Self-Funded Employer Group Plan Overview for Cigna And

Provider NewsFlash

September 2012

Self-Funded Employer Group Plan Overview for Cigna and

Great West

Purpose of this communication

· To provide an overview of the appropriate processes and procedures to follow when a member’s benefits are managed through a self-funded employer group. These self-funded employer groups include Cigna Shared Administration Plan, and Payer Solutions for Great West. The CareCentrix Service Authorization Form (SAF) will list a plan name of Shared Admin if the member is covered through a self-funded employer group. The second page of this communication shows an example SAF for future reference.

What do I need to know?

· Standard Cigna/Great West rules, such as precertification and medical necessity criteria, do not apply to this population of members. The self-funded employer group will maintain their own eligibility, benefits, and precertification rules.

· Cigna Shared Administration and Great West Payer Solutions’ members may elect to be managed by a Care Allies Case Manager. Should this occurs, the Care Allies Case Manager will issue all authorization decisions for the member.

What do I need to do?

· For all Self-Funded Plans the provider should verify eligibility and benefits directly with the employer group or the Third Party Administrator. Cigna or Great West Member Services would be able to provide you with the phone number for eligibility and benefit review.

· Please do not inquire with the employer group about member’s precert requirements or whether a case manager is assigned. If there are precert requirements or a case manager assigned your service authorization will list this information under the auth memo field.

· If a member is managed by a Care Allies Case Manager, CareCentrix is responsible to verify initial eligibility and benefits and will obtain the initial authorization from Care Allies. The provider will be responsible for contacting the Case Manager directly for all reauthorizations, including add-on services. The case manager’s name and phone number will be listed under the auth memo field of your service authorization form . Care Allies can also be contacted by calling 1-800-768-4695.

· If the member is not managed by a Care Allies Case Manager, and authorizations are not required for services, the provider is responsible for checking ongoing eligibility and benefits each month, as explained on the CareCentrix SAF.

· If the member is not managed by a Care Allies Case Manager, but the Fund requires authorization for services, CareCentrix will designate on the SAF the name and number of the entity responsible for reauthorizations. The provider will be responsible for obtaining any necessary reauthorizations, including add-on services.

· Authorization requirements may vary by the services/equipment being provided. It is important for providers to check the SAF and to call the phone numbers listed on the SAF for eligibility and authorizations prior to rendering any ongoing services.

· Providers should submit all claims to CareCentrix. Services may be recouped if an authorization was required but not obtained.

Provider NewsFlash

September 2012

Self-Funded Employer Group Plan Overview for Cigna and

Great West

Thank you for your prompt attention and cooperation.