CIGNA Product Overview OrthoNet’s arrangement with CIGNA shall apply to CIGNA’s HMO Managed Care, FlexCare/POS and Open Access plans. PPO is only managed in the State of Illinois. UTILIZATION MANAGEMENT Eligibility Verification CIGNA members should present their ID card at your facility. It will include all pertinent information including the Plan Type and toll free number to verify eligibility.

THERAPY AUTHORIZATIONS Initial Therapy Evaluation Authorization is not required for the first therapy visit. All visits after the initial evaluation require pre-authorization by OrthoNet. All therapy procedures performed on this first visit are considered part of the initial evaluation and will be paid at the established per visit rate. Request for Therapy Following Initial Visit Authorization is required for all visits beyond the patient’s first visit. To authorize visits after the first session, complete an OrthoNet CIGNA Fax Request Form and an Initial Evaluation Form, and fax them to OrthoNet at 1-888-230-6265. Please include a copy of the physician’s prescription with your request. OrthoNet will verify eligibility and make a determination of the number of therapy visits to be authorized for the member’s condition. An authorization determination letter will be faxed to the requesting therapy provider. (Note: A CIGNA Fax Request Form must accompany all requests for authorization and supporting documentation. However, you may use your own evaluation form provided it includes the information required on the OrthoNet form.) Requesting Additional Therapy Visits Should additional therapy visits be required, complete the Fax Request Form and Functional Progress Chart (or your progress notes with the equivalent information), and fax them to OrthoNet at 1-888-230-6265 for review. An authorization determination will be faxed back to the requesting therapy provider.

Urgent Requests When an occasion arises where there is a need for an urgent review and the continuity of care may be compromised, you may call OrthoNet at 1-866-874-0727. OrthoNet’s

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Medical Management staff will respond to your inquiry. Requests of this nature will be monitored to assure that requests are appropriate. Therapy Visits A therapy visit is considered as any treatment rendered to a Member for any length of time on a given calendar day. The visit includes any and all services rendered to the member that day. Any disposables or supplies, other than the splints described below, are included in the per visit fee. This includes, but is not limited to, items such as theraband, exercise putty, exercise sheets/videos/equipment, disposable electrodes, elastic bandages, and iontophoresis medications.

Requesting Authorization for Splints In the course of treatment it may be determined that a splint will be needed in addition to the therapy treatment. If so, prior authorization is requested in order to facilitate claims payment. Please submit a separate Fax Request Form along with supporting documentation when requesting prior authorization for a splint. Provide a description of the splint and appropriate HCPCS “L” code in the Request Other Procedure section of the Fax Request Form. Fax Request Form All requests for authorization shall be submitted to OrthoNet by FAX. OrthoNet has provided you with a MASTER CIGNA Fax Request Form that you should use to make clean copies to submit requests for therapy authorization. The Fax Number for CIGNA requests is 888-230-6265. This fax number is part of our document management system which expedites the delivery of your requests and supporting documentation to our care management team for timely consideration.

Treatment Prior to Authorization If you treat a patient prior to receipt of OrthoNet’s authorization determination letter for those visits, please be advised that authorization may not have been given and that those visits might not be eligible for benefits. Should you need to, you may call our medical management staff at 866-874-0727 to ascertain the status of a member’s authorization. Our authorizations all bear expiration dates. Should you wish to request an extension of an unexpired authorization, please call medical management at 866-874-0727 prior to the expiration date of the authorization. OrthoNet’s policy is that expiration dates will be extended if calls are received prior to the expiration date as long as it fits within the member’s benefit timeframes.

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Fax Transmission Logging Occasionally faxes transmitted to OrthoNet do not arrive in their entirety or are otherwise received unreadable. We may therefore request you to refax the entire transmission. We have an automatic document logging system that records all incoming transmissions (date and time received) and, as such, we can verify the arrival of transmissions should that be necessary for those few faxes that may not arrive at our fax system in a readable format.

Authorizations for More Than One Condition If authorization to treat more than one clinical condition is desired, please submit a separate Fax Request Form and provide appropriate clinical documentation for each condition with its own cover sheet. This will allow us to authorize visits for each condition separately, keeping consistent with the CIGNA benefit structure. APPEALS PROCESS Utilization Review Appeals Process All Utilization Review (clinical) Appeals Requests should be submitted directly to CIGNA HealthCare as follows: If the ID card indicates: Cigna Network: Cigna Healthcare Inc. National Appeals Unit (NAO) PO Box 188011 Chattanooga, TN 37422

If the ID card indicates: GWH-Cigna Network: Great-West Healthcare P.O. Box 668 Kennett, MO 63857 When submitting an appeal for Medical Necessity claim denial, the following must be included: • • •

The original Explanation of Benefits (EOB), Explanation of Payment (EOP). The documentation that supports why the decision should be overturned, such as operative reports, medical records, etc. Completed Health Care Professional Payment Appeal form[167k]. Select: Medical Necessity.

(Note: The phone number for provider appeals can be located on the non-certification letter received from CIGNA)

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Please Note: OrthoNet does not process utilization management appeals. All appeals should be directed to the appropriate address above. Any appeal requests sent to an address other than those listed are subject to delays in processing. Always refer to the CIGNA website for the most current information for utilization review (clinical) appeals: http://www.cigna.com/healthcare-professionals/resources-for-health-careprofessionals/clinical-payment-and-reimbursement-policies/claim-policiesprocedures-and-guidelines/claim-adjustment

Member Grievance Process A CIGNA member who would like to register a grievance about some aspect of care can contact the appropriate department referenced on the back if their member ID Card.

CLAIMS All claims for CIGNA Therapy services shall be submitted to OrthoNet. It is essential that you submit complete and accurate information to assure that claims are paid in a timely and accurate manner. You may submit claims in one of the following formats: • Electronic Claim Submission: • HCFA 1500 Form When to File a Claim Claims with required information must be submitted within 90 days* following the date that services are rendered. In those cases where CIGNA is secondary payor for any reason (i.e. auto, third party liability, worker’s compensation) the claims will be paid if it is submitted within 30 days of receiving a determination of benefits from the other payor, health plan or insurance carrier. CIGNA members cannot be billed for claims denied due to late submission. *Exceptions: New Jersey: Claims with required information must be submitted within 180 days following the date that services are rendered. In those cases where CIGNA is secondary payor for any reason (i.e. auto, third party liability, worker’s compensation) the claims will be paid if it is submitted within 30 days of receiving a determination of benefits from the other payor, health plan or insurance carrier. CIGNA members cannot be billed for claims denied due to late submission. New York: Claims with required information must be submitted within 120 days following the date that services are rendered. In those cases where CIGNA is secondary payor for any reason (i.e. auto, third party liability, worker’s compensation) the claims

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will be paid if it is submitted within 30 days of receiving a determination of benefits from the other payor, health plan or insurance carrier. CIGNA members cannot be billed for claims denied due to late submission. Where to Send Paper Claims All claims for Therapy services shall be sent to: OrthoNet (CIGNA claims) P.O. Box 5016 White Plains, NY 10602 (Note: Do not fax claims. Faxed claims will be returned. )

Electronic Submissions OrthoNet receives electronic claims submissions for CIGNA through WebMD. Please submit all electronic claims submissions for payment under WebMD Payor ID# 13381. If you have any questions on electronic submissions, you may contact WebMD directly at 1-800-845-6592.

Claim Resubmission’s and Duplicate Claims In any event duplicate or resubmitted claims will only be accepted if payment for a previous claim for the same dates of service has not been made beyond 30 days of the initial submission of the claim.

Correspondence Correspondence concerning claims matters should include the control number on the Explanation of Benefits Remittance Advice or member name, ID, provider number and list of billed charges. Coding Criteria OrthoNet’s standard is to accept current CPT and ICD-codes and modifiers. Copay If the Member has a standard co-payment, Providers are required to collect applicable copay at the time of the therapy visit. If the Member has a percentage-co-insurance/HSA or high deductible plan responsibility, the Provider should collect the appropriate member co-insurance, after claims have been adjudicated by OrthoNet, based on the OrthoNetCIGNA EOB.

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Coordination of Benefits Providers are required to verify member insurance coverage including primary and secondary insurance and bill appropriately. In the event that members other insurance is primary providers are obligated to bill primary insurance first then submit EOB along with claim to OrthoNet for remainder of payment. Provider Payment Payment for CIGNA Therapy services shall be paid at the contracted rate for each visit no matter the number or therapeutic services or modalities rendered on the particular date of service. Payment will only be made for the Initial Evaluation visit and authorized therapy visits thereafter. Appeals for Claim Payment Issues Appeals for claim payment issues should be submitted in writing to: OrthoNet PO Box 5045 White Plains, NY 10602 (Attn: CIGNA Claims Appeals Dept.) Claims Appeal Process Appeals must be submitted within 180 days from the date of denial on the Explanation of Benefits(EOB) or as required by law. The appeal process is initiated by submitting a written request to OrthoNet. This request should include the following information, which can be obtained from the Explanation of Benefits(EOB): • • • • •

Patient Name and Patient ID number Control number of the claim being appealed (Claim ID Number) Provider Name and Provider ID number Issue or reason for appeal Any pertinent information that would be of assistance in reviewing your request

Review of a Claim Appeal Receipt of your request for an appeal will be acknowledged within fifteen (15) business days. The acknowledgement will include any information needed to render a decision on the appeal. During the review additional information may be requested. A written response to your appeal will be sent (after receipt of all necessary information needed to make a determination) within 30 business days of receipt of the appeal at OrthoNet. The appeal notice of determination shall include the review findings, an explanation of the

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denial/issue and, if the initial determination is upheld, instructions on additional appeal options, if any exist.

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