Overview of CIGNA Settlement and Claims Distribution Funds
This overview provides essential information on the CIGNA Settlement Fund, including a $30 million Claims Distribution Fund without limitations and a $15 million Foundation Fund. It outlines the different compensation categories, such as Category A and Category 1 and 2 compensations, each covering specific CPT codes and medical necessity claims. Physicians can file claims within 180 days from notification, and guidelines for documentation are included. The document details significant dates for the settlement process and claims submission instructions, ensuring eligibility and compliance.
Overview of CIGNA Settlement and Claims Distribution Funds
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Presentation Transcript
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 • 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 • 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 • 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 • 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 • 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 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 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 • 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 • 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 • 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 @ MCPA@mail.jus.state.nc.us.
