FREQUENTLY ASKED QUESTIONS

BACKGROUND:

  1. What is this litigation about?
  2. Has the Court approved the Settlement?
  3. Am I covered by this Settlement?
  4. What relief does the Settlement provide for the Class?
  5. How much are the attorneys' fees and costs?
  6. How much are the representative plaintiffs' incentive awards?
  7. Whom do I contact if I have questions?
  8. Who is the Settlement Administrator?
  9. Who may submit requests for payment?
  10. When can I submit requests for payment and what is the duration of the claims period?
  11. What kinds of requests for payment can I make?
  12. What are Claim Coding and Bundling Edits?
  13. May I seek payment under all categories?
   13a   If I file a Category A claim, can I change my mind and file claims against
           the Claim Distribution Fund?
  1. What about protection of confidential health information pursuant to HIPAA?
  2. Where do I get claim forms?
  3. What is the significance of signing the certification to the Proof of Claim?
  4. What claims are excluded from consideration by the Settlement Administrator?
  5. Will a check that I receive from the Settlement funds have an expiration date?
  6. What should I do if a check is lost or stolen?
  7. THE CATEGORY A SETTLEMENT FUND:

  8. How do I make a request for payment from the Category A Settlement Fund?
  9. If a Physician Group or Physician Organization wishes to submit claims for compensation from the Category A Settlement Fund on behalf of Physicians in the group or organization, can they submit one Category A Claim Form?
  10. If a Physician Group or Physician Organization wishes to file for Category A compensation on behalf of Physicians in the group or organization, can each Physician receive an individual payment to himself or herself?
  11. How will the payment be determined for a Category A claim?
  12. When will I receive payment from the Category A Settlement Fund?
  13. THE CLAIM DISTRIBUTION FUND:

  14. How do I submit a Proof of Claim Form for the Claim Distribution Fund?
  15. Can a Physician Group or Physician Organization submit claims to the Claim Distribution Fund (i.e., for Category One Compensation, Category Two Compensation, and/or Medical Necessity Denial Compensation) on behalf of its members?
  16. What if I maintain electronic records?
  17. THE CLAIM DISTRIBUTION FUND -
    CATEGORY ONE COMPENSATION:

  18. Under what circumstances is Category One Compensation available?
   28a   What does the Category One Code List show?
  1. What are the requirements for submitting a valid Proof of Claim for Category One Compensation?
  2. What happens if documentation for a request for Category One Compensation is inadequate?
  3. What happens if a request for Category One Compensation is invalid?
  4. How do I correctly certify a Proof of Claim for Category One Compensation?
  5. What is the timeline for decisions on a Category One request for compensation?
  6. THE CLAIM DISTRIBUTION FUND -
    CATEGORY TWO COMPENSATION:

  7. Under what circumstances is Category Two Compensation available?
  8. What is the Facilitation List and where can I obtain it?
  9. What are the requirements for submitting a valid Proof of Claim for Category Two Compensation?
  10. What documentation do I need to submit with a Proof of Claim for Category Two Compensation?
  11. What are the exceptions to the Clinical Information documentation requirement?
  12. Is there a list of modifier 51 exempt and add-on codes for which CIGNA HealthCare may have systematically applied Multiple Procedure Logic during the Class Period?
  13. When will the Settlement Administrator make a decision regarding the adequacy of documentation?
  14. How do I correctly certify a Proof of Claim for Category Two Compensation?
  15. What is the timeline for decisions on a Category Two request for payment?
  16. How are denials of Category Two requests for payment handled?
  17. What is the timing of External Review decisions?
  18. How are claims handled that were originally submitted to CIGNA Healthcare on or after August 24, 2003?
  19. How are claims handled that were originally submitted to CIGNA HealthCare on or before August 23, 2003?
  20. THE CLAIM DISTRIBUTION FUND -
    MEDICAL NECESSITY DENIAL COMPENSATION

  21. Under what circumstances is Medical Necessity Denial Compensation available?
  22. What documentation do I need to submit with a Proof of Claim for Medical Necessity Denial Compensation?
  23. How do I request information about the types of required Clinical Information?
  24. What procedures should be followed for Proofs of Claim for Medical Necessity Denial Compensation?

 

 

1. What is this litigation about?

The Litigation was brought by representative plaintiffs on behalf of a class of physicians against a number of managed care companies, including Aetna, Inc., Aetna-USHC, Inc., Anthem, Inc., CIGNA, Coventry Health Care, Inc., Health Net, Inc., Humana Health Plan, Inc., Humana, Inc., PacifiCare Health Systems, Inc., Prudential Insurance Company of America, United Health Care, United Health Group and Wellpoint Health Networks, Inc. (collectively, "defendants"). The class action lawsuits are part of a federal multi-district litigation that is pending in the U.S. District Court for the Southern District of Florida (the "Court") called In re Managed Care Litigation, MDL Docket No. 1334. Shane, et al. v. Humana, Inc. et al., Master File No. 00-1334-MD-MORENO, is the lead physician case in this litigation. Kaiser, et al. v. CIGNA Corporation, CIGNA HealthCare of St. Louis, Inc., and CIGNA HealthCare of Texas, Inc. was transferred to the Court to become part of the multi-district litigation (referred to collectively as the "Litigation"). The complaints in the Litigation allege that at various times from 1990 to the present, these companies engaged in a conspiracy to improperly deny, delay and/or reduce payment to physicians.

The Class Representative Plaintiffs and certain medical societies have agreed to settle all claims against CIGNA HealthCare in the Litigation in exchange for CIGNA HealthCare's adoption of a number of commitments and initiatives regarding its disclosures and business practices, the funding of a not-for-profit Foundation, and the establishment of alternate settlement funds against which Class Members can submit requests for payment.

Please refer to the Agreement for details of the Settlement. The Agreement is available for viewing and downloading here. Please note that the Court has approved amended dates for implementing certain commitments in the Settlement Agreement.

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2. Has the Court approved the Settlement?

Yes, the Court has approved the Settlement. The Final Approval date is April 22, 2004.

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3. Am I covered by this Settlement?

This Settlement applies to the following Class: Any and all Physicians, Physician Groups, or Physician Organizations (or persons or entities claiming by or through them, such as a Physicians' Assistant or Advanced Practice Registered Nurse) who or which provided Covered Services to any individual enrolled in or covered by a health benefit plan insured or administered by CIGNA HealthCare or a health benefit plan insured or administered by any other managed care company named as a defendant in Shane, et al. v. Humana, Inc., et al. from August 4, 1990 through September 5, 2003. The defendants in Shane are listed in Q&A 1.

The Class does not include any Physician who is or was an employee of a CIGNA HealthCare staff-model HMO at the time of providing Covered Services. You are not covered by the Settlement if you filed a timely and valid notice to opt out of the Settlement.

The term "Physician" under the Settlement means an individual duly licensed by a state licensing board as a Medical Doctor or as a Doctor of Osteopathy and shall include without limitation both Participating Physicians and Non-Participating Physicians. “Physician Group” means two or more Physicians, and those claiming by or through them, who practice under a single taxpayer identification number. "Physician Organization" means any association, partnership, corporation or other form of organization (including without limitation independent practice associations and physician hospital organizations), and those claiming by or through them, that arranges for care to be provided by Physicians to CIGNA HealthCare Members and that may be organized under multiple taxpayer identification numbers. If you do not meet one of these definitions, you are not a class member and are not eligible to submit claims under this Settlement.

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4. What relief does the Settlement provide for the Class?

The following section briefly describes the benefits provided by CIGNA HealthCare for which you are eligible as a Class Member:

A. Prospective Relief: Additional Disclosures; Changes in Business Practices

As a part of the Settlement, CIGNA HealthCare has agreed to certain commitments regarding its disclosures and business practices. For example, CIGNA HealthCare has agreed to:

  • provide members of the Class access to CIGNA HealthCare's medical necessity external review process;
  • establish an independent, external billing dispute review process for resolving disputes with members of the Class concerning many Claim Coding and Bundling Edits. Information about Claim Coding and Bundling Edits is available in Q&A 12.
  • continue to pursue initiatives designed to facilitate the automated adjudication of claims submitted by Physicians and thereby shorten the average time taken by CIGNA HealthCare to pay valid claims;
  • fund initiatives to reduce the percentage of resubmitted claims;
  • disclose payment rules and conform its bundling and other electronic editing rules as specified in the Agreement;
  • devote resources to improve accuracy of information about eligibility of plan members;
  • enable members of the Class to obtain by e-mail applicable fee schedule amounts for billing codes related to their practice;
  • establish a compliance dispute resolution mechanism to address disputes regarding CIGNA HealthCare's compliance with Section 7 of the Agreement.
  • where all necessary information is available to CIGNA HealthCare, pay interest on valid claims not paid within 15 business days for electronically submitted claims and 30 calendar days for paper claims, in accordance with the timetable and terms set forth in the Agreement.

In addition, CIGNA HealthCare will disclose additional information about its claim administration policies and procedures on its existing internet website at www.CIGNAforHCP.com and www.CIGNA.com. These changes, as well as others, are more fully described in the Agreement.

B. Medical Foundation

CIGNA HealthCare has provided Fifteen Million Dollars ($15,000,000.00) in funding to the Physicians' Foundation for Health Systems Innovations, Inc., a not-for-profit medical foundation established by representatives of medical societies that have signed or joined the Settlement (the "Foundation").

Members of the Class may elect to have their Settlement payments from the Category A Settlement Fund (discussed in the next section) contributed on their behalf to the Foundation, or to a foundation established by a medical society that has signed or joined the Settlement. A list of these eligible medical society foundations can be viewed and downloaded at the Signatory Medical Society Foundation List. A list is also attached to the Category A Proof of Claim Form.

C. Monetary Compensation

The monetary compensation outlined here is more fully described in the answers to Questions 20-47 below.

Under the Settlement, Class Members can receive compensation from either one of two funds established by CIGNA HealthCare: 1) the "Category A Settlement Fund"; or 2) the "Claim Distribution Fund," which includes compensation related to Claim Coding and Bundling Edits and denials of claims on Medical Necessity grounds. To be eligible for either category of compensation, a Class Member must submit Proofs of Claim, as described below and in Section 8 of the Agreement. Additional information regarding how to submit Proofs of Claim has been mailed to Class Members in the Notice of Commencement of Claims Period.

Category A Settlement Fund:

CIGNA HealthCare has established the Category A Settlement Fund in the amount of Thirty Million Dollars ($30,000,000.00). All Class Members are eligible to apply for payment from this Settlement fund, whether or not they have submitted any claims to CIGNA HealthCare from August 4, 1990 to September 5, 2003, as long as they have submitted claims for payment during that period to any one of the defendants listed in Q&A 1. Each Class Member who makes a valid request for compensation from this fund will receive a proportionate share of the Fund, calculated in accordance with the formula set forth in the Agreement and described in the answer to Question 21 below. A Class Member may elect either to receive the payment or to direct that the payment be contributed to (a) the Foundation established under the terms of the Settlement or to (b) a foundation established by a medical society that signed or joined the Settlement. Any Class Member filing a Proof of Claim from the Category A Settlement Fund is not eligible to seek Category One Compensation, Category Two Compensation or Medical Necessity Denial Compensation, described generally below.

Claim Distribution Fund:

CIGNA HealthCare has established the uncapped Claim Distribution Fund to pay three categories of compensation to members of the Class who submitted claims to CIGNA HealthCare during the Class Period and were affected by Claim Coding and Bundling Edits and/or Medical Necessity denials and who submit Valid Proofs of Claim. CIGNA HealthCare will replenish this fund as often as necessary to pay all Valid Proofs of Claim.

The three categories of compensation under the Claim Distribution Fund are as follows:

Category One Compensation: The parties have agreed to a list of specific CPT® code combinations which qualify for Category One Compensation. The Category One Code List can be viewed and downloaded here. It is also available at www.hmosettlements.com, www.milbergweiss.com, www.kttlaw.com, and www.whatleydrake.com. A copy of this list is attached to the Agreement as Exhibit 1. Class Members who submit Valid Proofs of Claim will receive reimbursement for the denial of payment for Category One Codes in the specific circumstances (i.e., the code combinations) and within the date of service limitations set forth on the Category One Code List. All Valid Proofs of Claim for Category One Compensation will be paid at the amount stated in the Category One Code List.

Category Two Compensation: Category Two Proofs of Claim are not limited to specific codes and/or code combinations. Class Members may resubmit claims to CIGNA HealthCare that they believe were improperly denied and/or reduced during the Class Period (including those involving the code combinations on the Category One Code List that are outside the time periods on that list). A Class Member who submits a Valid Proof of Claim may, under Category Two, receive reimbursement for the code(s) which were originally denied or paid at a reduced amount. CIGNA HealthCare will use its best efforts to make available a Facilitation List to assist members of the Class in identifying claims that may be eligible for Category Two Compensation. Class Members can obtain the Facilitation List specific to their claims from the Settlement Administrator. Information about the Facilitation List is available in Q&A 32. In most cases, Class Members must submit clinical documentation in support of the request for Category Two payment. If CIGNA HealthCare denies the Proof of Claim based on CIGNA HealthCare's determination that the original decision to reduce or deny payments was an appropriate application of Claim Coding and Bundling Edits, it will automatically be sent to an external reviewer for a final decision.

Compensation for Erroneous Denials of Claims on Medical Necessity Grounds: Class Members may resubmit claims that they believe were improperly denied as not medically necessary or as experimental or investigational. If CIGNA HealthCare determines, upon reconsideration, that it denied a claim for services or supplies that were Medically Necessary or not experimental or investigational at the time they were provided, the Class Member will receive Medical Necessity Denial Compensation. If CIGNA HealthCare denies the Proof of Claim submitted by a Class Member, it will automatically be sent to an external reviewer for a final decision. For Proofs of Claim that are determined to be valid, either by CIGNA HealthCare or the external reviewer, Class Members will receive payment for the code(s) that were originally denied.

D. Arbitration Waiver

With regard to this Litigation only, CIGNA HealthCare will waive its right to require those members of the Class with valid and enforceable arbitration provisions to arbitrate their Fee for Service Claims for services provided during the Class Period against CIGNA HealthCare. This waiver will permit all members of the Class to participate in the Settlement compensation funds, even if they have valid and enforceable arbitration provisions in their contracts with CIGNA HealthCare.

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5. How much are the attorneys' fees and costs?

The Court approved class counsels' application for fees and costs in the amount of Fifty-five Million Dollars ($55,000,000.00). CIGNA HealthCare has paid this award under the terms of the Settlement.

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6. How much are the representative plaintiffs' incentive awards??

The Court approved awards in the amount of Seven Thousand Five Hundred Dollars ($7,500.00) for each Class Representative Plaintiff. CIGNA HealthCare has paid these awards under the terms of the Settlement.

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7. Whom do I contact if I have questions?

Please call or write to the Settlement Administrator. You may also reach the Settlement Administrator through this site via "Contact Us".

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8. Who is the Settlement Administrator?

The Court approved Poorman-Douglas Corporation, a nationally recognized, independent Settlement Administrator, to fulfill certain duties that are required by the Settlement, such as mailing notices and Proof of Claim Forms, processing claims, and making settlement payments to entitled Class Members. You may reach the Settlement Administrator in a number of ways, including via this site through "Contact Us", by calling toll-free at 1-877-683-9363, or by mail at:

CIGNA Physician Settlement
Settlement Administrator
P.O. Box 3170
Portland, OR 97208-3170

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9. Who may submit requests for payment?

  • If you are a member of the Class, you may submit requests for payment as described below.
  • If you filed a timely and valid request to opt out of the Settlement, you are not a member of the Class and may not seek payment from the Settlement funds.
  • Class Members may seek payment from either the Category A Settlement Fund or the Claim Distribution Fund, but not both.
  • Requests to the Category A Settlement Fund: All Class Members (or their heirs or legal representatives in the case of deceased Class Members) may submit requests for payment from the Category A Settlement Fund, whether or not they have submitted any claims to CIGNA HealthCare during the period from August 4, 1990 through September 5, 2003, as long as they have submitted claims for payment during that period to any one of the defendants listed in Q&A 1.
  • Requests to the Claim Distribution Fund: Class Members (or their heirs or legal representatives in the case of deceased Class Members) whose claims for payment for services provided to CIGNA HealthCare Members during the Class Period (August 4, 1990 through April 22, 2004) were reduced or denied by CIGNA HealthCare based on Claim Coding or Bundling Edits or on grounds of Medical Necessity may make requests for payment from the Claim Distribution Fund.
  • Physician Groups and Physician Organizations may submit Proofs of Claim for compensation from the Category A Settlement Fund on behalf of Physicians employed by or otherwise working with them at the time the Proof of Claim Form is submitted, without the necessity of individual signatures from the individual Physicians. Physician Groups and Physician Organizations may submit Proofs of Claim for compensation from the Claim Distribution Fund on behalf of Physicians employed by or otherwise working with them at the time the claims were originally submitted, without the necessity of individual signatures from the individual Physicians. However, the Class Member that submits a Proof of Claim Form for compensation from the Claim Distribution Fund must be the Physician, Physician Group or Physician Organization that originally submitted the claim and must use the same tax identification number as was used on the original claim.
  • You may not submit requests for compensation if you are a non-physician health care provider, employed by or otherwise working with a Physician, Physician Group or Physician Organization, who provided services to a CIGNA HealthCare Member from August 4, 1990 through April 22, 2004 and claims for those services were submitted to CIGNA HealthCare by or through the Physician, Physician Group or Physician Organization. Proofs of Claim for such services can only be submitted by the Physician, Physician Group or Physician Organization that originally submitted the claim and must use the same tax identification number as was used on the original claim.

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10. When can I submit requests for payment and what is the duration of the claims period?

The Claims Period begins on August 23, 2004 and runs through February 18, 2005. Any requests for payment originally postmarked after February 18, 2005 will be denied by the Settlement Administrator. Any requests for payment submitted before August 23, 2004 will be treated as if received on that date.

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11. What kinds of requests for payment may I make?

Under the Settlement, you may choose compensation from one of two separate funds:

  1. The Category A Settlement Fund or
  2. The Claim Distribution Fund

CIGNA HealthCare has established a Category A Settlement Fund in an aggregate amount of Thirty Million Dollars ($30,000,000.00). Each Class Member filing a valid Category A request for payment will be entitled to a proportionate share of that Fund.

CIGNA HealthCare has also established an uncapped Claim Distribution Fund (which will be replenished by CIGNA HealthCare as needed to pay all Valid Proofs of Claim) to pay three categories of compensation to Class Members submitting valid requests for payment:

Category One Compensation and Category Two Compensation (described below and in Section 8.3.c of the Agreement) will be available to Class Members affected by Claim Coding and Bundling Edits during the Class Period.

Medical Necessity Denial Compensation (described below and in Section 8.3.d of the Agreement) will be available to Class Members affected by certain Medical Necessity denials during the Class Period.

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12. What are Claim Coding and Bundling Edits?

"Claim Coding and Bundling Edits" means adjustments to CPT® Codes or HCPCS Level II Codes included in claims in which (a) CIGNA HealthCare's payment is or was based on some, but not all, of the CPT® Codes or HCPCS Level II Codes included in the claim; (b) CIGNA HealthCare's payment was based on different billing codes than those billed to CIGNA HealthCare; (c) CIGNA HealthCare's payment for one or more CPT® Codes is or was reduced by application of Multiple Procedure Logic; or (d) any combination of the above.

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13. May I seek payment from both the Category A Settlement Fund and the Claim Distribution Fund?

No. You may seek compensation from either the Category A Settlement Fund or the Claim Distribution Fund, but not both. If you choose to seek compensation from the Claim Distribution Fund, you may submit requests for payment in any or all of the three separate categories paid from that Fund.

If you inadvertently seek relief from both the Category A Settlement Fund and the Claim Distribution Fund, the Settlement Administrator will process the request that is received first. If both are received on the same day, the Settlement Administrator will send you a letter asking which request you would like to have processed. If the Settlement Administrator does not receive a response from you within 20 days of the date of that letter, it will process the Category A Proof of Claim and will deny all requests for payment from the Claim Distribution Fund.

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13a. If I file a Category A claim, can I change my mind and file claims against the Claim Distribution Fund?

You may do so only if you submit a valid Category A Withdrawal Form postmarked by no later than February 1, 2005. By submitting a valid Category A Withdrawal Form, you will be entitled to submit claims to the Claims Distribution Fund for Category One, Two, or Medical Necessity Denial compensation. Any Category One, Two, or Medical Necessity Denial Proofs of Claim you subsequently submit must satisfy the existing requirements for filing such Proofs of Claim and must be postmarked by February 18, 2005. Note that by filing a Category A Withdrawal Form, you will not receive compensation from the Category A Claim Fund, unless you subsequently file a valid Category A Claim Form, which would also have to be postmarked by February 18, 2005.

Detailed instructions on how to withdraw your Category A claim are attached to the Category A Withdrawal Form, which you may obtain either from this link, under the "Documents" section of this webpage, or by calling the Settlement Administrator toll free at 1-877-683-9363.

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13. May I seek payment from both the Category A Settlement Fund and the Claim Distribution Fund?

No. You may seek compensation from either the Category A Settlement Fund or the Claim Distribution Fund, but not both. If you choose to seek compensation from the Claim Distribution Fund, you may submit requests for payment in any or all of the three separate categories paid from that Fund.

If you inadvertently seek relief from both the Category A Settlement Fund and the Claim Distribution Fund, the Settlement Administrator will process the request that is received first. If both are received on the same day, the Settlement Administrator will send you a letter asking which request you would like to have processed. If the Settlement Administrator does not receive a response from you within 20 days of the date of that letter, it will process the Category A Proof of Claim and will deny all requests for payment from the Claim Distribution Fund.

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14. What about protection of confidential health information pursuant to HIPAA?

If you seek compensation from the Claim Distribution Fund, the supporting documentation you submit will include confidential health information. CIGNA HealthCare and the Settlement Administrator have entered into a Business Associate Agreement with respect to the Health Insurance Portability and Accountability Act of 1996, as amended ("HIPAA") that protects the confidentiality of such information provided by you to the Settlement Administrator. The Settlement Administrator has taken appropriate steps to insure that the information will be maintained confidentially.

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15. Where do I get claim forms?

Proof of Claim Forms are available on this site in the "Documents" section.

You may also obtain these forms by calling the Settlement Administrator toll-free at 1-877-683-9363 or from the following websites: www.hmosettlements.com, www.milbergweiss.com, www.kttlaw.com, and www.whatleydrake.com.

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16. What is the significance of signing the certification to the Proof of Claim?

By signing and submitting a Proof of Claim, you are agreeing to be subject to the jurisdiction of the United States District Court for the Southern District of Florida for any proceedings relating to that Proof of Claim.

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17. What claims are excluded from consideration by the Settlement Administrator?

Retained Claims are not adjudicated by the Settlement Administrator. Retained Claims are essentially claims that were in the pipeline as of April 22, 2004. Specifically, a Retained Claim is a claim for payment for the provision of Covered Services if, as of April 22, 2004: (1) a claim has been filed with CIGNA HealthCare, but not finally adjudicated by it; or (2) no claim has yet been filed with CIGNA HealthCare and the period for filing such a claim has not expired. A claim is considered finally adjudicated when CIGNA HealthCare's internal appeals process has been completed. Physicians with Retained Claims must still go through CIGNA HealthCare's internal appeals process.

All other claims for services rendered before April 22, 2004 are released by the Settlement and are thus no longer subject to challenge by Class Members (except as specified in the next paragraph with respect to certain claims that were finally adjudicated between March 24 and April 21, 2004).

Retained Claims that involve the application of CIGNA HealthCare's coding and payment rules and methodologies will be handled by the Billing Dispute External Review Process established under the terms of Section 7.10 of the Settlement Agreement. For this type of claim only, Retained Claims also includes claims that were finally adjudicated between March 24 and April 21, 2004.

After any internal appeal has been exhausted, Class Members may submit such Retained Claims to the Billing Dispute External Review Process. This is the ONLY way to resolve Retained Claims that relate to the application of coding and payment rules and methodologies to patient specific factual situations, including, for example, the appropriate payment amount when two or more CPT® Codes are billed together, or whether the physician used modifiers appropriately.

Any such Retained Claim may be submitted to the Billing Dispute External Review Process if

  • it was not finally adjudicated by CIGNA HealthCare by April 22, 2004;
  • it was finally adjudicated within thirty (30) days before April 22, 2004 (i.e., between March 24 and April 21, 2004); and
  • it is submitted by no later than August 31, 2004, or within thirty (30) days of final adjudication under CIGNA HealthCare's internal appeals process, whichever is later.

Additional information about how to submit claims to the billing dispute process will be available by July 20, 2004 on the following websites: www.CIGNAforHCP.com and www.hmosettlements.com. Please continue to check for details.

Retained Claims NOT involving the application of coding and payment rules and methodologies are not subject to resolution under any adjudication process created in connection with the Settlement. However, your right to sue or seek other legal redress is not waived under the Settlement as to these Retained Claims.

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18. Will a check that I receive from the Settlement funds have an expiration date?

Yes, all checks issued by the Settlement Administrator will have an expiration date that is 90 days from the issuance date. If you do not cash a check by its expiration date, you may contact the Settlement Administrator who will re-issue the check so long as funds remain available in the Settlement fund.

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19. What should I do if a check is lost or stolen?

If a check issued by the Settlement Administrator is lost or stolen, contact the Settlement Administrator.

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THE CATEGORY A SETTLEMENT FUND:

20. How do I make a request for payment from the Category A Settlement Fund?

All Class Members are eligible for Category A Compensation regardless of whether or not you have submitted claims to CIGNA HealthCare from August 4, 1990 through September 5, 2003, as long as you have submitted claims for payment during that period to any one of the defendants listed in Q&A 1.

To request Category A Compensation, you must submit a Category A Proof of Claim Form by mail to the Settlement Administrator, Poorman-Douglas Corporation, at the following address:

CIGNA Physician Settlement
Settlement Administrator
P.O. Box 3170
Portland, OR 97208-3170

You must sign the Proof of Claim Form, certifying that:

  • you are a member of the Class, i.e. you are either a Physician in active practice or a retired Physician who was in active practice at any time from August 4, 1990 through September 5, 2003 (or their heirs or legal representatives in the case of deceased Class Members); and
  • you have not submitted a Proof of Claim Form for Category One Compensation, Category Two Compensation or Medical Necessity Denial Compensation.

Physician Groups and Physician Organizations may file a Proof of Claim Form on behalf of Physicians employed by or otherwise working with them at the time the Proof of Claim Form is submitted, without the necessity of individual signatures from the individual Physicians.

You must indicate on the Proof of Claim Form whether you elect to receive your share of the Category A Settlement Fund or to direct that your share be contributed on your behalf to the not-for profit Foundation (described in more detail in the first mailed notice) or to a foundation established by any medical society that signed or joined the Settlement. A description of the Foundation and a list of the eligible medical society foundations may be found at this site as well as at www.hmosettlements.com, www.milbergweiss.com, www.kttlaw.com, and www.whatleydrake.com. If you do not make an election on the Proof of Claim Form, the payment will be made directly to you.

Proof of Claim Forms are available here and at www.hmosettlements.com, www.milbergweiss.com, www.kttlaw.com, and www.whatleydrake.com. You may also obtain these forms by calling the Settlement Administrator, toll-free, at 1-877-683-9363.

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21. If a Physician Group or Physician Organization wishes to submit claims for compensation from the Category A Settlement Fund on behalf of Physicians in the group or organization, can they submit one Category A Claim Form?

Yes, the Physician Group or Physician Organization can submit a single Category A Claim Form on behalf of Physicians employed by or otherwise working with them at the time the Category A Claim Form is submitted, without the necessity of obtaining individual signatures from the individual Physicians. A group or organization cannot file a claim for Category A compensation on behalf of its former members.

A list of the Physicians on whose behalf the Category A Claim Form is filed must accompany the filing. This list must include the group or organization's name and TIN, the Physicians' full names, and, if available, the Physicians' individual TINs or Social Security Numbers. In addition, the Category A Claim Form must include the group or organization's TIN rather than a Physician TIN.

The Category A payment will include one share of the Category A Settlement Fund for each Physician Class Member included in the filing. A single check representing all the Physicians' shares will be sent to the group or organization for the group TIN.

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22. If a Physician Group or Physician Organization wishes to file for Category A compensation on behalf of Physicians in the group or organization, can each Physician receive an individual payment to himself or herself?

Yes. If a Physician Group or Physician Organization wishes to file for Category A compensation on behalf of its members, and each individual within the group or organization is to receive a separate payment, a separate Category A Claim Form must be submitted on behalf of each Physician. The group or organization can sign on behalf of Physicians employed by or otherwise working with them at the time the Category A Claim Form is submitted, without the necessity of obtaining individual signatures from the individual Physicians. A group or organization cannot file claims for Category A compensation on behalf of former members.

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23. How will the payment be determined for a Category A claim?

At the end of the Claims Period, the Settlement Administrator will determine the total number of Valid Category A Proofs of Claim submitted:

  1. by or on behalf of retired and deceased Physicians; and
  2. by Physicians in active practice.

The total number of Valid Category A Proofs of Claim submitted by, or on behalf of, retired and deceased Physicians will be doubled to reflect the fact that each such individual will receive twice the share of the Category A Settlement Fund than each Physician in active practice. Retired and deceased Physicians will receive this doubled amount because they will not receive the benefit of the prospective relief provided by CIGNA HealthCare under the terms of the Settlement.

The Settlement Administrator will add the total number of Physicians in active practice submitting Valid Proofs of Claim to the doubled number of retired and deceased Physicians. The resulting number will be divided into Thirty Million Dollars ($30,000,000.00).

The result is the base amount to be distributed to each Class Member, with twice the base amount to be distributed to each retired Physician or estate of a deceased Physician.

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24. When will I receive payment from the Category A Settlement Fund?

All payments from the Category A Settlement Fund will be made approximately two weeks after the Claims Period has ended.

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THE CLAIM DISTRIBUTION FUND:

 

25. How do I submit a Proof of Claim Form for the Claim Distribution Fund?

If you do not choose to submit a claim under Category A and you previously submitted claims to CIGNA HealthCare that were denied or for which payment was reduced, you may seek compensation from the Claim Distribution Fund for certain of these claims. This Fund contains three categories: Category One Compensation, Category Two Compensation, and Medical Necessity Denial Compensation. There is no limit on the number of requests for payment from this Fund you may submit. All valid requests for payment supported by adequate documentation will be considered for payment regardless of the total number or amount of such requests. Any claim submitted to CIGNA HealthCare from August 4, 1990 through April 22, 2004 (except for Retained Claims, as described in Q&A 17 that was denied or reduced based on a Claim Coding or Bundling Edit or on Medical Necessity grounds and has been finally adjudicated may be submitted.

General Guidelines

These guidelines apply to all claims submitted to the Claim Distribution Fund. For those Class Members who maintain electronic data, please note the process described in the answer to Question 24 below, which may be utilized to ensure compliance with the requirements for submitting claims to the Settlement Administrator.

(1) Requests for payment must be made on the appropriate Proof of Claim Form. You may submit one or more of each such Proof of Claim Form, as long as the requests for payment submitted with any subsequent Proof of Claim are not duplicative of requests for payment included with a previously submitted Proof of Claim Form.

(2) All Proofs of Claim seeking payment from the Claim Distribution Fund must be sent (by U.S. Postal Service or overnight delivery) to the Settlement Administrator, Poorman-Douglas Corporation, at the following address:

CIGNA Physician Settlement
Settlement Administrator
P.O. Box 3170
Portland, OR 92708-3170

The postmark date or airbill date is critical to the Settlement Administrator's procedures.

(3) All Proofs of Claim, including all supporting documents, must be submitted to the Settlement Administrator in paper form or on a CD, diskette or DVD. If submitted on a CD, diskette or DVD, the documents must be formatted in .pdf or .tif files. No other media or file format will be accepted by the Settlement Administrator. Please be sure all documentation is legible. E-mail and faxes will not be accepted. If supporting documentation is required, do not send original documents, as they will not be returned to you. Do not send x-rays or any other type of film.

(4) You must include a separate cover sheet with the documentation supporting each individual request for payment submitted with that Proof of Claim Form. Each individual request for payment must relate to a single episode of care, although it may seek compensation for multiple CPT® Codes. The information required for each cover sheet depends on the category under which the claim is submitted (i.e., Category One, Category Two, or Medical Necessity) and the type of supporting documentation attached (i.e., HCFA 1500 or CMS 1500, Remittance Forms or accounting records).

Cover Sheets are attached to the Proof of Claim Forms and are available at Documents and at www.hmosettlements.com, www.milbergweiss.com, www.kttlaw.com, and www.whatleydrake.com. You may also obtain these forms by calling the Settlement Administrator, toll-free, at 1-877-683-9363.

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26. Can a Physician Group or Physician Organization submit claims to the Claim Distribution Fund (i.e., for Category One Compensation, Category Two Compensation, and/or Medical Necessity Denial Compensation) on behalf of its members?

Yes, Physician Groups and Physician Organizations can submit Proofs of Claim for compensation from the Claim Distribution Fund on behalf of Physicians employed by or otherwise working with them at the time the claims were originally submitted, without the necessity of individual signatures from the individual Physicians. However, the group or organization that submits a Proof of Claim Form for compensation from the Claim Distribution Fund must be the group or organization that originally submitted the claim, and must file using the same TIN that was used on the original claims.

Payments will be made based on the TIN under which each claim was originally filed. Thus, payment for eligible claims originally filed under a Physician TIN will be made to that Physician, and payments for eligible claims originally filed under a group or organization TIN will be made to that group or organization.

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27. What if I maintain electronic records?

For those Class Members who maintain electronic records containing the information that would otherwise be included in a HCFA 1500 or CMS 1500 form, plaintiffs' counsel have made available a process at no cost to assist you in meeting the requirements for submitting Proofs of Claim to the Claims Administrator. If your practice management software can generate a print image file, it may be submitted electronically to a web portal that is being operated by Infinedi LLC. Infinedi will then take the information provided by you and generate the appropriate HCFA 1500 or CMS 1500 required by the Settlement Administrator. Where supporting documentation other than a HCFA 1500 or CMS 1500 form is required, Infinedi will allow you to upload it to their web portal if it is first scanned into a .pdf file or a .tif file. Infinedi will then mail the claims to the Settlement Administrator along with any additional information submitted by you . Infinedi has no responsibility for determining whether the claims you submit meet the requirements of the Settlement or are eligible for payment. If you submit claims through this method, you still must complete the necessary forms and sign the certification. No claims will be submitted by Infinedi to the Settlement Administrator until you complete the certification. Full instructions on how to submit claims electronically using Infinedi may be found on the web at www.cignaeclaims.com.

Physicians or Physician Groups using Infinedi are responsible for complying with all requirements and deadlines for claims submissions. It is anticipated that claims must be submitted before February 8, 2005 in order to ensure that Infinedi can complete all necessary steps for the submission of claims, including Physician certification, prior to the close of the Claims Period. Please note that it is the Physician's responsibility to verify the accuracy of information submitted to Infinedi and to complete all necessary steps to enable Infinedi to submit the Physician's information to the Settlement Administrator. To avoid the possibility that your claim will be denied as untimely, you are encouraged to submit claims to Infinedi as soon as possible after August 23, 2004, the beginning of the Claims Period.

There are companies other than Infinedi that may seek to offer Class Members assistance with submitting claims to the Settlement Administrator. These third party vendors are not related to or endorsed by CIGNA HealthCare, plaintiffs' counsel or the Settlement Administrator, and are not involved in administering the Settlement. Class Members are responsible for ensuring that their submitted claims comply with the terms of the Settlement Agreement. Class Members will not be reimbursed for any charges incurred in connection with the retention or submission of claims by such third parties.

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THE CLAIM DISTRIBUTION FUND - CATEGORY ONE COMPENSATION:

 

28. Under what circumstances is Category One Compensation available?

Category One Compensation applies only to denials of or reductions in payments resulting from certain specific Claim Coding and Bundling Edits. The code combinations that qualify for Category One treatment are found on the Category One Code List, attached to the Agreement as Exhibit 1. The Category One Code List can be obtained at this site or by visiting www.hmosettlements.com, www.hmocrisis.com, www.milbergweiss.com, www.archielamb.com, www.kttlaw.com, and www.whatleydrake.com or by calling the Settlement Administrator, toll free, at 1-877-683-9363.

The following are not eligible for Category One Compensation: denials of or reductions in payment for Category One Codes resulting from the application of other payment and benefit limitations (e.g., coordination of benefit rules, violations of preauthorization requirements, violations of referral requirements, limitations stemming from capitation or other risk-bearing agreements with the Class Member submitting the claim or with other health care providers).

Physician Groups and Physician Organizations may file a Proof of Claim on behalf of Physicians employed by or otherwise working with them at the time that the claims were originally submitted without the necessity of individual signatures from the individual Physicians; provided, however, the Class Member that submits the Proof of Claim Form must be the Physician, Physician Group or Physician Organization that originally submitted the claim and must use the same tax identification number as was used on the original claim.

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28a. What does the Category One Code List show?

The Category One Code List shows the CPT code combinations for which claim coding or bundling edits were in place during specified dates of service. The code identified in the "Dropped Code" column was denied by CIGNA and went unpaid during the dates of service shown on the list, while the CPT code in the "Paid Code" column was paid when reported in combination with the "Dropped Code." Appropriately submitted Category One compensation requests will be eligible for the specified fee shown in the far right column of the list to compensate physicians for the denial in payment of the identified "Dropped Code" during the specified dates of service.

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29. What are the requirements for submitting a Valid Proof of Claim for Category One Compensation?

In order to receive Category One Compensation, you must submit a Proof of Claim Form for Category One Compensation. A single Category One Proof of Claim Form may be used to submit multiple requests for Category One Compensation, provided the required supporting documentation for each separate request for payment is included. Each individual request for payment must relate to a single episode of care, although it may seek compensation for multiple CPT® Codes. A separate cover sheet must precede each individual request for payment. If you are submitting a HCFA 1500, a CMS 1500 or a Remittance Form (i.e., Explanation of Payments Form) as supporting documentation, on each cover sheet, you must indicate the CPT® Code(s) for which you are seeking payment, the date of service and the provider TIN (or Social Security number, if a TIN is not available). If you are submitting accounting records, you must also include the subscriber Social Security number and the patient name. The cover sheet is attached to the Category One Proof of Claim Form, which can be found here and at www.hmosettlements.com, www.milbergweiss.com, www.kttlaw.com, and www.whatleydrake.com

Codes without an asterisk on the Category One Code List:

For those codes without an asterisk on the list of Category One Code combinations, each separate request for payment must include separate documentation showing that codes were submitted for one or more Category One Codes listed in the Category One Code List under the circumstances (i.e., in the specific combination) and within the date of service limitations (if any) listed in that table. Unless the Settlement Administrator determines that it is false or fraudulent, acceptable documentation includes:

  • A copy of your HCFA 1500 form or CMS 1500 form showing the Category One Codes that were originally submitted to CIGNA HealthCare for payment under the circumstances and within the date of service limitations (if any) specified in the Category One Code List; or
  • A copy of the relevant CIGNA HealthCare Remittance Form showing the Category One Codes that were submitted for payment under the circumstances and within the date of service limitations (if any) specified in the Category One Code List; or
  • If you certify that the CIGNA HealthCare Remittance Form and the HCFA 1500 or CMS 1500 form cannot be located and are not available for submission, you may submit copies of internal accounting records (such as a printout of accounts receivable records or paid account records) with the Proof of Claim Form, if those records show, for the underlying claim and specific date of service concerned, the Category One Codes that were originally submitted to CIGNA HealthCare for payment under the circumstances and within the date of service limitations (if any) specified in the Category One Code List.

Codes with an asterisk on the Category One Code List:

For those codes with an asterisk on the Category One Code List, each separate request for payment must include separate documentation showing both the relevant codes that were submitted and that payment was denied or reduced for one or more Category One Codes listed in the Category One Code List under the circumstances (i.e., in the specific combinations) and within the date of service limitations (if any) listed in that table. Unless the Settlement Administrator determines that it is false or fraudulent, acceptable documentation includes any combination of the following, so long as it demonstrates the relevant codes that were both submitted and denied or reduced:

  • A copy of the relevant CIGNA HealthCare Remittance Form;
  • A copy of your HCFA 1500 form or CMS 1500 form;
  • If you certify that the CIGNA HealthCare Remittance Form and the HCFA 1500 or CMS 1500 form cannot be located and are not available for submission, or if those documents are insufficient to establish that the Category One Codes were submitted and denied or reduced, you may submit copies of internal accounting records (such as a printout of accounts receivable records or paid account records) with the Proof of Claim Form, if those records show, for the underlying claim and specific date of service concerned, the Category One Codes that were originally submitted to CIGNA HealthCare for payment under the circumstances and within the date of service limitations (if any) specified in the Category One Code List, and that payment was denied as submitted.

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30. What happens if documentation for a request for Category One Compensation is inadequate?

If the Settlement Administrator determines that any individual request for Category One Compensation does not include adequate documentation, it will notify you by mail that the request for payment has been rejected, and identify the reason(s) for the rejection. (The Settlement Administrator will process all other separate requests for payment submitted with the same Proof of Claim Form that are supported by adequate documentation.)

You will have the right to resubmit any rejected requests for payment in an effort to correct the deficiencies noted by the Settlement Administrator, provided that your resubmission is sent to the Settlement Administrator no later than thirty (30) calendar days from the date on which the Settlement Administrator's notice of the deficiencies was postmarked.

If the Settlement Administrator still concludes that the documentation is inadequate, then that request for payment will be denied. The Settlement Administrator will mail notification of this final determination to you.

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31. What happens if a request for Category One Compensation is invalid?

If the Settlement Administrator determines that any request for Category One Compensation is not valid either because you were seeking compensation for codes not on the Category One Code List, or because you are seeking compensation for services that were provided outside the circumstances and/or date of service limitations specified in the Category One Code List, the notification of denial will explain this. (The Settlement Administrator will process all other separate requests for payment submitted with the same Proof of Claim Form that are determined to be valid.)

You may be eligible for Category Two Compensation and the Settlement Administrator will indicate that you may submit a Category Two Proof of Claim Form regarding that request for payment within thirty (30) calendar days from the date the notification of denial was postmarked. If the Settlement Administrator already has adequate documentation to process that request for payment as a Category Two Proof of Claim), the Settlement Administrator will automatically process the request as such.

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32. How do I correctly certify a Proof of Claim for Category One Compensation?

No Proof of Claim Form for Category One Compensation will be accepted by the Settlement Administrator for processing unless you sign (or digitally sign, for those claims submitted through Infinedi) the certification indicating that:

  • the Category One Code(s) for which you are requesting payment describe services that were actually provided to a CIGNA HealthCare Member; and
  • the additional payment requested has not already been made by CIGNA HealthCare on resubmission of the claim or on an appeal; and
  • the claim to which the request relates has not been finally adjudicated and determined in a court of law or in an arbitrable forum, or resolved by a final and binding settlement.

If you submit internal accounting records in support of a Category One Proof of Claim, you must also certify that the CIGNA HealthCare Remittance Form and the claim form originally submitted to CIGNA HealthCare cannot be located and are not available for submission.

If you billed the CIGNA HealthCare Member to whom services or supplies were provided for the amount not originally paid by CIGNA HealthCare, and if the CIGNA HealthCare Member reimbursed you for such amount, it is expected that you will reimburse the CIGNA HealthCare Member by the amount you are compensated as a result of this Settlement.

By submitting a Proof of Claim, you are agreeing to be subject to the jurisdiction of the United States District Court for the Southern District of Florida for any proceedings relating to that Proof of Claim.

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33. What is the timeline for decisions on a Category One request for compensation?

The Settlement Administrator will use its best efforts to determine the validity of requests for payment for Category One Compensation within thirty (30) days of their submission, and will make payments in the amount listed in the Category One Code List within fourteen (14) calendar days of determining that a request is a Valid Proof of Claim. Individual requests for payment seeking more than $100 are subject to review by CIGNA HealthCare, which will have thirty (30) calendar days from the date the Settlement Administrator provides the request for payment to CIGNA HealthCare to object to the payment. However, if the Settlement Administrator approves a request after consideration of an objection by CIGNA HealthCare, such approval is final.

If the Settlement Administrator denies a request for Category One Compensation, the Settlement Administrator will notify you by mail of this rejection, and identify the reason(s) for rejection. You will have the right to seek reconsideration, provided that the request for reconsideration is sent to the Settlement Administrator within thirty (30) calendar days of the date on which the Settlement Administrator's notification of its denial decision was postmarked.

Upon reconsideration, if the Settlement Administrator upholds its denial, the Settlement Administrator will notify you of the denial and of the reasons for denial. An adverse decision by the Settlement Administrator upon reconsideration is final and is not subject to further reconsideration by the Settlement Administrator, the Court or any other form of review.

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THE CLAIM DISTRIBUTION FUND - CATEGORY TWO COMPENSATION:

 

34. Under what circumstances is Category Two Compensation available?

Category Two Compensation may be sought for all denials of or reductions in payment with respect to claims submitted to CIGNA HealthCare resulting from the application of Claim Coding and Bundling Edits other than those for which Category One Compensation applies. If Category One Compensation applies, it is the exclusive remedy.

The following are not eligible for Category Two Compensation: denials of or reductions in payment for CPT® Codes or HCPCS Level II Codes resulting from the application of payment and benefit limitations other than Claim Coding and Bundling Edits (e.g., coordination of benefit rules, violations of preauthorization requirements, violations of referral requirements, limitations stemming from capitation or other risk-bearing agreements with the Class Member submitting the Proof of Claim or with other health care providers).

Physician Groups and Physician Organizations may file a Proof of Claim on behalf of Physicians employed by or otherwise working with them at the time that the original claims were submitted, without the necessity of individual signatures from the individual Physicians; provided, however, that the Class Member that submits the Proof of Claim Form must be the Physician, Physician Group or Physician Organization that originally submitted the claim and must use the same tax identification number as was used on the original claim when submitting the Proof of Claim.

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35. What is the Facilitation List and where can I obtain it?

In order to assist you in identifying claims which are eligible for Category Two Compensation, CIGNA HealthCare has used its best efforts to create an electronic Facilitation List. The Facilitation List is specific to each individual Class Member and includes the following types of claims:

  1. claims for which CIGNA HealthCare denied payment for CPT® Codes 99201-99499 (CPT® Evaluation and Management Codes) due to the application of Claim Coding and Bundling Edits;
  2. claims in which CIGNA HealthCare made payment on the basis of code 90769 (CIGNA HealthCare's "well woman" benefit code);
  3. claims in which Evaluation and Management Codes were billed with a procedure code and either code was denied payment; and
  4. claims in which Evaluation and Management Codes were billed with add-on codes, and either code was denied payment.

Please note that, depending on the nature of the claims involved, the Facilitation List is limited as to the time period covered, claim systems from which payment was made and the level of detail that can be provided. The Facilitation List may therefore not include all claims in these categories that may be eligible for Category Two Compensation. You may submit requests for payment relating to claims that do not appear on the Facilitation List. The Facilitation List may also include claims that are not eligible for Category Two Compensation.

You may request the Facilitation List specifically related to your potential claims at Contact Us or call the Settlement Administrator toll-free at 1-877-683-9363.

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36. What are the requirements for submitting a Valid Proof of Claim for Category Two Compensation?

In order to receive Category Two Compensation, you must submit a Category Two Proof of Claim Form. A single Proof of Claim Form may be used to submit multiple requests for Category Two Compensation, provided the required supporting documentation for each separate request for payment is included. Each individual request for payment must relate to a single episode of care, although it may seek compensation for multiple CPT® Codes. A separate cover sheet must precede each individual request for payment. On each cover sheet, you must indicate the CPT® Code(s) for which you are seeking payment, the subscriber Social Security number, the patient name, the date of service, and the provider TIN (or Social Security number, if the TIN is not available). The cover sheet is attached to the Category Two Proof of Claim Form, which can be found at Documents and at www.hmosettlements.com, www.milbergweiss.com, www.kttlaw.com, and www.whatleydrake.com

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37. What documentation do I need to submit with a request for Category Two Compensation?

Proof of Claim Forms for Category Two Compensation must include the following with each separate request for payment:

  1. documentation evidencing that, for the underlying claim concerned,

    1. you were denied payment, in whole or in part; or
    2. you received reduced payment, including payment for a different billing code than the one(s) billed, for one or more CPT® Code(s) or HCPCS Level II Code(s); or
    3. you received a reduced payment based upon the application of Multiple Procedure Logic; and
  2. a complete copy of the Clinical Information (including but not limited to clinical notes and/or operative reports as appropriate) generated in connection with your services on the specific date of service concerned (except for those specific types of claims described in Q&A 38).

For purposes of the requirement described in (a) above, a copy of the relevant CIGNA HealthCare Remittance Form (i.e., Explanation of Payments Form) showing that payment was denied as submitted on the CPT® Codes or HCPCS Level II Codes in question, in whole or in part, will be adequate documentation unless the Settlement Administrator determines that the records are false or fraudulent.

In the event that you cannot locate the CIGNA HealthCare Remittance Form applicable to a given claim, you may submit copies of internal accounting records (such as printouts of accounts receivable records or paid account records) if those records show for the underlying claim and specific date of service concerned, all CPT® Codes or HCPCS Level II Codes that were submitted to CIGNA HealthCare for payment and those that remain unpaid, in whole or in part.

If your internal accounting records do not show all CPT® Codes or HCPCS Level II Codes that were submitted to CIGNA HealthCare for payment on the claim in question, then you may supplement the internal accounting records with additional documentation for that claim, such as the HCFA 1500 form or CMS 1500 form.

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38. What are the exceptions to the Clinical Information documentation requirement?

There are two exceptions to the requirement that clinical notes, operative reports or other Clinical Information be submitted with a Category Two request for payment:

(1). The requirement does not apply to requests for payment based on claims that:

  1. CIGNA HealthCare failed to recognize modifiers 50, RT, LT, FA-F9, or TA-T9, and thus denied payment for one or more CPT® Codes as duplicative of other CPT® Codes reported; and/or
  2. HCPCS Level II "J" Code was translated into an incorrect or overbroad CPT® Code and payment was denied based on that incorrect translation.

For claims of this type, you only need to submit:

  • a copy of the HCFA 1500 or CMS 1500 form used to submit the original claim to CIGNA HealthCare showing the precise manner in which all services or supplies included in the claim were originally billed to CIGNA HealthCare; and
  • documentation showing that payment was denied, in whole or in part, for the CPT® Codes or HCPCS Level II Codes concerned (such as a copy of the relevant CIGNA HealthCare Remittance Form or your internal accounting records).

If you are unable to show, through the above documentation, how the services or supplies were originally billed to CIGNA HealthCare (inclusive of the modifiers submitted with each CPT® Code or HCPCS Level II Code billed), then you may not submit the request for payment under these special documentation exceptions, but instead must submit the request for payment with the Clinical Information documentation described above.

(2). The requirement that clinical notes, operative reports or other Clinical Information be submitted also does not apply to requests for payment based on the contention that CIGNA HealthCare incorrectly processed one or more modifier 51 exempt CPT® Codes and/or add-on CPT® Codes using CIGNA HealthCare's Multiple Procedure Logic when those codes were exempt from multiple procedure reduction. However, for these claims, you must submit a copy of the documentation showing that payment was denied, in whole or in part, for the CPT® Codes concerned. Such documentation may include a copy of the relevant CIGNA HealthCare Remittance Form or your internal accounting records.

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39. Is there a list of modifier 51 exempt and add-on codes for which CIGNA HealthCare may have systematically applied Multiple Procedure Logic during the Class Period?

For the purpose of assisting Class Members in identifying certain claims eligible for Category Two Compensation, CIGNA HealthCare agreed in the Settlement to use reasonable efforts to determine whether it could compile a list of those modifier 51 exempt codes and add-on codes for which it may have systematically applied Multiple Procedure Logic during the Class Period. After investigating the feasibility of creating such a list, CIGNA HealthCare determined that it would not be possible without extraordinary effort to compile a list of the codes and the time periods in which Multiple Procedure Logic was systematically applied to individual modifier 51 exempt codes and add-on codes.

Because of the possibility that Multiple Procedure Logic was applied to modifier 51 exempt codes and add-on codes for some portion of the Class Period (depending on when the codes became listed as modifier 51 exempt or add-on, the CIGNA HealthCare system on which the claims were processed, and other factors), CIGNA HealthCare has provided below the current list of all modifier 51 exempt codes and add-on codes. Because this list includes only those codes currently classified as modifier 51 exempt or add-on, it may not include all modifier 51 exempt or add-on codes as to which reimbursement is available on the basis of CIGNA HealthCare's application of Multiple Procedure Logic.

To obtain reimbursement for reductions of modifier 51 exempt and add-on codes as a result of the application of Multiple Procedure Logic, you must meet the documentary requirements set forth on the Category Two Proof of Claim Form and in Q&A 36.

[CODE LIST]

 

40. When will the Settlement Administrator make a decision regarding the adequacy of documentation?

The Settlement Administrator will use its best efforts to determine the adequacy of the documentation accompanying each request for Category Two Compensation within fourteen (14) calendar days of the date of receipt by the Settlement Administrator.

If the Settlement Administrator determines that any individual request for Category Two Compensation does not include adequate documentation, it will notify you by mail that the request for payment has been rejected, and identify the reason(s) for the rejection. (The Settlement Administrator will process all other separate requests for payment submitted with the same Proof of Claim Form that are supported by adequate documentation.)

You will have the right to resubmit any rejected requests for payment in an effort to correct the deficiencies noted by the Settlement Administrator, provided that your resubmission is sent to the Settlement Administrator no later than thirty (30) calendar days from the date on which the Settlement Administrator's notice of the deficiencies was postmarked.

If the Settlement Administrator still concludes that the documentation is inadequate, then that request for payment will be denied. The Settlement Administrator will mail notification of this final determination to you.

If the Settlement Administrator determines that a request for payment submitted under Category Two should have been submitted under another category, and the Settlement Administrator has adequate documentation to process the request for payment in the proper category, the Settlement Administrator will automatically do so.

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41. How do I correctly certify a Proof of Claim for Category Two Compensation?

No Proof of Claim Form for Category Two Compensation will be accepted by the Settlement Administrator for processing unless you sign the certification (or digitally sign, for those claims submitted through Infinedi) indicating that:

  1. the CPT® Code(s) or HCPCS Level II Code(s) for which you are requesting payment (or additional payment) describe services or supplies that were actually provided to a CIGNA HealthCare Member;
  2. the additional payment requested has not already been made by CIGNA HealthCare on resubmission of the claim or on an appeal; and
  3. the claim to which the request for payment relates has not been finally adjudicated and determined in a court of law or in an arbitrable forum, or resolved by a final and binding settlement.

If you billed the CIGNA HealthCare Member to whom services or supplies were provided for the amount not originally paid by CIGNA HealthCare, and if the CIGNA HealthCare Member reimbursed you for such amount, it is expected that you will reimburse the CIGNA HealthCare Member by the amount you are compensated as a result of this Settlement.

If you submit internal accounting records in support of a Category Two Proof of Claim, you must also certify that the CIGNA HealthCare Remittance Form and the claim form originally submitted to CIGNA HealthCare cannot be located and are not available for submission.

By submitting a Proof of Claim, you are agreeing to be subject to the jurisdiction of the United States District Court for the Southern District of Florida for any proceedings relating to that Proof of Claim.

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42. What is the timeline for decisions on a Category Two request for payment?

Upon determining that you have made a timely Proof of Claim for Category Two Compensation, that the Proof of Claim Form contains all required information and documentation and that you have properly certified the Proof of Claim, the Settlement Administrator will forward the individual requests for payment to CIGNA HealthCare for processing within fourteen (14) calendar days of receipt by the Settlement Administrator.

CIGNA HealthCare will have thirty (30) calendar days from the date that the Settlement Administrator transmits a request for payment to CIGNA HealthCare to make a determination whether to approve or deny, in whole or in part, the request for payment and to notify the Settlement Administrator of that determination.

If CIGNA HealthCare approves (or fails to deny within thirty (30) calendar days) a Category Two request for payment, the request for payment will be deemed a Valid Proof of Claim, and payment will be mailed to you.

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43. How are denials of Category Two requests for payment handled?

If CIGNA HealthCare denies a Category Two request for payment based on CIGNA HealthCare's determination that the original decision to reduce or deny payment was an appropriate application of Claim Coding and Bundling Edits, that request for payment will automatically be forwarded to an Independent Review Entity to determine the appropriateness of CIGNA HealthCare's decision. The parties have agreed that Millennium Healthcare Consulting, Inc. will serve as the Independent Review Entity.

If the denial is based on any other determination (e.g., that the claim to which the Proof of Claim relates is a Resolved Claim, that the individual to whom the services or supplies were provided was not a CIGNA HealthCare Member at the time, etc.), the denied request will be subject to automatic review by the Settlement Administrator.

In either case, CIGNA HealthCare will be responsible for creating a review file and transmitting that file to the Settlement Administrator within thirty (30) calendar days of its denial. The Settlement Administrator will provide you with a copy of that file.

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44. What is the timing of External Review decisions?

The Settlement Administrator or the Independent Review Entity, as appropriate, will use its best efforts to complete External Review within thirty (30) calendar days of receiving the review file. If the Settlement Administrator or the Independent Review Entity overturns CIGNA HealthCare's decision, payment will be mailed to you.

If CIGNA HealthCare's decision is upheld, you will be notified by mail of the denial and of the reason(s) for the denial. Decisions of the Settlement Administrator and Independent Review Entity are final and are not subject to review by the Court or any other court or tribunal. No requests for reconsideration are permitted.

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45. How are claims handled that were originally submitted to CIGNA HealthCare on or after August 24, 2003?

Any payment for claims relating to services or supplies delivered to a CIGNA HealthCare Member on or after August 24, 2003 will be made at the CIGNA HealthCare Member's benefit amount (i.e., the applicable fee schedule amount or reasonable and customary charge less the CIGNA HealthCare Member's required coinsurance payments, copayments, and deductible contributions, if applicable). You will be free to collect any applicable coinsurance payments, copayments, and deductible contributions directly from the CIGNA HealthCare Member to whom the services were provided. Please note that because these payments will be "bulked" with other claim payments, you will not receive documentation informing you that compensation for settlement claims is included; instead, you will receive the documentation normally received in the ordinary course of business. You will, however, receive a letter from the Settlement Administrator notifying you that payment has been approved and will be paid directly from CIGNA HealthCare.

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46. How are claims handled that were originally submitted to CIGNA HealthCare on or before August 23, 2003

Any payments made for claims relating to services or supplies delivered to a CIGNA HealthCare Member on or before August 23, 2003 will be made from the Claim Distribution Fund by the Settlement Administrator on the basis of the National Medicare Fee Schedule in effect on June 1, 2001, without any deductions for the CIGNA HealthCare Member's coinsurance payments, copayments, and deductible contributions. You may not seek further compensation from the CIGNA HealthCare Member or the CIGNA HealthCare Member's employer or employer plan.

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CLAIM DISTRIBUTION FUND - MEDICAL NECESSITY DENIAL COMPENSATION:

47. Under what circumstances is Medical Necessity Denial Compensation available?

Medical Necessity Denial Compensation may be sought for claims that you believe were improperly denied as not Medically Necessary or as experimental or investigational. Upon the submission of timely and proper Proof of Claim Forms and all other required documentation, CIGNA HealthCare will reconsider and, where appropriate, make or fund additional payments to Class Members for claims that were submitted to CIGNA HealthCare and denied, in whole or in part, on the grounds that the services or supplies were either experimental or investigational or not Medically Necessary.

Medical Necessity Denial Compensation will be available under this Agreement only for denials of payment based on CIGNA HealthCare's judgment that the services or supplies were either experimental or investigational or were not Medically Necessary.

The following are not eligible for Medical Necessity Denial Compensation: denials of or reductions in payment for CPT® Codes or HCPCS Level II Codes resulting from the application of other payment and benefit limitations (e.g., coordination of benefit rules, violations of preauthorization requirements, violations of referral requirements, and limitations stemming from capitation or other risk-bearing agreements with the Class Member submitting the Proof of Claim or with other health care providers). In addition, no Medical Necessity Denial Compensation is available where the services or supplies were excluded from coverage (other than under a general exclusion for cosmetic services or supplies) under the CIGNA HealthCare Member's Plan Documents.

Physician Groups and Physician Organizations may submit Proofs of Claim on behalf of Physicians employed by or otherwise working with them at the time that the original claim was submitted, without the necessity of individual signatures from the individual Physicians; provided, however, that the Class Member that submits the Proof of Claim Form must be the Physician, Physician Group or Physician Organization that originally submitted the claim and must use the same tax identification number as was used on the original claim when submitting the Proof of Claim.

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48. What documentation do I need to submit with a Proof of Claim for Medical Necessity Denial Compensation?

In order to receive Medical Necessity Denial Compensation, you must submit a Proof of Claim Form for Medical Necessity Denial Compensation. A single Proof of Claim Form may be used to submit multiple requests for Medical Necessity Denial Compensation, provided the required supporting documentation for each separate request for payment is included. Each individual request for payment must relate to a single episode of care, although it may seek compensation for multiple CPT® Codes. A separate cover sheet must precede each individual request for payment. On each cover sheet, you must indicate the CPT® code(s) for which you are seeking payment, the subscriber Social Security number, the patient name, the date of service, and the provider TIN (or Social Security number, if a TIN is not available). The cover sheet is attached to the Proof of Claim Form for Medical Necessity Denial Compensation, which can be found here and at www.hmosettlements.com, www.milbergweiss.com, www.kttlaw.com, and www.whatleydrake.com.

Proof of Claim Forms for Medical Necessity Denial Compensation must include with each separate request for payment:

  1. documentation showing that you submitted claims for payment to CIGNA HealthCare for services or supplies provided to a CIGNA HealthCare Member, and thereafter payment was denied for one or more CPT® Codes or HCPCS Level II Codes due to CIGNA HealthCare's determination that the medical services, procedures or supplies corresponding to such codes were either not Medically Necessary or were experimental or investigational; and
  2. a complete copy of the Clinical Information generated in connection with your services. You are not required to submit Clinical Information that relates to dates of service occurring more than ninety (90) calendar days before the date of service at issue.

For purposes of requirement (a) above, a copy of the relevant CIGNA HealthCare Remittance Form (i.e., Explanation of Payments Form) showing that payment was denied for one or more CPT® Codes or HCPCS Level II Codes will constitute adequate documentation unless the Settlement Administrator determines that the records are false or fraudulent. If you cannot locate the CIGNA HealthCare Remittance Form applicable to a given claim, you may submit copies of internal accounting records (such as printouts of accounts receivable records or paid account records) if those records show that the CPT® Codes or HCPCS Level II Codes in question were submitted to CIGNA HealthCare for payment and remain unpaid.

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49. How do I request information about the types of required Clinical Information?

To assist you in determining what types of Clinical Information to include with your Medical Necessity Denial Proofs of Claim, CIGNA HealthCare has provided the Settlement Administrator with information about the types of Clinical Information, by billing code, that CIGNA HealthCare has traditionally required to be submitted for review in order to make Medical Necessity determinations. This information is available to you from the Settlement Administrator within fourteen (14) calendar days after you request it. It may also be found at Clinical Documentation.

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50. What procedures should be followed for Proofs of Claim for Medical Necessity Denial Compensation?

Except for the documentation requirements described above, the procedures for submitting and processing a Proof of Claim Form for Medical Necessity Denial Compensation are identical to the procedures for submitting and processing a Proof of Claim Form for Category Two Compensation. The parties have agreed that Hayes Plus, Inc. will serve as the Independent Review Entity for denials of requests for Medical Necessity Denial Compensation.

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