Cigna utilization management review and preauthorization concerns addressed

The AASM has heard from members around the country experiencing issues related to utilization management review and preauthorization for diagnostic sleep testing, including the credentialing and appeals processes. Leadership and staff are taking action on your behalf and working with carriers to ensure their processes are centered on quality care for our patients.

The AASM has been in contact with Cigna as well as CareCentrix, the utilization management company it contracts with, regarding issues communicated by members to the national office. This dialogue has been productive, and the AASM appreciates the efforts of Cigna and CareCentrix to respond to these concerns. Following are summaries of issues raised by AASM members with the response of CareCentrix. We hope this provides clarification as you continue to navigate the preauthorization and appeal processes.

Concerns Related to Credentialing
Cigna credentials providers of OCST for their covered lives. However, the AASM has heard from members that there are sometimes barriers in this process, specifically with sleep providers adding OCST services to their existing contracts. According to CareCentrix, Cigna has provided direction to CareCentrix to allow any contracted diagnostic provider to be deemed an appropriate OCST provider, therefore, allowing for the approval of services to this rendering provider. Tom Gaffney, the President of the Sleep Division at CareCentrix advises members to contact the CareCentrix Network Management team at (888) 497-5337 extension 181130 to ensure their issues regarding credentialing are handled appropriately.

Concerns Related to Maintenance of Preauthorization Approvals and Documentation
Some of our members have reported issues related to preauthorization documentation, specifically approval for a diagnostic test for a patient followed by payment denial for the same patient. CareCentrix strongly encourages providers to use the Cigna Sleep Website, which is a dedicated portal for the sleep management program. Utilization of this website is the most efficient way to request services and check authorization status. Further, it’s the standard operating procedure of CareCentrix to maintain an authorization history for a minimum of 12 months. CareCentrix advises members to contact the CareCentrix Network Management team at (888) 497-5337 extension 181130 with independent examples for further clarification and assistance.

Concerns Related to Time Spent During Appeal Process
AASM members have reported excessive wait times when calling for a peer-to-peer review of a denial for a sleep study. CareCentrix has outlined the review and appeal process as follows: When CareCentrix is not able to approve a sleep study, the ordering physician will receive a faxed courtesy notification of denial on the day of the decision, which includes an offer of a peer-to-peer conversation between the ordering physician and the Medical Director who made the denial decision. If the ordering physician disagrees with the denial decision, he/she may call and request to speak to the Medical Director. CareCentrix staff will arrange a phone appointment between the ordering doctor and the Medical Director within one day of receiving the request, during which the ordering doctor may present new information not considered in the denial decision. If the medical director is not available, a comparable peer medical director may be scheduled for the conversation. Appeals are handled by Cigna, and those are frequently handled in writing if the denied service is not medically urgent. Members are encouraged to refer to Cigna’s policies on appealing denial decisions.

The AASM is committed to assisting members navigate the utilization management and preauthorization processes and will continue to provide information and updates to members.

2013-07-09T00:00:00+00:00 July 9th, 2013|Clinical Resources|