Cigna Policy Change Requires Documentation for Certain Services

As the health care industry focuses increasingly on quality care, requests for supporting documentation to substantiate care are on the rise. In late April, CIGNA began requiring documentation be submitted when certain services are reported with modifiers appended.

The AMA opposed the initial extensive list of codes this was required for and subsequently, a shorter list was generated. This list of procedures requiring documentation is accessible on the secure CIGNA for Health Care Professionals Web site. To access the list, click on "Resources" then "Claim Editing Procedures" once you have logged in.

Pursuant to the implementation of Cigna's policy, most providers will be affected by the requirement to provide documentation when an evaluation and management code is reported with the -25 modifier appended. It is important to note that CIGNA's policy applies to all provider types.

Additionally, CIGNA specifically indicates that its policy does not supersede state regulations. Some states currently have regulations governing burdensome paperwork and requirements placed on providers during the claims process. For example, the New York regulation S4905(g) governs burdensome paperwork requests by insurers and indicates:

"When making prospective, concurrent and retrospective determinations, utilization review agents shall collect only such information as is necessary to make such determination and shall not routinely require health care providers to numerically code diagnoses or procedures to be considered for certification or routinely request copies of medical records of all patients reviewed. During prospective or concurrent review, copies of medical records shall only be required when necessary to verify that the health care services subject to such review are medically necessary. In such cases, only the necessary or relevant sections of the medical record shall be required. A utilization review agent may request copies of partial or complete medical records retrospectively."

It is important for providers to be aware of any state regulations governing the claims review process to determine if any insurer's requests for information violate state regulations.

If you have already begun submitting claims to CIGNA with documentation in accordance with the new policy and you have questions or have experienced any problems in submitting claims or documentation, please contact the American Chiropractic Association's Insurance Relations Department for assistance.

Source: American Chiropractic Association