provider Customer Service Questions: 800-230-6138
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including
Cigna Health and Life Insurance Company, Cigna HealthCare of South Carolina, Inc., Cigna HealthCare of North Carolina, Inc.,
Cigna HealthCare of Georgia, Inc., Cigna HealthCare of Arizona, Inc., Cigna HealthCare of St. Louis, Inc., HealthSpring Life &
Health Insurance Company, Inc., HealthSpring of Florida, Inc., Bravo Health Mid-Atlantic, Inc., and Bravo Health Pennsylvania,
Inc. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. © 2021
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