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Loudoun County School Board
ANNUAL COMPLIANCE RIDER
EFFECTIVE DATE: January 1, 2017
ACASOM17
3320020
This document printed in December, 2016 takes the place of any documents previously issued to you which
described your benefits.
Printed in U.S.A.
Home Office: Bloomfield, Connecticut
Mailing Address: Hartford, Connecticut 06152
CIGNA HEALTH AND LIFE INSURANCE COMPANY, a Cigna company (hereinafter
called Cigna)
ANNUAL COMPLIANCE RIDER
No. ACASOM17
Policyholder: Loudoun County School Board
Rider Eligibility: Each Employee
Policy No. or Nos. 3320020-OAP2, NETPS
EFFECTIVE DATE: January 1, 2017
You will become insured on the date you become eligible, if you are in Active Service on that date, or if
you are not in Active Service on that date due to your health status. If you are not insured for the benefits
described in your certificate on that date, the effective date of this annual compliance rider will be the date
you become insured.
This Annual Compliance Rider forms a part of the certificate issued to you by Cigna describing the
benefits provided under the policy(ies) specified above.
This Annual Compliance Rider replaces any other Annual Compliance Rider issued to you on a prior date.
The provisions set forth in this Annual Compliance Rider comply with legislative requirements regarding
group insurance plans covering insureds. These provisions supersede any provisions in your certificate to
the contrary unless the provisions in your certificate result in greater benefits.
READ THE FOLLOWING
NOTE: The provisions identified in this rider are specifically applicable ONLY for:
Benefit plans which have been made available by your Employer to you and/or your Dependents;
Benefit plans for which you and/or your Dependents are eligible;
Benefit plans which you have elected for you and/or your Dependents;
Benefit plans which are currently effective for you and/or your Dependents.
HC-RDR1 04-10
V1 AC
myCigna.com 4
Important Notices
Important Information
Mental Health Parity and Addiction Equity Act
The page regarding “Mental Health Parity and Addiction
Equity Act” found on the Important Information section in
your medical certificate is hereby NULL and VOID.
HC-NOT69 12-14
AC
The following Notice page concerning Discrimination is
Against the Law is added to your medical certificate
Discrimination is Against the Law
Cigna, in its role as benefits administrator, complies with
applicable Federal civil rights laws and does not discriminate
on the basis of race, color, national origin, age, disability or
sex. Cigna does not exclude people or treat them differently
because of race, color, national origin, age, disability or sex.
Cigna:
Provides free aids and services to people with disabilities to
communicate effectively with Cigna, such as qualified sign
language interpreters and written information in other
formats (large print, audio, accessible electronic formats,
other formats).
Provides free language services to people whose primary
language is not English, such as qualified interpreters and
information written in other languages.
If you need these services, contact Customer Service/Member
Services at the toll-free phone number shown on your ID card,
and ask an associate for assistance.
If you believe that Cigna has failed to provide these services
or discriminated in another way on the basis of race, color,
national origin, age, disability or sex, you can file a grievance
by sending an email to [email protected] or by
writing to the following address: Cigna, Nondiscrimination
Complaint Coordinator, P.O. Box 188016, Chattanooga, TN
37422.
If you need assistance filing a written grievance, please call
the toll-free phone shown on your ID card or send an email to
You can also file a civil rights complaint with the U.S.
Department of Health and Human Services, Office for Civil
Rights electronically through the Office for Civil Rights
Complaint Portal, available at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail at:
U.S. Department of Health and Human Services, 200
Independence Avenue, SW, Room 509F, HHH Building,
Washington, D.C. 20201; or by phone at 1-800-368-1019,
800-537-7697 (TDD).
Complaint forms are available at
http://www.hhs.gov/ocr/office/file/index.html.
HC-NOT76 10-16
AC
The following Notice page concerning Proficiency of
Language Assistance Services is added to your medical
certificate:
Proficiency of Language Assistance Services
ATTENTION: Language assistance services, free of charge,
are available to you. For current Cigna customers, call the
number on the back of your ID card. Otherwise, call 1-800-
244-6224 (TTY: Dial 711).
Spanish
ATENCIÓN: tiene a su disposición servicios gratuitos de
asistencia lingüística. Si es un cliente actual de Cigna, llame al
número que figura en el reverso de su tarjeta de identificación.
Si no lo es, llame al 1-800-244-6224 (los usuarios de TTY
deben llamar al 711).
Chinese
注意:我們可為您免費提供語言協助服務。對於 Cigna
的現有客戶,請致電您的 ID
卡背面的號碼。其他客戶請致電 1-800-244-6224
(聽障專線:請撥 711)。
Vietnamese
CHÚ Ý: Có dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Dành cho khách hàng hiện tại của Cigna, gọi số ở mặt sau thẻ Hội viên. Các trường hợp khác xin gọi số 1-800-244-6224 (TTY: Quay số 711).
Korean
주의: 언어 지원 서비스를 비용없이 이용하실 수
있습니다. 기존 Cigna 가입자의 경우, 가입자 ID 카드
뒷면에 있는 전화번호로 연락해 주십시오. 아니면 1-800-
244-6224번으로 연락해 주십시오(TTY: 711번으로 전화).
Tagalog
PAUNAWA: Makakakuha ka ng mga serbisyo sa tulong sa
wika nang libre. Para sa mga kasalukuyang customer ng
Cigna, tawagan ang numero sa likuran ng iyong ID card. O
kaya, tumawag sa 1-800-244-6224 (TTY: I-dial ang 711).
myCigna.com 5
Russian
ВНИМАНИЕ: вам могут предоставить бесплатные
услуги перевода. Если вы уже участвуете в плане Cigna,
позвоните по номеру, указанному на обратной стороне
вашей идентификационной карточки участника плана.
Если вы не являетесь участником одного из наших
планов, позвоните по номеру 1-800-244-6224 (TTY: 711).
Arabic
Cignaلعمالء م.خدمات الترجمة المجانية متاحة لك برجاء االنتباة
برجاء االتصال بالرقم المدون علي ظهر بطاقتكم الحاليين
(.177: اتصل ب TTY) 6224-244-800-1او اتصل بالشخصية.
French Creole
ATANSYON: Gen sèvis èd nan lang ki disponib gratis pou
ou. Pou kliyan Cigna yo, rele nimewo ki dèyè kat ID ou.
Sinon, rele nimewo 1-800-244-6224 (TTY: Rele 711).
French
ATTENTION: des services d’aide linguistique vous sont
proposés gratuitement. Si vous êtes un client actuel de Cigna,
veuillez appeler le numéro indiqué au verso de votre carte
d’identité. Sinon, veuillez appeler le numéro 1-800-244-6224
(ATS: composez le numéro 711).
Portuguese
ATENÇÃO: Tem ao seu dispor serviços de assistência
linguística, totalmente gratuitos. Para clientes Cigna atuais,
ligue para o número que se encontra no verso do seu cartão de
identificação. Caso contrário, ligue para 1-800-244-6224
(Dispositivos TTY: marque 711).
Polish
UWAGA: W celu skorzystania z dostępnej, bezpłatnej
pomocy językowej, obecni klienci firmy Cigna mogą dzwonić
pod numer podany na odwrocie karty identyfikacyjnej.
Wszystkie inne osoby prosimy o skorzystanie z numeru 1-
800-244-6224 (TTY: wybierz 711).
Japanese
お知らせ:無料の日本語サポートサービスをご利用いた
だけます。現在のCignaのお客様は、IDカード裏面の電
話番号におかけ下さい。その他の方は、1-800-244-
6224におかけください。(文字電話: 番号711)。
Italian
ATTENZIONE: sono disponibili servizi di assistenza
linguistica gratuiti. Per i clientI Cigna attuali, chiamare il
numero sul retro della tessera ID. In caso contrario, chiamare
il numero 1-800-244-6224 (utenti TTY: chiamare il numero
711).
German
Achtung: Die Leistungen der Sprachunterstützung stehen
Ihnen kostenlos zur Verfügung. Für gegenwärtige Cigna-
Kunden, Bitte rufen Sie die Nummer auf der Rückseite Ihres
Personalausweises. Sonst, rufen Sie 1-800-244-6224 (TTY:
Wählen Sie 711).
Persian (Farsi)
برای : خدمات کمکی زبان، رایگان در دسترس شما است. توجه
، لطفا با شماره ای که در پشت کارت Cignaمشتریان فعلی
1- در غیر اینصورت، با شمارهشناسایی شما است تماس بگيرید.
را شماره گيری کنيد(. TTY :177) تماس بگیرید 6224-244-800
HC-NOT77 10-16 AC
myCigna.com 6
Important Information About Your
Medical Plan
The paragraph regarding “Direct Access for Mental Health
and Substance Abuse Services” shown under the Important
Information About Your Medical Plan section of your
medical certificate has been revised to show the following:
Direct Access for Mental Health and Substance Use
Disorder Services
Insureds covered by this plan are allowed direct access to a
licensed/certified Participating Provider for covered Mental
Health and Substance Use Disorder Services. There is no
requirement to obtain an authorization of care from your
Primary Care Physician for individual or group therapy visits
to the Participating Provider of your choice for Mental Health
and Substance Use Disorder Services.
HC-IMP166 12-15
AC
The Schedule
If you are enrolled in a medical plan with In- and Out-of-
Network features and subject to Out-of-Pocket maximums, the
following provision is added to The Schedule shown in your
medical certificate:
Out-of-Pocket Expenses – For In-Network Charges Only
Out-of-Pocket Expenses are Covered Expenses incurred for
charges that are not paid by the benefit plan because of any
Deductibles, Copayments or Coinsurance. When the Out-of-
Pocket Maximum shown in The Schedule is reached, all
Covered Expenses, except charges for non-compliance
penalties, are payable by the benefit plan at 100%.
In addition, any existing “Out-of-Pocket Expenses” heading in
The Schedule of your In- and Out-of-Network medical
certificate is revised to read as follows:
Out of Pocket Expenses – For Out-of-Network Charges
Only
SCHED AC4
The Schedule
If The Schedule in your medical certificate contains an entry
for “Rx cap contribution to the combined Medical/Pharmacy
Out-of-Pocket Maximum” the text for “Option 2” found in
that section is replaced as follows:
Option 2: Pharmacy paid at Pharmacy Program levels until the
total Out-of-Pocket Maximum has been met, then paid at
100% for In-Network charges.
SCHED AC8
The Schedule
The following note is added to the “Maximum Reimbursable
Charge” section of The Schedule in your medical certificate:
Note:
Some providers forgive or waive the cost share obligation (e.g.
your copayment, deductible and/or coinsurance) that this plan
requires you to pay. Waiver of your required cost share
obligation can jeopardize your coverage under this plan. For
more details, see the Exclusions Section.
SCHED AC10
The Schedule
The Schedule shown in your medical certificate is amended to
accommodate the following provisions:
Any references to “Substance Abuse” are hereby replaced
with the term “Substance Use Disorder”.
The Nutritional Evaluation maximum will not apply to the
treatment of mental health and substance use disorder
conditions.
The Mental Health Inpatient heading is revised as follows:
Inpatient
Includes Acute Inpatient and Residential Treatment
The Mental Health Outpatient Physician’s Office Visit
heading is revised as follows:
Outpatient - Office Visits
Includes individual, family and group psychotherapy;
medication management, etc.
myCigna.com 7
The Mental Health Outpatient Facility heading is revised as
follows:
Outpatient - All Other Services
Includes Partial Hospitalization, Intensive Outpatient Services,
etc.
The Substance Use Disorder Inpatient heading is revised as
follows:
Inpatient
Includes Acute Inpatient Detoxification, Acute Inpatient
Rehabilitation and Residential Treatment
The Substance Use Disorder Outpatient Physician’s Office
Visit heading is revised as follows:
Outpatient - Office Visits
Includes individual, family and group psychotherapy;
medication management, etc.
The Substance Use Disorder Outpatient Facility heading is
revised as follows:
Outpatient - All Other Services
Includes Partial Hospitalization, Intensive Outpatient Services,
etc.
SCHED AC15
Certification Requirements - Out-of-Network
The following replaces any existing bullet regarding a
registered bed patient in the Pre-Admission
Certification/Continued Stay Review for Hospital
Confinement section of your medical certificate when you or
your Dependent require treatment in a Hospital:
as a registered bed patient, except for 48/96 hour maternity
stays;
HC-PAC1 11-14
V11 AC1
Certification Requirements – Out-of-Network
Any reference to “Substance Abuse” is hereby replaced with
the term “Substance Use Disorder”.
If you are enrolled in a Network Point of Service medical
benefit plan, the following replaces any existing bullet
regarding Residential Treatment Services (if not already
included) in the Pre-Admission Certification/Continued Stay
Review for Hospital Confinement section when you or your
Dependent require treatment in a Hospital:
for Mental Health or Substance Use Disorder Residential
Treatment Services.
HC-PAC44 12-15
AC
Prior Authorization/Pre-Authorized
The following replaces any existing bullet regarding inpatient
Hospital services in the Prior Authorization/Pre-Authorized
section of your medical certificate for services that require
Prior Authorization:
inpatient Hospital services, except for 48/96 hour maternity
stays;
HC-PRA1 11-14
V5 AC
Prior Authorization/Pre-Authorized
The following bullet has been added to the Services that
require Prior Authorization in the Prior Authorization/Pre-
Authorized section of your medical certificate:
Services that require Prior Authorization include, but are not
limited to:
Partial Hospitalization;
HC-PRA19 12-15
AC
Covered Expenses
The following replaces the existing “Clinical Trials”
paragraphs shown in the Covered Expenses section of your
medical certificate:
Clinical Trials
This benefit plan covers routine patient care costs related to a
qualified clinical trial for an individual who meets the
following requirements:
(a) is eligible to participate in an approved clinical trial
according to the trial protocol with respect to treatment of
cancer or other life-threatening disease or condition; and
(b) either
the referring health care professional is a participating
health care provider and has concluded that the
individual’s participation in such trial would be
myCigna.com 8
appropriate based upon the individual meeting the
conditions described in paragraph (a); or
the individual provides medical and scientific
information establishing that the individual’s
participation in such trial would be appropriate based
upon the individual meeting the conditions described in
paragraph (a).
For purposes of clinical trials, the term “life-threatening
disease or condition” means any disease or condition from
which the likelihood of death is probable unless the course of
the disease or condition is interrupted.
The clinical trial must meet the following requirements:
The study or investigation must:
be approved or funded by any of the agencies or entities
authorized by federal law to conduct clinical trials;
be conducted under an investigational new drug application
reviewed by the Food and Drug Administration; or
involve a drug trial that is exempt from having such an
investigational new drug application.
Routine patient care costs are costs associated with the
provision of health care items and services including drugs,
items, devices and services otherwise covered by this benefit
plan for an individual who is not enrolled in a clinical trial
and, in addition:
services required solely for the provision of the
investigational drug, item, device or service;
services required for the clinically appropriate monitoring of
the investigational drug, device, item or service;
services provided for the prevention of complications
arising from the provision of the investigational drug,
device, item or service; and
reasonable and necessary care arising from the provision of
the investigational drug, device, item or service, including
the diagnosis or treatment of complications.
Routine patient care costs do not include:
the investigational drug, item, device, or service, itself; or
items and services that are provided solely to satisfy data
collection and analysis needs and that are not used in the
direct clinical management of the patient.
If your plan includes In-Network providers, Clinical trials
conducted by non-participating providers will be covered at
the In-Network benefit level if:
there are not In-Network providers participating in the
clinical trial that are willing to accept the individual as a
patient, or
the clinical trial is conducted outside the individual's state of
residence.
HC-COV1 10-13
V12 AC
Covered Expenses
The following replaces the “Mental Health and Substance
Abuse Services” section shown under the Covered Expenses
in your medical certificate:
Mental Health and Substance Use Disorder Services
Mental Health Services are services that are required to treat
a disorder that impairs the behavior, emotional reaction or
thought processes. In determining benefits payable, charges
made for the treatment of any physiological conditions related
to Mental Health will not be considered to be charges made
for treatment of Mental Health.
Substance Use Disorder is defined as the psychological or
physical dependence on alcohol or other mind-altering drugs
that requires diagnosis, care, and treatment. In determining
benefits payable, charges made for the treatment of any
physiological conditions related to rehabilitation services for
alcohol or drug abuse or addiction will not be considered to be
charges made for treatment of Substance Use Disorder.
Inpatient Mental Health Services
Services that are provided by a Hospital while you or your
Dependent is Confined in a Hospital for the treatment and
evaluation of Mental Health. Inpatient Mental Health Services
include Mental Health Residential Treatment Services.
Mental Health Residential Treatment Services are services
provided by a Hospital for the evaluation and treatment of the
psychological and social functional disturbances that are a
result of subacute Mental Health conditions.
Mental Health Residential Treatment Center means an
institution which specializes in the treatment of psychological
and social disturbances that are the result of Mental Health
conditions; provides a subacute, structured, psychotherapeutic
treatment program, under the supervision of Physicians;
provides 24-hour care, in which a person lives in an open
setting; and is licensed in accordance with the laws of the
appropriate legally authorized agency as a residential
treatment center.
A person is considered confined in a Mental Health
Residential Treatment Center when she/he is a registered bed
patient in a Mental Health Residential Treatment Center upon
the recommendation of a Physician.
Outpatient Mental Health Services
Services of Providers who are qualified to treat Mental Health
when treatment is provided on an outpatient basis, while you
or your Dependent is not Confined in a Hospital, and is
provided in an individual, group or Mental Health Partial
myCigna.com 9
Hospitalization or Intensive Outpatient Therapy Program.
Covered services include, but are not limited to, outpatient
treatment of conditions such as: anxiety or depression which
interfere with daily functioning; emotional adjustment or
concerns related to chronic conditions, such as psychosis or
depression; emotional reactions associated with marital
problems or divorce; child/adolescent problems of conduct or
poor impulse control; affective disorders; suicidal or
homicidal threats or acts; eating disorders; or acute
exacerbation of chronic Mental Health conditions (crisis
intervention and relapse prevention) and outpatient testing and
assessment.
Mental Health Partial Hospitalization Services are rendered
not less than 4 hours and not more than 12 hours in any 24-
hour period by a certified/licensed Mental Health program in
accordance with the laws of the appropriate legally authorized
agency.
A Mental Health Intensive Outpatient Therapy Program
consists of distinct levels or phases of treatment that are
provided by a certified/licensed Mental Health program in
accordance with the laws of the appropriate, legally authorized
agency. Intensive Outpatient Therapy Programs provide a
combination of individual, family and/or group therapy in a
day, totaling nine or more hours in a week.
Inpatient Substance Use Disorder Rehabilitation Services
Services provided for rehabilitation, while you or your
Dependent is Confined in a Hospital, when required for the
diagnosis and treatment of abuse or addiction to alcohol and/or
drugs. Inpatient Substance Use Disorder Services include
Residential Treatment services.
Substance Use Disorder Residential Treatment Services are services provided by a Hospital for the evaluation and
treatment of the psychological and social functional
disturbances that are a result of subacute Substance Use
Disorder conditions.
Substance Use Disorder Residential Treatment Center
means an institution which specializes in the treatment of
psychological and social disturbances that are the result of
Substance Use Disorder; provides a subacute, structured,
psychotherapeutic treatment program, under the supervision of
Physicians; provides 24-hour care, in which a person lives in
an open setting; and is licensed in accordance with the laws of
the appropriate legally authorized agency as a residential
treatment center.
A person is considered confined in a Substance Use Disorder
Residential Treatment Center when she/he is a registered bed
patient in a Substance Use Disorder Residential Treatment
Center upon the recommendation of a Physician.
Outpatient Substance Use Disorder Rehabilitation Services
Services provided for the diagnosis and treatment of
Substance Use Disorder or addiction to alcohol and/or drugs,
while you or your Dependent is not Confined in a Hospital,
including outpatient rehabilitation in an individual, or a
Substance Use Disorder Partial Hospitalization or Intensive
Outpatient Therapy Program.
Substance Use Disorder Partial Hospitalization Services are
rendered no less than 4 hours and not more than 12 hours in
any 24-hour period by a certified/licensed Substance Use
Disorder program in accordance with the laws of the
appropriate legally authorized agency.
A Substance Use Disorder Intensive Outpatient Therapy
Program consists of distinct levels or phases of treatment that
are provided by a certified/licensed Substance Use Disorder
program in accordance with the laws of the appropriate legally
authorized agency. Intensive Outpatient Therapy Programs
provide a combination of individual, family and/or group
therapy in a day, totaling nine, or more hours in a week.
Substance Use Disorder Detoxification Services
Detoxification and related medical ancillary services are
provided when required for the diagnosis and treatment of
addiction to alcohol and/or drugs. Cigna will decide, based on
the Medical Necessity of each situation, whether such services
will be provided in an inpatient or outpatient setting.
Exclusions
The following are specifically excluded from Mental Health
and Substance Use Disorder Services:
treatment of disorders which have been diagnosed as
organic mental disorders associated with permanent
dysfunction of the brain.
developmental disorders, including but not limited to,
developmental reading disorders, developmental arithmetic
disorders, developmental language disorders or
developmental articulation disorders.
counseling for activities of an educational nature.
counseling for borderline intellectual functioning.
counseling for occupational problems.
counseling related to consciousness raising.
vocational or religious counseling.
I.Q. testing.
custodial care, including but not limited to geriatric day
care.
psychological testing on children requested by or for a
school system.
occupational/recreational therapy programs even if
combined with supportive therapy for age-related cognitive
decline.
HC-COV481 12-15
AC
myCigna.com 10
Covered Expenses
The following page replaces the "Transplant Services" section
shown under the Covered Expenses section in your medical
certificate:
Transplant Services
charges made for human organ and tissue Transplant
services which include solid organ and bone marrow/stem
cell procedures at designated facilities throughout the
United States. procedures at designated facilities throughout
the United States or its territories. This coverage is subject
to the following conditions and limitations.
Transplant services include the recipient’s medical, surgical
and Hospital services; inpatient immunosuppressive
medications; and costs for organ or bone marrow/stem cell
procurement. Transplant services are covered only if they are
required to perform any of the following human to human
organ or tissue transplants: allogeneic bone marrow/stem cell,
autologous bone marrow/stem cell, cornea, heart, heart/lung,
kidney, kidney/pancreas, liver, lung, pancreas or intestine
which includes small bowel-liver or multi-visceral.
All Transplant services, other than cornea, are covered at
100% when received at Cigna LIFESOURCE Transplant
Network® facilities. Cornea transplants are not covered at
Cigna LIFESOURCE Transplant Network® facilities.
Transplant services, including cornea, received at participating
facilities specifically contracted with Cigna for those
Transplant services, other than Cigna LIFESOURCE
Transplant Network® facilities, are payable at the In-Network
level. Transplant services received at any other facilities,
including Non-Participating Providers and Participating
Providers not specifically contracted with Cigna for
Transplant services, are covered at the Out-of-Network level.
All Transplant services, other than cornea, must be received at
a Cigna LIFESOURCE Transplant Network® facility. Cornea
transplants are payable when received from Participating
Provider facilities other than Cigna LIFESOURCE Transplant
Network® facilities. Transplant services received at any other
facilities are not covered.
Coverage for organ procurement costs are limited to costs
directly related to the procurement of an organ, from a cadaver
or a live donor. Organ procurement costs shall consist of
surgery necessary for organ removal, organ transportation and
the transportation (refer to Transplant Travel Services),
hospitalization and surgery of a live donor. Compatibility
testing undertaken prior to procurement is covered if
Medically Necessary. Costs related to the search for, and
identification of a bone marrow or stem cell donor for an
allogeneic transplant are also covered.
Transplant Travel Services
Charges made for non-taxable travel expenses incurred by you
in connection with a preapproved organ/tissue transplant are
covered subject to the following conditions and limitations.
Transplant travel benefits are not available for cornea
transplants. Benefits for transportation and lodging are
available to you only if you are the recipient of a preapproved
organ/tissue transplant from a designated Cigna
LIFESOURCE Transplant Network® facility. The term
recipient is defined to include a person receiving authorized
transplant related services during any of the following:
evaluation, candidacy, transplant event, or post-transplant
care. Travel expenses for the person receiving the transplant
will include charges for: transportation to and from the
transplant site (including charges for a rental car used during a
period of care at the transplant facility); and lodging while at,
or traveling to and from the transplant site.
In addition to your coverage for the charges associated with
the items above, such charges will also be considered covered
travel expenses for one companion to accompany you. The
term companion includes your spouse, a member of your
family, your legal guardian, or any person not related to you,
but actively involved as your caregiver who is at least 18 years
of age. The following are specifically excluded travel
expenses: any expenses that if reimbursed would be taxable
income, travel costs incurred due to travel within 60 miles of
your home; food and meals; laundry bills; telephone bills;
alcohol or tobacco products; and charges for transportation
that exceed coach class rates.
These benefits are only available when the covered person is
the recipient of an organ/tissue transplant. Travel expenses for
the designated live donor for a covered recipient are covered
subject to the same conditions and limitations noted above.
Charges for the expenses of a donor companion are not
covered. No benefits are available when the covered person is
a donor.
HC-COV482 12-15
AC
myCigna.com 11
Exclusions, Expenses Not Covered and
General Limitations
The following exclusion regarding “cosmetic surgery and
therapies” under the Exclusions, Expenses Not Covered and
General Limitations section of your medical certificate is
revised as follows:
cosmetic surgery and therapies. Cosmetic surgery or therapy
is defined as surgery or therapy performed to improve or
alter appearance or self-esteem.
HC-EXC228 10-16
V1 AC
Exclusions, Expenses Not Covered and
General Limitations
The following exclusion regarding “transsexual surgery”
under the Exclusions, Expenses Not Covered and General
Limitations section of your medical certificate is hereby
NULL and VOID:
transsexual surgery including medical or psychological
counseling and hormonal therapy in preparation for, or
subsequent to, any such surgery.
HC-EXC228 10-16
AC
Exclusions, Expenses Not Covered and
General Limitations
The bullet regarding charges which you are not obligated to
pay found in the Exclusions, Expenses Not Covered and
General Limitations section of your medical certificate is
revised as follows:
charges which you are not obligated to pay or for which you
are not billed or for which you would not have been billed
except that they were covered under this plan. For example,
if Cigna determines that a provider is or has waived,
reduced, or forgiven any portion of its charges and/or any
portion of copayment, deductible, and/or coinsurance
amount(s) you are required to pay for a Covered Service (as
shown on the Schedule) without Cigna’s express consent,
then Cigna in its sole discretion shall have the right to deny
the payment of benefits in connection with the Covered
Service, or reduce the benefits in proportion to the amount
of the copayment, deductible, and/or coinsurance amounts
waived, forgiven or reduced, regardless of whether the
provider represents that you remain responsible for any
amounts that your plan does not cover. In the exercise of
that discretion, Cigna shall have the right to require you to
provide proof sufficient to Cigna that you have made your
required cost share payment(s) prior to the payment of any
benefits by Cigna. This exclusion includes, but is not
limited to, charges of a Non-Participating Provider who has
agreed to charge you or charged you at an in-network
benefits level or some other benefits level not otherwise
applicable to the services received.
The following bullet is added to the Exclusions, Expenses
Not Covered and General Limitations section of your
medical certificate:
charges arising out of or relating to any violation of a
healthcare-related state or federal law or which themselves
are a violation of a healthcare-related state or federal law.
HC-EXC56 10-14
V6 AC
Exclusions, Expenses Not Covered and
General Limitations
The paragraph regarding “Experimental, investigational and
unproven services” found in the Exclusions, Expenses Not
Covered and General Limitations section of your medical
certificate is revised as follows:
Experimental, investigational and unproven services are
medical, surgical, diagnostic, psychiatric, Substance Use
Disorder or other health care technologies, supplies,
treatments, procedures, drug therapies or devices that are
determined by the utilization review Physician to be:
The following bullet regarding “cosmetic surgery and
therapies” found in the Exclusions, Expenses Not Covered
and General Limitations section of your medical certificate
has been revised as follows:
cosmetic surgery and therapies. Cosmetic surgery or therapy
is defined as surgery or therapy performed to improve or
alter appearance.
The term “mental retardation” shown in the bullet regarding
“nonmedical counseling or ancillary services” found in the
Exclusions, Expenses Not Covered and General
Limitations section of your medical certificate is hereby
changed to “intellectual disabilities”.
HC-EXC190 12-15
AC
myCigna.com 12
Exclusions, Expenses Not Covered and
General Limitations
The bullet regarding phase I, II or III clinical trials under the
experimental, investigational or unproven services exclusion
found in the Exclusions, Expenses Not Covered and
General Limitations section of your medical certificate is
revised as follows:
the subject of an ongoing phase I, II or III clinical trial,
except for routine patient care costs related to qualified
clinical trials as provided in the “Clinical Trials” section(s)
of this plan.
HC-EXC56 10-13
V5 AC
Expenses For Which A Third Party May
Be Responsible
The following bullets are added under the “Additional Terms”
section of your medical certificate entitled Expenses For
Which A Third Party May Be Responsible:
Additional Terms
The plan hereby disavows all equitable defenses in the
pursuit of its right of recovery. The plan’s recovery rights
are neither affected nor diminished by equitable defenses.
Participants must assist the plan in pursuing any recovery
rights by providing requested information.
HC-SUB1 04-10
V9 AC
Payment of Benefits
The following paragraph replaces the existing paragraph in the
subsection entitled “Recovery of Overpayment” found in the
Payment of Benefits section of your certificate:
Recovery of Overpayment
When an overpayment has been made by Cigna, Cigna will
have the right at any time to: recover that overpayment from
the person to whom or on whose behalf it was made; or offset
the amount of that overpayment from a future claim payment.
In addition, your acceptance of benefits under this plan and/or
assignment of Medical Benefits separately creates an equitable
lien by agreement pursuant to which Cigna may seek recovery
of any overpayment. You agree that Cigna, in seeking
recovery of any overpayment as a contractual right or as an
equitable lien by agreement, may pursue the general assets of
the person or entity to whom or on whose behalf the
overpayment was made.
HC-POB1 09-13
V7 AC
Definitions
Dependent
If Dependents are covered under the plan, the following
paragraph regarding anyone who is eligible as an Employee in
the "Dependent" definition in the Definitions section in your
medical certificate is hereby changed to read as follows:
Anyone who is eligible as an Employee will not be considered
as a Dependent spouse. A child under age 26 may be covered
as either an Employee or as a Dependent child. You cannot be
covered as an Employee while also covered as a Dependent of
an Employee.
HC-DFS734 05-14
V1 AC
Definitions
Hospital
Any reference to “Substance Abuse” is hereby replaced with
the term “Substance Use Disorder”.
If you are enrolled in a Network/Network Point of Service
medical benefit plan, the following replaces any existing bullet
regarding “an institution which: specializes in” (if not already
included) under the definition of “Hospital” in the Definitions
section of your medical certificate:
The term Hospital means:
an institution which: specializes in treatment of Mental
Health and Substance Use Disorder or other related illness;
provides residential treatment programs; and is licensed in
accordance with the laws of the appropriate legally
authorized agency.
HC-DFS806 12-15
AC
myCigna.com 13
Definitions
Hospital Confinement or Confined in a Hospital
Any reference to “Substance Abuse” is hereby replaced with
the term “Substance Use Disorder”.
If you are enrolled in a Network/Network Point of Service
medical benefit plan, the following replaces any existing page
regarding “Hospital Confinement or Confined in a Hospital”
in the Definitions section of your medical certificate:
A person will be considered Confined in a Hospital if he is:
a registered bed patient in a Hospital upon the
recommendation of a Physician;
receiving treatment for Mental Health and Substance Use
Disorder Services in a Mental Health or Substance Use
Disorder Residential Treatment Center.
HC-DFS807 12-15
AC
Definitions
Maximum Reimbursable Charge
For the definition Maximum Reimbursable Charge shown
in your medical certificate, any reference to “Substance
Abuse” is hereby replaced with the term “Substance Use
Disorder”.
HC-DFS792 05-15
V1 AC
Definitions
The following replaces any definition of “Review
Organization” that is found in your medical certificate in the
section entitled Definitions:
Review Organization
The term Review Organization refers to an affiliate of Cigna
or another entity to which Cigna has delegated responsibility
for performing utilization review services. The Review
Organization is an organization with a staff of clinicians which
may include Physicians, Registered Graduate Nurses, licensed
mental health and substance use disorder professionals, and
other trained staff members who perform utilization review
services.
HC-DFS808 12-15
AC
The following Federal Requirements replace any such
provisions shown in your Certificate.
Federal Requirements
The following pages explain your rights and responsibilities
under federal laws and regulations. Some states may have
similar requirements. If a similar provision appears elsewhere
in this booklet, the provision which provides the better benefit
will apply.
HC-FED1 10-10 AC
Notice of Provider Directory/Networks
Notice Regarding Provider Directories and Provider
Networks
A list of network providers is available to you without charge
by visiting the website or by calling the phone number on your
ID card. The network consists of providers, including
hospitals, of varied specialties as well as general practice,
affiliated or contracted with Cigna or an organization
contracting on its behalf.
HC-FED78 10-10
AC
Special Enrollment Rights Under the Health
Insurance Portability & Accountability Act
(HIPAA)
If you or your eligible Dependent(s) experience a special
enrollment event as described below, you or your eligible
Dependent(s) may be entitled to enroll in the Plan outside of a
designated enrollment period upon the occurrence of one of
the special enrollment events listed below. If you are already
enrolled in the Plan, you may request enrollment for you and
your eligible Dependent(s) under a different option offered by
the Employer for which you are currently eligible. If you are
not already enrolled in the Plan, you must request special
enrollment for yourself in addition to your eligible
Dependent(s). You and all of your eligible Dependent(s) must
be covered under the same option. The special enrollment
events include:
Acquiring a new Dependent. If you acquire a new
Dependent(s) through marriage, birth, adoption or
placement for adoption, you may request special enrollment
for any of the following combinations of individuals if not
already enrolled in the Plan: Employee only; spouse only;
Employee and spouse; Dependent child(ren) only;
Employee and Dependent child(ren); Employee, spouse and
Dependent child(ren). Enrollment of Dependent children is
myCigna.com 14
limited to the newborn or adopted children or children who
became Dependent children of the Employee due to
marriage.
HC-FED71 12-14
AC
Special Enrollment Rights Under the Health
Insurance Portability & Accountability Act
(HIPAA)
Except as stated above, special enrollment must be
requested within 30 days after the occurrence of the
special enrollment event. If the special enrollment event is
the birth or adoption of a Dependent child, coverage will
be effective immediately on the date of birth, adoption or
placement for adoption. Coverage with regard to any other
special enrollment event will be effective no later than the
first day of the first calendar month following receipt of
the request for special enrollment.
HC-FED71 12-14
V1 AC
Effect of Section 125 Tax Regulations on This
Plan
Your Employer has chosen to administer this Plan in
accordance with Section 125 regulations of the Internal
Revenue Code. Per this regulation, you may agree to a pretax
salary reduction put toward the cost of your benefits.
Otherwise, you will receive your taxable earnings as cash
(salary).
A. Coverage Elections
Per Section 125 regulations, you are generally allowed to
enroll for or change coverage only before each annual benefit
period. However, exceptions are allowed if your Employer
agrees and you enroll for or change coverage within 30 days
of the following:
the date you meet the Special Enrollment criteria described
above; or
the date you meet the criteria shown in the following
Sections B through H.
B. Change of Status
A change in status is defined as:
change in legal marital status due to marriage, death of a
spouse, divorce, annulment or legal separation;
change in number of Dependents due to birth, adoption,
placement for adoption, or death of a Dependent;
change in employment status of Employee, spouse or
Dependent due to termination or start of employment,
strike, lockout, beginning or end of unpaid leave of absence,
including under the Family and Medical Leave Act
(FMLA), or change in worksite;
changes in employment status of Employee, spouse or
Dependent resulting in eligibility or ineligibility for
coverage;
change in residence of Employee, spouse or Dependent to a
location outside of the Employer’s network service area;
and
changes which cause a Dependent to become eligible or
ineligible for coverage.
C. Court Order
A change in coverage due to and consistent with a court order
of the Employee or other person to cover a Dependent.
D. Medicare or Medicaid Eligibility/Entitlement
The Employee, spouse or Dependent cancels or reduces
coverage due to entitlement to Medicare or Medicaid, or
enrolls or increases coverage due to loss of Medicare or
Medicaid eligibility.
E. Change in Cost of Coverage
If the cost of benefits increases or decreases during a benefit
period, your Employer may, in accordance with plan terms,
automatically change your elective contribution.
When the change in cost is significant, you may either
increase your contribution or elect less-costly coverage. When
a significant overall reduction is made to the benefit option
you have elected, you may elect another available benefit
option. When a new benefit option is added, you may change
your election to the new benefit option.
F. Changes in Coverage of Spouse or Dependent Under
Another Employer’s Plan
You may make a coverage election change if the plan of your
spouse or Dependent: incurs a change such as adding or
deleting a benefit option; allows election changes due to
Special Enrollment, Change in Status, Court Order or
Medicare or Medicaid Eligibility/Entitlement; or this Plan and
the other plan have different periods of coverage or open
enrollment periods.
G. Reduction in work hours
If an Employee’s work hours are reduced below 30
hours/week (even if it does not result in the Employee losing
eligibility for the Employer’s coverage); and the Employee
(and family) intend to enroll in another plan that provides
Minimum Essential Coverage (MEC). The new coverage must
be effective no later than the 1st day of the 2
nd month following
the month that includes the date the original coverage is
revoked.
myCigna.com 15
H. Enrollment in Qualified Health Plan (QHP)
The Employee must be eligible for a Special Enrollment
Period to enroll in a QHP through a Marketplace or the
Employee wants to enroll in a QHP through a Marketplace
during the Marketplace’s annual open enrollment period; and
the disenrollment from the group plan corresponds to the
intended enrollment of the Employee (and family) in a QHP
through a Marketplace for new coverage effective beginning
no later than the day immediately following the last day of the
original coverage.
HC-FED70 12-14
AC1
Eligibility for Coverage for Adopted Children
Any child who is adopted by you, including a child who is
placed with you for adoption, will be eligible for Dependent
Insurance, if otherwise eligible as a Dependent, upon the date
of placement with you. A child will be considered placed for
adoption when you become legally obligated to support that
child, totally or partially, prior to that child’s adoption.
If a child placed for adoption is not adopted, all health
coverage ceases when the placement ends, and will not be
continued.
The provisions in the “Exception for Newborns” section of
this document that describe requirements for enrollment and
effective date of insurance will also apply to an adopted child
or a child placed with you for adoption.
HC-FED67 09-14
AC
Women’s Health and Cancer Rights Act
(WHCRA)
Do you know that your plan, as required by the Women’s
Health and Cancer Rights Act of 1998, provides benefits for
mastectomy-related services including all stages of
reconstruction and surgery to achieve symmetry between the
breasts, prostheses, and complications resulting from a
mastectomy, including lymphedema? Call Member Services at
the toll free number listed on your ID card for more
information.
HC-FED12 10-10
AC
Pre-Existing Conditions Under the Health
Insurance Portability & Accountability Act
(HIPAA)
Any Pre-existing Condition Limitation under this plan will no
longer be imposed.
HC-FED32 04-11
AC1
Obtaining a Certificate of Creditable Coverage
Under This Plan
The section entitled “Obtaining a Certificate of Creditable
Coverage Under This Plan” shown under the Federal
Requirements provision of your medical certificate is hereby
removed.
Upon loss of coverage under this Plan, a Certificate of
Creditable Coverage will be mailed to each terminating
individual at the last address on file. You or your Dependent
may also request a Certificate of Creditable Coverage, without
charge, at any time while enrolled in the Plan and for 24
months following termination of coverage. You may need this
document as evidence of your prior coverage to reduce any
pre-existing condition limitation period under another plan, to
help you get special enrollment in another plan, or to obtain
certain types of individual health coverage even if you have
health problems. To obtain a Certificate of Creditable
Coverage, contact the Plan Administrator or call the toll-free
customer service number on the back of your ID card.
HC-FED15 10-10
AC
Claim Determination Procedures
The following complies with federal law. Provisions of
applicable laws of your state may supersede.
Procedures Regarding Medical Necessity Determinations
In general, health services and benefits must be Medically
Necessary to be covered under the plan. The procedures for
determining Medical Necessity vary, according to the type of
service or benefit requested, and the type of health plan.
Medical Necessity determinations are made on a preservice,
concurrent, or postservice basis, as described below:
Certain services require prior authorization in order to be
covered. The booklet describes who is responsible for
obtaining this review. You or your authorized representative
(typically, your health care professional) must request prior
authorization according to the procedures described below, in
myCigna.com 16
the booklet, and in your provider’s network participation
documents as applicable.
When services or benefits are determined to be not covered,
you or your representative will receive a written description of
the adverse determination, and may appeal the determination.
Appeal procedures are described in the booklet, in your
provider’s network participation documents as applicable, and
in the determination notices.
Preservice Determinations
When you or your representative requests a required prior
authorization, Cigna will notify you or your representative of
the determination within 15 days after receiving the request.
However, if more time is needed due to matters beyond
Cigna’s control, Cigna will notify you or your representative
within 15 days after receiving your request. This notice will
include the date a determination can be expected, which will
be no more than 30 days after receipt of the request. If more
time is needed because necessary information is missing from
the request, the notice will also specify what information is
needed, and you or your representative must provide the
specified information to Cigna within 45 days after receiving
the notice. The determination period will be suspended on the
date Cigna sends such a notice of missing information, and the
determination period will resume on the date you or your
representative responds to the notice.
If the determination periods above would seriously jeopardize
your life or health, your ability to regain maximum function,
or in the opinion of a health care professional with knowledge
of your health condition, cause you severe pain which cannot
be managed without the requested services, Cigna will make
the preservice determination on an expedited basis. Cigna will
defer to the determination of the treating health care
professional regarding whether an expedited determination is
necessary. Cigna will notify you or your representative of an
expedited determination within 72 hours after receiving the
request.
However, if necessary information is missing from the
request, Cigna will notify you or your representative within 24
hours after receiving the request to specify what information is
needed. You or your representative must provide the specified
information to Cigna within 48 hours after receiving the
notice. Cigna will notify you or your representative of the
expedited benefit determination within 48 hours after you or
your representative responds to the notice. Expedited
determinations may be provided orally, followed within 3 days
by written or electronic notification.
If you or your representative fails to follow Cigna’s
procedures for requesting a required preservice determination,
Cigna will notify you or your representative of the failure and
describe the proper procedures for filing within 5 days (or 24
hours, if an expedited determination is required, as described
above) after receiving the request. This notice may be
provided orally, unless you or your representative requests
written notification.
Concurrent Determinations
When an ongoing course of treatment has been approved for
you and you wish to extend the approval, you or your
representative must request a required concurrent coverage
determination at least 24 hours prior to the expiration of the
approved period of time or number of treatments. When you
or your representative requests such a determination, Cigna
will notify you or your representative of the determination
within 24 hours after receiving the request.
Postservice Determinations
When you or your representative requests a coverage
determination or a claim payment determination after services
have been rendered, Cigna will notify you or your
representative of the determination within 30 days after
receiving the request. However, if more time is needed to
make a determination due to matters beyond Cigna’s control,
Cigna will notify you or your representative within 30 days
after receiving the request. This notice will include the date a
determination can be expected, which will be no more than 45
days after receipt of the request.
If more time is needed because necessary information is
missing from the request, the notice will also specify what
information is needed, and you or your representative must
provide the specified information to Cigna within 45 days
after receiving the notice. The determination period will be
suspended on the date Cigna sends such a notice of missing
information, and the determination period will resume on the
date you or your representative responds to the notice.
Notice of Adverse Determination
Every notice of an adverse benefit determination will be
provided in writing or electronically, and will include all of
the following that pertain to the determination: information
sufficient to identify the claim including, if applicable, the
date of service, provider and claim amount; diagnosis and
treatment codes, and their meanings; the specific reason or
reasons for the adverse determination including, if applicable,
the denial code and its meaning and a description of any
standard that was used in the denial; reference to the specific
plan provisions on which the determination is based; a
description of any additional material or information necessary
to perfect the claim and an explanation of why such material
or information is necessary; a description of the plan’s review
procedures and the time limits applicable, including a
statement of a claimant’s rights to bring a civil action under
section 502(a) of ERISA following an adverse benefit
determination on appeal, (if applicable); upon request and free
of charge, a copy of any internal rule, guideline, protocol or
other similar criterion that was relied upon in making the
adverse determination regarding your claim; and an
myCigna.com 17
explanation of the scientific or clinical judgment for a
determination that is based on a Medical Necessity,
experimental treatment or other similar exclusion or limit; a
description of any available internal appeal and/or external
review process(es); information about any office of health
insurance consumer assistance or ombudsman available to
assist you with the appeal process; and in the case of a claim
involving urgent care, a description of the expedited review
process applicable to such claim.
HC-FED79 03-13
AC
Medical - When You Have a Complaint or an
Appeal
For the purposes of this section, any reference to "you" or
"your" also refers to a representative or provider designated by
you to act on your behalf; unless otherwise noted.
We want you to be completely satisfied with the care you
receive. That is why we have established a process for
addressing your concerns and solving your problems.
Start With Customer Service
We are here to listen and help. If you have a concern
regarding a person, a service, the quality of care, contractual
benefits, or a rescission of coverage, you may call the toll-
free number on your ID card, explanation of benefits, or
claim form and explain your concern to one of our Customer
Service representatives. You may also express that concern
in writing.
We will do our best to resolve the matter on your initial
contact. If we need more time to review or investigate your
concern, we will get back to you as soon as possible, but in
any case within 30 days. If you are not satisfied with the
results of a coverage decision, you may start the appeals
procedure.
Internal Appeals Procedure
To initiate an appeal, you must submit a request for an appeal
in writing to Cigna within 180 days of receipt of a denial
notice. You should state the reason why you feel your appeal
should be approved and include any information supporting
your appeal. If you are unable or choose not to write, you may
ask Cigna to register your appeal by telephone. Call or write
us at the toll-free number on your ID card, explanation of
benefits, or claim form.
Your appeal will be reviewed and the decision made by
someone not involved in the initial decision. Appeals
involving Medical Necessity or clinical appropriateness will
be considered by a health care professional.
We will respond in writing with a decision within 30 calendar
days after we receive an appeal for a required preservice or
concurrent care coverage determination or a postservice
Medical Necessity determination. We will respond within 60
calendar days after we receive an appeal for any other
postservice coverage determination. If more time or
information is needed to make the determination, we will
notify you in writing to request an extension of up to 15
calendar days and to specify any additional information
needed to complete the review.
In the event any new or additional information (evidence) is
considered, relied upon or generated by Cigna in connection
with the appeal, this information will be provided
automatically to you as soon as possible and sufficiently in
advance of the decision, so that you will have an opportunity
to respond. Also, if any new or additional rationale is
considered by Cigna, Cigna will provide the rationale to you
as soon as possible and sufficiently in advance of the decision
so that you will have an opportunity to respond.
You may request that the appeal process be expedited if, (a)
the time frames under this process would seriously jeopardize
your life, health or ability to regain maximum functionality or
in the opinion of your health care provider would cause you
severe pain which cannot be managed without the requested
services; or (b) your appeal involves nonauthorization of an
admission or continuing inpatient Hospital stay.
If you request that your appeal be expedited based on (a)
above, you may also ask for an expedited external review at
the same time, if the time to complete an expedited review
would be detrimental to your medical condition.
When an appeal is expedited, Cigna will respond orally with a
decision within 72 hours, followed up in writing.
External Review Procedure
If you are not fully satisfied with the decision of Cigna's
internal appeal review and the appeal involves medical
judgment or a rescission of coverage, you may request that
your appeal be referred to an Independent Review
Organization (IRO). The IRO is composed of persons who are
not employed by Cigna, or any of its affiliates. A decision to
request an external review to an IRO will not affect the
claimant's rights to any other benefits under the plan.
There is no charge for you to initiate an external review. Cigna
and your benefit plan will abide by the decision of the IRO.
To request a review, you must notify the Appeals Coordinator
within 4 months of your receipt of Cigna's appeal review
denial. Cigna will then forward the file to a randomly selected
IRO. The IRO will render an opinion within 45 days.
When requested, and if a delay would be detrimental to your
medical condition, as determined by Cigna's reviewer, or if
your appeal concerns an admission, availability of care,
continued stay, or health care item or service for which you
myCigna.com 18
received emergency services, but you have not yet been
discharged from a facility, the external review shall be
completed within 72 hours.
Notice of Benefit Determination on Appeal
Every notice of a determination on appeal will be provided in
writing or electronically and, if an adverse determination, will
include: information sufficient to identify the claim including,
if applicable, the date of service, provider and claim amount;
diagnosis and treatment codes, and their meanings; the
specific reason or reasons for the adverse determination
including, if applicable, the denial code and its meaning and a
description of any standard that was used in the denial;
reference to the specific plan provisions on which the
determination is based; a statement that the claimant is entitled
to receive, upon request and free of charge, reasonable access
to and copies of all documents, records, and other Relevant
Information as defined below; a statement describing any
voluntary appeal procedures offered by the plan and the
claimant’s right to bring an action under ERISA section
502(a), if applicable; upon request and free of charge, a copy
of any internal rule, guideline, protocol or other similar
criterion that was relied upon in making the adverse
determination regarding your appeal, and an explanation of the
scientific or clinical judgment for a determination that is based
on a Medical Necessity, experimental treatment or other
similar exclusion or limit; and information about any office of
health insurance consumer assistance or ombudsman available
to assist you in the appeal process. A final notice of an adverse
determination will include a discussion of the decision.
You also have the right to bring a civil action under section
502(a) of ERISA if you are not satisfied with the decision on
review. You or your plan may have other voluntary alternative
dispute resolution options such as Mediation. One way to find
out what may be available is to contact your local U.S.
Department of Labor office and your State insurance
regulatory agency. You may also contact the Plan
Administrator.
Relevant Information
Relevant Information is any document, record or other
information which: was relied upon in making the benefit
determination; was submitted, considered or generated in the
course of making the benefit determination, without regard to
whether such document, record, or other information was
relied upon in making the benefit determination; demonstrates
compliance with the administrative processes and safeguards
required by federal law in making the benefit determination;
or constitutes a statement of policy or guidance with respect to
the plan concerning the denied treatment option or benefit for
the claimant's diagnosis, without regard to whether such
advice or statement was relied upon in making the benefit
determination.
Legal Action
If your plan is governed by ERISA, you have the right to bring
a civil action under section 502(a) of ERISA if you are not
satisfied with the outcome of the Appeals Procedure. In most
instances, you may not initiate a legal action against Cigna
until you have completed the appeal processes. However, no
action will be brought at all unless brought within 3 years after
a claim is submitted for In-Network Services or within three
years after proof of claim is required under the Plan for Out-
of-Network services.
HC-FED82 03-14
AC
COBRA Continuation Rights Under Federal
Law
For You and Your Dependents
Who is Entitled to COBRA Continuation?
Only a “qualified beneficiary” (as defined by federal law) may
elect to continue health insurance coverage. A qualified
beneficiary may include the following individuals who were
covered by the Plan on the day the qualifying event occurred:
you, your spouse, and your Dependent children. Each
qualified beneficiary has their own right to elect or decline
COBRA continuation coverage even if you decline or are not
eligible for COBRA continuation.
The following individuals are not qualified beneficiaries for
purposes of COBRA continuation: domestic partners,
grandchildren (unless adopted by you), stepchildren (unless
adopted by you). Although these individuals do not have an
independent right to elect COBRA continuation coverage, if
you elect COBRA continuation coverage for yourself, you
may also cover your Dependents even if they are not
considered qualified beneficiaries under COBRA. However,
such individuals’ coverage will terminate when your COBRA
continuation coverage terminates. The sections titled
“Secondary Qualifying Events” and “Medicare Extension For
Your Dependents” are not applicable to these individuals.
HC-FED54 12-13
AC1
myCigna.com 19
COBRA Continuation Rights Under Federal
Law
For You and Your Dependents
The following paragraphs regarding the “Trade Act of 2002”
are hereby rendered NULL and VOID:
Trade Act of 2002
The Trade Act of 2002 created a new tax credit for certain
individuals who become eligible for trade adjustment
assistance and for certain retired Employees who are receiving
pension payments from the Pension Benefit Guaranty
Corporation (PBGC) (eligible individuals). Under the new tax
provisions, eligible individuals can either take a tax credit or
get advance payment of 72.5% of premiums paid for qualified
health insurance, including continuation coverage. If you have
questions about these new tax provisions, you may call the
Health Coverage Tax Credit Customer Contact Center toll-free
at 1-866-628-4282. TDD/TYY callers may call toll-free at 1-
866-626-4282. More information about the Trade Act is also
available at www.doleta.gov/tradeact.
In addition, if you initially declined COBRA continuation
coverage and, within 60 days after your loss of coverage under
the Plan, you are deemed eligible by the U.S. Department of
Labor or a state labor agency for trade adjustment assistance
(TAA) benefits and the tax credit, you may be eligible for a
special 60 day COBRA election period. The special election
period begins on the first day of the month that you become
TAA-eligible. If you elect COBRA coverage during this
special election period, COBRA coverage will be effective on
the first day of the special election period and will continue for
18 months, unless you experience one of the events discussed
under “Termination of COBRA Continuation” above.
Coverage will not be retroactive to the initial loss of coverage.
If you receive a determination that you are TAA-eligible, you
must notify the Plan Administrator immediately.
HC-FED66 07-14
AC
Medical Conversion Privilege/Conversion
Available Following Continuation
Any provisions regarding “Medical Conversion Privilege” or
“Conversion Available Following Continuation” under this
plan are hereby NULL and VOID.
HC-FED66 07-14
AC1
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Home Office: Bloomfield, Connecticut
Mailing Address: Hartford, Connecticut 06152
CIGNA HEALTH AND LIFE INSURANCE COMPANY, a Cigna company (hereinafter
called Cigna)
CERTIFICATE RIDER
No. CR7BIASO35-4
Policyholder: Loudoun County School Board
Rider Eligibility: Each Employee as reported to the insurance company by your Employer
Policy No. or Nos. 3320020-OAP2
EFFECTIVE DATE: January 1, 2017
You will become insured on the date you become eligible if you are in Active Service on that date or if you are
not in Active Service on that date due to your health status. If you are not insured for the benefits described in
your certificate on that date, the effective date of this certificate rider will be the date you become insured.
This certificate rider forms a part of the certificate issued to you by Cigna describing the benefits provided under
the policy(ies) specified above.
HC-RDR1 04-10
V1
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The sections entitled Calendar Year Deductible and Out-of-Pocket Maximum in THE SCHEDULE — Open Access Plus
Medical Benefits — in your certificate are changed to read as attached.
The page in your certificate coded HC-DFS673 V1 is replaced by the page coded HC-DFS673 V1 M attached to this certificate
rider.
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Open Access Plus Medical Benefits
The Schedule
BENEFIT HIGHLIGHTS IN-NETWORK OUT-OF-NETWORK .
Calendar Year Deductible
Individual
$500 per person $1,000 per person
Family Maximum
$1,000 per family $2,000 per family
Family Maximum Calculation
Individual Calculation:
Family members meet only their individual deductible and then their claims will be covered under the plan coinsurance; if the family deductible has been met prior to their individual deductible being met, their claims will be paid at the plan coinsurance.
Out-of-Pocket Maximum
Individual $2,000 per person $4,000 per person
Family Maximum
$4,000 per family $8,000 per family
Family Maximum Calculation
Individual Calculation:
Family members meet only their individual Out-of-Pocket and then their claims will be covered at 100%; if the family Out-of-Pocket has been met prior to their individual Out-of-Pocket being met, their claims will be paid at 100%.
myCigna.com 4
Definitions
Dependent
Dependents are:
your lawful spouse; and
any child of yours who is:
less than 26 years old.
26 or more years old, unmarried, and primarily supported
by you and incapable of self-sustaining employment by
reason of mental or physical disability which arose while
the child was covered as a Dependent under this Plan, or
while covered as a dependent under a prior plan with no
break in coverage.
Proof of the child's condition and dependence must be
submitted to Cigna within 31 days after the date the child
ceases to qualify above. From time to time, but not more
frequently than once a year, Cigna may require proof of
the continuation of such condition and dependence.
The term child means a child born to you or a child legally
adopted by you. It also includes a stepchild or a child for
whom you are the legal guardian.
Anyone who is eligible as an Employee will not be considered
as a Dependent spouse. A child under age 26 may be covered
as either an Employee or as a Dependent child. You cannot be
covered as an Employee while also covered as a Dependent of
an Employee.
No one may be considered as a Dependent of more than one
Employee.
HC-DFS673 07-14
V1 M
myCigna.com 1
Home Office: Bloomfield, Connecticut
Mailing Address: Hartford, Connecticut 06152
CIGNA HEALTH AND LIFE INSURANCE COMPANY, a Cigna company (hereinafter
called Cigna)
CERTIFICATE RIDER
No. CR7MNASO35-3
Policyholder: Loudoun County School Board
Rider Eligibility: Each Employee who resides in Massachusetts
Policy No. or Nos. 3320020-OAP2
EFFECTIVE DATE: January 1, 2017
You will become insured on the date you become eligible if you are in Active Service on that date or if you are
not in Active Service on that date due to your health status. If you are not insured for the benefits described in
your certificate on that date, the effective date of this certificate rider will be the date you become insured.
This certificate rider forms a part of the certificate issued to you by Cigna describing the benefits provided under
the policy(ies) specified above.
HC-RDR1 04-10
V1
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The pages in your certificate coded HC-MANCR1 and HC-MANCR2V3 are replaced by the pages coded HC-MANCR1 and
HC-MANCR2V4 attached to this certificate rider.
myCigna.com 3
Notice To Massachusetts Residents
This Open Access Plus Medical
Benefits health plan, alone, does not
meet Minimum Creditable
Coverage standards and will not
satisfy the individual mandate that
you have health insurance. For
additional information, please see the
section “Massachusetts Requirement
to Purchase Health Insurance,”
immediately preceding the Schedule.
HC-MANCR1
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Massachusetts Requirement To Purchase Health Insurance:
This Open Access Plus Medical Benefits health plan, alone, does not meet Minimum Creditable Coverage standards
that are effective January 1, 2016, as part of the Massachusetts Health Care Reform Law because:
Prescription drugs are not covered.
The out-of-pocket maximum does not include one or more of the following for in-network services: all copayments of
any size, coinsurance, deductibles, or similar charges for Essential Health Benefits.
If you purchase this health plan only, you will not satisfy the statutory requirement that you have health insurance meeting
these standards.
If this health plan is offered to you through your place of employment, contact your employer or other plan sponsor to
determine if it offers other health plan options that meet Minimum Creditable Coverage standards. Your employer or other
plan-sponsor also may offer supplemental plans you can add to this insured health plan in order to meet Minimum
Creditable Coverage.
If this health plan is not offered to you through your place of employment and you want to learn about other health plan
options available to individuals, you may contact the Division of Insurance by calling (617) 521-7794 or visiting its
website at www.mass.gov/doi, or the Connector by calling 1-877-MA-ENROLL or visiting its website at
www.mahealthconnector.org.
THIS DISCLOSURE IS FOR MINIMUM CREDITABLE COVERAGE STANDARDS THAT ARE EFFECTIVE
JANUARY 1, 2016. BECAUSE THESE STANDARDS MAY CHANGE, REVIEW YOUR HEALTH PLAN
MATERIAL EACH YEAR TO DETERMINE WHETHER YOUR PLAN MEETS THE LATEST STANDARDS.
If you have questions about this notice, you may contact the Division of Insurance by calling (617) 521-7794 or
visiting its website at www.mass.gov/doi.
HC-MANCR2V4
Loudoun County School Board
EXTRATERRITORIAL LEGISLATION
EFFECTIVE DATE: January 1, 2017
ETALLM17A
3320020
This document printed in December, 2016 takes the place of any documents previously issued to you which
described your benefits.
Printed in U.S.A.
Table of Contents
IMPORTANT INFORMATION ............................................................................................................................ 4
CERTIFICATE RIDER – Arkansas Residents ...................................................................................................... 5
CERTIFICATE RIDER – Colorado Residents ...................................................................................................... 7
CERTIFICATE RIDER – Connecticut Residents .................................................................................................. 8
CERTIFICATE RIDER – Delaware Residents ...................................................................................................... 8
CERTIFICATE RIDER – Florida Residents ........................................................................................................ 11
CERTIFICATE RIDER – Georgia Residents ...................................................................................................... 14
CERTIFICATE RIDER – Idaho Residents .......................................................................................................... 16
CERTIFICATE RIDER – Illinois Residents ........................................................................................................ 20
CERTIFICATE RIDER – Kansas Residents ........................................................................................................ 21
CERTIFICATE RIDER – Kentucky Residents .................................................................................................... 21
CERTIFICATE RIDER – Louisiana Residents.................................................................................................... 26
CERTIFICATE RIDER – Maine Residents ......................................................................................................... 28
CERTIFICATE RIDER – Maryland Residents .................................................................................................... 31
CERTIFICATE RIDER – Massachusetts Residents ............................................................................................ 33
CERTIFICATE RIDER – Minnesota Residents .................................................................................................. 35
CERTIFICATE RIDER – Missouri Residents ..................................................................................................... 37
CERTIFICATE RIDER – Nebraska Residents .................................................................................................... 39
CERTIFICATE RIDER – New Hampshire Residents ......................................................................................... 39
CERTIFICATE RIDER – New Jersey Residents ................................................................................................. 40
CERTIFICATE RIDER – New Mexico Residents............................................................................................... 40
CERTIFICATE RIDER – North Carolina Residents ........................................................................................... 53
CERTIFICATE RIDER – Ohio Residents ........................................................................................................... 54
CERTIFICATE RIDER – Oregon Residents ....................................................................................................... 61
CERTIFICATE RIDER – Pennsylvania Residents .............................................................................................. 64
CERTIFICATE RIDER – South Carolina Residents ........................................................................................... 67
CERTIFICATE RIDER – Texas Residents .......................................................................................................... 67
CERTIFICATE RIDER – Utah Residents ........................................................................................................... 77
CERTIFICATE RIDER – Vermont Residents ..................................................................................................... 79
CERTIFICATE RIDER – Wyoming Residents ................................................................................................... 87
myCigna.com 4
CIGNA HEALTH AND LIFE INSURANCE COMPANY, a Cigna company (hereinafter
called Cigna)
CERTIFICATE RIDER
Policyholder: Loudoun County School Board
Rider Eligibility: Each Employee as noted within this certificate rider
Policy No. or Nos.: 3320020
Effective Date: January 1, 2017
This rider forms a part of the certificate issued to you by Cigna describing the benefits provided under the
policy(ies) specified above. This rider replaces any other issued to you previously.
IMPORTANT INFORMATION
For Residents of States other than the State of Virginia:
State-specific riders contain provisions that may add to or change your certificate provisions.
The provisions identified in your state-specific rider, attached, are ONLY applicable to Employees residing in
that state. The state for which the rider is applicable is identified at the beginning of each state specific rider in the
"Rider Eligibility" section.
Additionally, the provisions identified in each state-specific rider only apply to:
(a) Benefit plans made available to you and/or your Dependents by your Employer;
(b) Benefit plans for which you and/or your Dependents are eligible;
(c) Benefit plans which you have elected for you and/or your Dependents;
(d) Benefit plans which are currently effective for you and/or your Dependents.
Please refer to the Table of Contents for the state-specific rider that is applicable for your residence state.
HC-ETRDR
myCigna.com 5
CIGNA HEALTH AND LIFE INSURANCE
COMPANY, a Cigna company (hereinafter called
Cigna)
CERTIFICATE RIDER – Arkansas Residents
Rider Eligibility: Each Employee who is located in Arkansas
You will become insured on the date you become eligible,
including if you are not in Active Service on that date due to
your health status.
This rider forms a part of the certificate issued to you by
Cigna.
The provisions set forth in this rider comply with the legal
requirements of Arkansas for group insurance plans covering
insureds located in Arkansas. These provisions supersede any
provisions in your certificate to the contrary unless the
provisions in your certificate result in greater benefits.
HC-ETARRDR
Eligibility – Effective Date
Dependent Insurance
Exception for Adopted Children
Any Dependent child adopted by you while you are insured
will become insured from the date the adopted child is placed
with you, or from the date you file the petition for adoption, if
you elect Dependent Insurance no later than 90 days from the
date of the petition for adoption, or from the date of
placement, whichever is later. A newborn adopted child will
become insured from the moment of birth, if the petition is
filed and if you elect Dependent Insurance no later than 90
days from the child’s birth.
If you do not elect to insure your adopted child within such 90
days, or if your petition for adoption is dismissed or denied, no
benefits for expenses incurred beyond the 90th day following
placement or filing of the petition to adopt, whichever is later,
will be payable.
HC-ELG1 04-10
V23-ET2
Covered Expenses
charges made for anesthesia, hospitalization services and/or
ambulatory surgical facility charges performed in
connection with dental procedures when such services are
required to effectively perform the procedures and the
patient is:
under seven years of age and it is determined by two
dentists that treatment in a hospital or ambulatory surgical
center is required without delay due to a significantly
complex dental condition;
a person with a serious diagnosed mental or physical
condition; or
a person with a significant behavioral problem as
determined by their Physician.
charges for colorectal cancer examinations and laboratory
tests for covered persons who are fifty years of age or older;
less than fifty years of age and at high risk for colorectal
cancer according to American Cancer Society colorectal
cancer screening guidelines as they existed on January 1,
2005; or are experiencing the following symptoms of
colorectal cancer as determined by a Physician: bleeding
from the rectum or blood in the stool; or a change in bowel
habits, such as diarrhea, constipation, or narrowing of the
stool, that lasts more than five days.
The colorectal screening shall involve an examination of the
entire colon, including the following examinations and
laboratory tests:
an annual fecal occult blood test utilizing the take-home
multiple sample method, or an annual fecal
immunochemical test in conjunction with a flexible
sigmoidoscopy every five years;
a double-contrast barium enema every five years; or
a colonoscopy every ten years; and any additional
medically recognized screening tests for colorectal cancer
required by the Director of the Department of Health, as
determined in consultation with appropriate health care
organizations.
charges for prostate cancer examinations and laboratory
tests once a year for non-symptomatic covered persons who
are forty years of age or older in accordance with the
National Comprehensive Cancer Guidelines.
The following applies only to state employees and public
school employees:
charges for diagnosis and treatment of autism spectrum
disorder, as defined in the most recent edition of the
“Diagnostic and Statistical Manual of Mental Disorders”.
The following treatment is covered when Medically
Necessary and evidence-based:
applied behavior analysis;
myCigna.com 6
pharmacy care;
psychiatric care;
psychological care;
therapeutic care;
equipment determined necessary to provide evidence-
based treatment;
any care determined to be Medically Necessary and
evidence-based.
In addition, Covered Expenses will include expenses incurred
at any of the Approximate Age Intervals shown below for a
Dependent child who is age 18 or less, for charges made for
Child Preventive Care Services consisting of the following
services delivered or supervised by a Physician, in keeping
with prevailing medical standards:
a history;
physical examination;
development assessment;
anticipatory guidance;
appropriate immunizations, which are not subject to any
copay, coinsurance, deductible, or dollar limit; and
laboratory tests;
excluding any charges for:
more than one visit to one provider for Child Preventive
Care Services at each of the Approximate Age Intervals up
to a total of 20 visits for each Dependent child;
services for which benefits are otherwise provided under
this Comprehensive Medical Benefits section;
services for which benefits are not payable according to the
Expenses Not Covered section.
Approximate Age Intervals are: Birth, 2 weeks, 2 months, 4
months, 6 months, 9 months, 12 months, 15 months, 18
months, 2 years, 3 years, 4 years, 5 years, 6 years, 8 years, 10
years, 12 years, 14 years, 16 years, and 18 years.
charges made for family planning, including medical
history, physical exam, related laboratory tests, medical
supervision in accordance with generally accepted medical
practices, other medical services, information and
counseling on contraception, implanted/injected
contraceptives, after appropriate counseling, medical
services connected with surgical therapies (tubal ligations,
vasectomies).
charges made for corrective surgery and related medical
care for Covered Persons of any age diagnosed as having a
craniofacial anomaly if the surgery and treatment are
Medically Necessary to improve a functional impairment, as
determined by a nationally accredited cleft-craniofacial
team. Medical care coverage includes dental care, vision
care, and the use of at least one hearing aid. Craniofacial
anomaly means a congenital or acquired musculoskeletal
disorder that primarily affects the cranial facial tissue.
charges for gastric pacemakers to treat gastroparesis, a
neuromuscular stomach disorder in which food empties into
the stomach more slowly than normal.
Telemedicine
Charges for covered services performed through telemedicine
on the same basis and to the same extent as the same service
would be covered if provided in-person.
Telemedicine means the medium of delivering clinical
healthcare services by means of real-time two-way
electronic audio-visual communications, including
without limitation the application of secure video
conferencing, to provide or support the healthcare
delivery that facilitates the assessment, diagnosis,
consultation, or treatment of a patient’s health care while
the patient is at an Originating Site and the healthcare
professional is at a Distant Site.
Distant Site means the location of the healthcare
professional delivering healthcare services through
telemedicine at the time the services are provided.
Originating Site means the offices of a healthcare
professional or a licensed healthcare entity where the
patient is located at the time services are provided by a
healthcare professional through telemedicine; and the
home of a patient in connection with treatment for end-
stage renal disease.
HC-COV145 04-10
V4-ET2
Covered Expenses
External Prosthetic Appliances and Devices
charges for orthotic and prosthetic devices and services will
be no less than eighty percent (80%) of Medicare allowable
charges as defined by the Center of Medicare Medicaid
Services, Health care Common Procedure Coding System as
of January 1, 2009. Devices must be prescribed and
provided by a licensed doctor of medicine, doctor of
osteopathy, or doctor of podiatric medicine, an orthotist, or
prosthetist, and are subject to prior authorization.
Deductibles, co-payments and co-insurance provisions will
not be more restrictive than those that apply to other
medical conditions.
HC-COV9 04-10
V9 ET
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Definitions
Dependent
The term child means a child born to you or a child legally
adopted by you from the date you file a petition for adoption.
HC-DFS705 10-15
V1-ET
CIGNA HEALTH AND LIFE INSURANCE
COMPANY, a Cigna company (hereinafter called
Cigna)
CERTIFICATE RIDER – Colorado Residents
Rider Eligibility: Each Employee who is located in Colorado
You will become insured on the date you become eligible,
including if you are not in Active Service on that date due to
your health status.
This rider forms a part of the certificate issued to you by
Cigna.
The provisions set forth in this rider comply with the legal
requirements of Colorado group insurance plans covering
insureds located in Colorado. These provisions supersede any
provisions in your certificate to the contrary unless the
provisions in your certificate result in greater benefits.
HC-ETCORDR
Definitions
Dependent
Dependents include:
your lawful spouse or your partner in a Civil Union;
HC-DFS675 01-15
V2-ET
Emergency Service Provider
The term Emergency Service Provider means a local
government, or an authority formed by two or more local
governments, that provide fire-fighting and fire prevention
services, emergency medical services, ambulance services, or
search and rescue services, or a not-for-profit non-
governmental entity organized for the purpose of providing
any such services, through the use of bona fide volunteers.
HC-DFS236 04-10
V1-ET
Employee
The term Employee means a full-time employee of the
Employer who is currently in Active Service. The term does
not include employees who are part-time or temporary or who
normally work less than 30 hours a week for the Employer.
The term Employee may include officers, managers and
Employees of the Employer, the bona fide volunteers if the
Employer is an Emergency Service Provider, the partners if
the Employer is a partnership, the officers, managers, and
Employees of subsidiary or affiliated corporations of a
corporation Employer, and the individual proprietors,
partners, and Employees of individuals and firms, the
business of which is controlled by the insured Employer
through stock ownership, contract, or otherwise.
HC-DFS239 04-10
V1-ET
Employer
The term Employer means the Policyholder and all Affiliated
Employers. The term Employer may include an Emergency
Service Provider, any municipal or governmental corporation,
unit, agency or department thereof, and the proper officers, as
such, of an Emergency Service Provider or an unincorporated
municipality or department thereof, as well as private
individuals, partnerships, and corporations.
HC-DFS240 04-10
V1-ET
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CIGNA HEALTH AND LIFE INSURANCE
COMPANY, a Cigna company (hereinafter called
Cigna)
CERTIFICATE RIDER – Connecticut Residents
Rider Eligibility: Each Employee who is located in
Connecticut
You will become insured on the date you become eligible,
including if you are not in Active Service on that date due to
your health status.
This rider forms a part of the certificate issued to you by
Cigna.
The provisions set forth in this rider comply with the legal
requirements of Connecticut group insurance plans covering
insureds located in Connecticut. These provisions supersede
any provisions in your certificate to the contrary unless the
provisions in your certificate result in greater benefits.
HC-ETCTRDR
Certification Requirements - Out-of-Network
For You and Your Dependents
Pre-Admission Certification/Continued Stay Review for
Hospital Confinement
Covered Expenses incurred will be reduced by the lesser of
50% or the amount of the penalty under the plan or $500
(whichever is less) for Hospital charges made for each
separate admission to the Hospital unless PAC is received:
prior to the date of admission; or in the case of an
emergency admission, within 48 hours after the date of
admission.
Covered Expenses incurred for which benefits would
otherwise be payable under this plan for the charges listed
below will be reduced by the lesser of 50% or the amount of
the penalty under the plan or $500 (whichever is less):
Hospital charges for Bed and Board, for treatment listed
above for which PAC was performed, which are made for
any day in excess of the number of days certified through
PAC or CSR.
The following only applies if the plan includes Outpatient
Certification Requirements:
Covered Expenses incurred will be reduced by the lesser of
the amount of the penalty under the plan, $500 or 50% for
charges made for any outpatient diagnostic testing or
procedure performed unless Outpatient Certification is
received prior to the date the testing or procedure is
performed.
HC-PAC2 10-14
V2-ET
Definitions
Dependent
Federal rights may not be available to same-sex spouses, or
Civil Union partners or Dependents.
Connecticut law allows same-sex marriages, and grants parties
to a civil union the same benefits, protections and
responsibilities that flow from marriage under state law.
However, some or all of the benefits, protections and
responsibilities related to health insurance that are available to
married persons of the opposite sex under federal law may not
be available to same-sex spouses, or parties to a civil union.
HC-DFS673 01-15
V5-ET2
CIGNA HEALTH AND LIFE INSURANCE
COMPANY, a Cigna company (hereinafter called
Cigna)
CERTIFICATE RIDER – Delaware Residents
Rider Eligibility: Each Employee who is located in Delaware
You will become insured on the date you become eligible,
including if you are not in Active Service on that date due to
your health status.
This rider forms a part of the certificate issued to you by
Cigna.
The provisions set forth in this rider comply with the legal
requirements of Delaware group insurance plans covering
insureds located in Delaware. These provisions supersede any
provisions in your certificate to the contrary unless the
provisions in your certificate result in greater benefits.
HC-ETDERDR
myCigna.com 9
Covered Expenses
charges made for treatment of Serious Mental Illness. Such
Covered Expenses will be payable the same as for other
illnesses. Any Mental Illness Maximums in the Schedule
and any Full Payment Area exceptions for mental illness
will not apply to Serious Mental Illness.
HC-COV446 01-15
V2-ET1
When You Have A Complaint Or An
Appeal
For the purposes of this section, any reference to "you", "your"
or "Member" also refers to a representative or provider
designated by you to act on your behalf, unless otherwise
noted.
We want you to be completely satisfied with the care you
receive. That is why we have established a process for
addressing your concerns and solving your problems.
Start with Member Services
We are here to listen and help. If you have a concern regarding
a person, a service, the quality of care, or contractual benefits,
you can call our toll-free number and explain your concern to
one of our Customer Service representatives. You can also
express that concern in writing. Please call or write to us at the
following:
Customer Services Toll-Free Number or address that
appears on your Benefit Identification card, explanation
of benefits or claim form.
We will do our best to resolve the matter on your initial
contact. If we need more time to review or investigate your
concern, we will get back to you as soon as possible, but in
any case within 30 days.
If you are not satisfied with the results of a coverage decision,
you can start the appeals procedure.
Appeals Procedure
Cigna has a two step appeals procedure for coverage
decisions. To initiate an appeal, you must submit a request for
an appeal in writing within 365 days of receipt of a denial
notice. You should state the reason why you feel your appeal
should be approved and include any information supporting
your appeal. If you are unable or choose not to write, you may
ask to register your appeal by telephone. Call or write to us at
the toll-free number or address on your Benefit Identification
card, explanation of benefits or claim form.
Level One Appeal
Your appeal will be reviewed and the decision made by
someone not involved in the initial decision. Appeals
involving Medical Necessity or clinical appropriateness will
be considered by a health care professional.
For level one appeals, we will respond in writing with a
decision within fifteen calendar days after we receive an
appeal for a required preservice or concurrent care coverage
determination (decision). We will respond within 30 calendar
days after we receive an appeal for a postservice coverage
determination. If more time or information is needed to make
the determination, we will notify you in writing to request an
extension of up to 15 calendar days and to specify an
additional information needed to complete the review.
You may request that the appeal process be expedited if, the
time frames under this process would seriously jeopardize
your life, health or ability to regain maximum function or in
the opinion of your Physician would cause you severe pain
which cannot be managed without the requested services; or
your appeal involves nonauthorization of an admission or
continuing inpatient Hospital stay. Cigna's Physician reviewer,
in consultation with the treating Physician, will decide if an
expedited appeal is necessary. When an appeal is expedited,
we will respond orally with a decision within 72 hours,
followed up in writing.
Level Two Appeal
If you are dissatisfied with our level one appeal decision, you
may request a second review. To start a level two appeal,
follow the same process required for a level one appeal.
Most requests for a second review will be conducted by the
Appeals Committee, which consists of at least three people.
Anyone involved in the prior decision may not vote on the
Committee. For appeals involving Medical Necessity or
clinical appropriateness, the Committee will consult with at
least one Physician reviewer in the same or similar specialty
as the care under consideration, as determined by Cigna's
Physician reviewer. You may present your situation to the
Committee in person or by conference call.
For level two appeals we will acknowledge in writing that we
have received your request and schedule a Committee review.
For required preservice and concurrent care coverage
determinations, the Committee review will be completed
within 15 calendar days. For postservice claims, the
Committee review will be completed within 30 calendar days.
If more time or information is needed to make the
determination, we will notify you in writing to request an
extension of up to 15 calendar days and to specify any
additional information needed by the Committee to complete
the review. You will be notified in writing of the Committee's
decision within five working days after the Committee
meeting, and within the Committee review time frames above
if the Committee does not approve the requested coverage.
You may request that the appeal process be expedited if, the
time frames under this process would seriously jeopardize
myCigna.com 10
your life, health or ability to regain maximum function or in
the opinion of your Physician would cause you severe pain
which cannot be managed without the requested services; or
your appeal involves nonauthorization of an admission or
continuing inpatient Hospital stay. Cigna's Physician reviewer,
in consultation with the treating Physician will decide if an
expedited appeal is necessary. When an appeal is expedited,
we will respond orally with a decision within 72 hours,
followed up in writing.
Independent Review Procedure
If you are not fully satisfied with the decision of Cigna's level-
two appeal review regarding your Medical Necessity or
clinical appropriateness issue, you may request that your
appeal be referred to an Independent Review Organization.
The Independent Review Organization is composed of persons
who are not employed by Cigna HealthCare or any of its
affiliates. A decision to use the voluntary level of appeal will
not affect the claimant's rights to any other benefits under the
plan.
There is no charge for you to initiate this independent review
process. Cigna will abide by the decision of the Independent
Review Organization.
In order to request a referral to an Independent Review
Organization, certain conditions apply. The reason for the
denial must be based on a Medical Necessity or clinical
appropriateness determination by Cigna. Administrative,
eligibility or benefit coverage limits or exclusions are not
eligible for appeal under this process.
To request a review, you must notify the Appeals Coordinator
within 180 days of your receipt of Cigna's level-two appeal
review denial. Cigna will then forward the file to the
Independent Review Organization.
The Independent Review Organization will render an opinion
within 30 days. When requested and when a delay would be
detrimental to your condition, as determined by Cigna's
Physician reviewer, the review shall be completed within 3
days.
The Independent Review Program is a voluntary program
arranged by Cigna.
Appeal to the State of Delaware
You have the right to appeal a claim denial for medical
reasons or to appeal a claim denial for non-medical reasons to
the Delaware Insurance Department. The Delaware Insurance
Department also provides free informal mediation services
which are in addition to, but do not replace, your right to
appeal this decision. You can contact the Delaware Insurance
Department for information about an appeal or mediation by
calling the Consumer Services Division at (302) 674-7310.
You may go to the Delaware Insurance Department at The
Rodney Building, 841 Silver Lake Blvd., Dover, DE 19904
between the hours of 8:30 a.m. and 4:00 p.m. to personally
discuss the appeal or mediation process. You may also wish to
submit a complaint by sending an email to the Delaware
Insurance Department at [email protected], or by
using the complaint form, found at
http://www.delawareinsurance.gov/complaint/complaintform.
pdf and faxing the complaint to (302) 739-6278.
All appeals must be filed within 60 days from the date you
receive this notice otherwise this decision will be final.
Notice of Benefit Determination on Appeal
Every notice of a determination on appeal will be provided in
writing or electronically and, if an adverse determination, will
include: the specific reason or reasons for the adverse
determination; reference to the specific plan provisions on
which the determination is based; a statement that the claimant
is entitled to receive, upon request and free of charge,
reasonable access to and copies of all documents, records, and
other Relevant Information as defined; a statement describing
any voluntary appeal procedures offered by the plan and the
claimant's right to bring an action under ERISA section
502(a); upon request and free of charge, a copy of any internal
rule, guideline, protocol or other similar criterion that was
relied upon in making the adverse determination regarding
your appeal, and an explanation of the scientific or clinical
judgment for a determination that is based on a Medical
Necessity, experimental treatment or other similar exclusion
or limit.
You also have the right to bring a civil action under Section
502(a) of ERISA if you are not satisfied with the decision on
review. You or your plan may have other voluntary alternative
dispute resolution options such as Mediation. One way to find
out what may be available is to contact your local U.S.
Department of Labor office and your State insurance
regulatory agency. You may also contact the Plan
Administrator.
Relevant Information
Relevant Information is any document, record, or other
information which was relied upon in making the benefit
determination; was submitted, considered, or generated in the
course of making the benefit determination, without regard to
whether such document, record, or other information was
relied upon in making the benefit determination; demonstrates
compliance with the administrative processes and safeguards
required by federal law in making the benefit determination;
or constitutes a statement of policy or guidance with respect to
the plan concerning the denied treatment option or benefit or
the claimant's diagnosis, without regard to whether such
advice or statement was relied upon in making the benefit
determination.
Legal Action
If your plan is governed by ERISA, you have the right to bring
a civil action under Section 502(a) of ERISA if you are not
myCigna.com 11
satisfied with the outcome of the Appeals Procedure. In most
instances, you may not initiate a legal action against Cigna
until you have completed the Level One and Level Two
Appeal processes. If your Appeal is expedited, there is no
need to complete the Level Two process prior to bringing
legal action.
HC-APL63 04-10
V1-ET
CIGNA HEALTH AND LIFE INSURANCE
COMPANY, a Cigna company (hereinafter called
Cigna)
CERTIFICATE RIDER – Florida Residents
Rider Eligibility: Each Employee who is located in Florida
The benefits of the policy providing your coverage are
primarily governed by the law of a state other than
Florida.
You will become insured on the date you become eligible,
including if you are not in Active Service on that date due to
your health status.
This rider forms a part of the certificate issued to you by
Cigna.
The provisions set forth in this rider comply with the legal
requirements of Florida group insurance plans covering
insureds located in Florida. These provisions supersede any
provisions in your certificate to the contrary unless the
provisions in your certificate result in greater benefits.
HC-ETFLRDR
Eligibility – Effective Date
Dependent Insurance
Effective Date of Dependent Insurance
Insurance for your Dependents will become effective on the
date you elect it by signing an approved payroll deduction
form, but no earlier than the day you become eligible for
Dependent Insurance. All of your Dependents as defined will
be included. A newborn child will be covered for the first 31
days of life even if you fail to enroll the child. If you enroll the
child after the first 31 days and by the 60th day after his birth,
coverage will be offered at an additional premium. Coverage
for an adopted child will become effective from the date of
placement in your home or from birth for the first 31 days
even if you fail to enroll the child. However, if you enroll the
adopted child between the 31st and 60th days after his birth or
placement in your home, coverage will be offered at an
additional premium.
HC-ELG9 04-10
V1-ET
Important Information About Your
Medical plan
Direct Access For A Dermatologist
Individuals covered by this plan may have direct access to any
participating dermatologist for a maximum of 5 visits per
contract year without an authorization of care. The 5 visits do
not have to be with the same provider. Any additional visits
will require authorization. Included in this benefit are
management of the dermatologic condition as well as minor
procedures. All other procedures that are not minor will
require prior authorization.
HC-IMP174 12-15
ET1
Covered Expenses
charges made for or in connection with mammograms for
breast cancer screening or diagnostic purposes, including,
but not limited to: a baseline mammogram for women ages
35 through 39; a mammogram for women ages 40 through
49, every two years or more frequently based on the
attending Physician's recommendations; a mammogram
every year for women age 50 and over; and one or more
mammograms upon the recommendation of a Physician for
any woman who is at risk for breast cancer due to her
family history; has biopsy proven benign breast disease; or
has not given birth before age 30. A mammogram will be
covered with or without a Physician’s recommendation,
provided the mammogram is performed at an approved
facility for breast cancer screening.
charges made for diagnosis and Medically Necessary
surgical procedures to treat dysfunction of the
temporomandibular joint. Appliances and non-surgical
treatment including for orthodontia are not covered.
charges for the treatment of cleft lip and cleft palate
including medical, dental, speech therapy, audiology and
nutrition services, when prescribed by a Physician.
myCigna.com 12
charges for general anesthesia and hospitalization services
for dental procedures for an individual who is under age 8
and for whom it is determined by a licensed Dentist and the
child's Physician that treatment in a Hospital or ambulatory
surgical center is necessary due to a significantly complex
dental condition or developmental disability in which
patient management in the dental office has proven to be
ineffective; or has one or more medical conditions that
would create significant or undue medical risk if the
procedure were not rendered in a Hospital or ambulatory
surgical center.
charges for the services of certified nurse-midwives,
licensed midwives, and licensed birth centers regardless of
whether or not such services are received in a home birth
setting.
charges for or in connection with Medically Necessary
diagnosis and treatment of osteoporosis for high risk
individuals. This includes, but is not limited to individuals
who: have vertebral abnormalities; are receiving long-term
glucocorticoid (steroid) therapy; have primary
hyperparathyroidism; have a family history of osteoporosis;
and/or are estrogen-deficient individuals who are at clinical
risk for osteoporosis.
charges for an inpatient Hospital stay following a
mastectomy will be covered for a period determined to be
Medically Necessary by the Physician and in consultation
with the patient. Postsurgical follow-up care may be
provided at the Hospital, Physician's office, outpatient
center, or at the home of the patient.
charges for newborn and infant hearing screening and
Medically Necessary follow-up evaluations. When ordered
by the treating Physician, a newborn’s hearing screening
must include auditory brainstem responses or evoked
otacoustic emissions or other appropriate technology
approved by the FDA. All screenings shall be conducted by
a licensed audiologist, Physician, or supervised individual
who has training specific to newborn hearing screening.
Newborn means an age range from birth through 29 days.
Infant means an age range from 30 days through 12 months.
In addition, Covered Expenses will include expenses incurred
at any of the Approximate Age Intervals shown below, for a
Dependent child who is age 15 or less, for charges made for
Child Preventive Care Services consisting of the following
services delivered or supervised by a Physician, in keeping
with prevailing medical standards:
a history;
physical examination;
development assessment;
anticipatory guidance; and
appropriate immunizations and laboratory tests;
excluding any charges for:
more than one visit to one provider for Child Preventive
Care Services at each of the Approximate Age Intervals, up
to a total of 18 visits for each Dependent child;
services for which benefits are otherwise provided under
this Covered Expenses section;
services for which benefits are not payable, according to the
Expenses Not Covered section.
It is provided that any Deductible that would otherwise apply
will be waived for those Covered Expenses incurred for Child
Preventive Care Services. Approximate Age Intervals are:
Birth, 2 months, 4 months, 6 months, 9 months, 12 months, 15
months, 18 months, 2 years, 3 years, 4 years, 5 years, 6 years,
8 years, 10 years, 12 years, 14 years and 15 years.
HC-COV25 04-10
V1-ET1
Medical Conversion Privilege
For You and Your Dependents
When a person's Medical Expense Insurance ceases, he may
be eligible to be insured under an individual policy of medical
care benefits (called the Converted Policy).
A Converted Policy will be issued by Cigna only to a person
who:
resides in a state that requires offering a conversion
policy,
is Entitled to Convert, and
applies in writing and pays the first premium for the
Converted Policy to Cigna within 31 days after the date
his insurance ceases. Evidence of good health is not
needed.
Employees Entitled to Convert
You are Entitled to Convert Medical Expense Insurance for
yourself and all of your Dependents who were insured when
your insurance ceased but only if:
you are not eligible for other individual insurance coverage
on a guaranteed issue basis.
you have been insured for at least three consecutive months
under the policy or under it and a prior policy issued to the
Policyholder.
your insurance ceased because you were no longer in Active
Service or no longer eligible for Medical Expense
Insurance.
you are not eligible for Medicare.
you would not be Overinsured.
myCigna.com 13
you have paid all required premium or contribution.
you have not performed an act or practice that constitutes
fraud in connection with the coverage.
you have not made an intentional misrepresentation of a
material fact under the terms of the coverage.
your insurance did not cease because the policy in its
entirety canceled.
If you retire, you may apply for a Converted Policy within 31
days after your retirement date in place of any continuation of
your insurance that may be available under this plan when you
retire, if you are otherwise Entitled to Convert.
Dependents Entitled to Convert
The following Dependents are also Entitled to Convert:
a child who is not eligible for other individual insurance
coverage on a guaranteed issue basis, and whose insurance
under this plan ceases because he no longer qualifies as a
Dependent or because of your death;
a spouse who is not eligible for other individual insurance
coverage on a guaranteed issue basis, and whose insurance
under this plan ceases due to divorce, annulment of
marriage or your death;
your Dependents whose insurance under this plan ceases
because your insurance ceased solely because you are
eligible for Medicare;
but only if that Dependent: is not eligible for other individual
insurance coverage on a guaranteed issue basis, is not eligible
for Medicare, would not be Overinsured, has paid all required
premium or contribution, has not performed an act or practice
that constitutes fraud in connection with the coverage, and has
not made an intentional misrepresentation of a material fact
under the terms of the coverage.
Overinsured
A person will be considered Overinsured if either of the
following occurs:
his insurance under this plan is replaced by similar group
coverage within 31 days.
the benefits under the Converted Policy, combined with
Similar Benefits, result in an excess of insurance based on
Cigna's underwriting standards for individual policies.
Similar Benefits are: those for which the person is covered by
another hospital, surgical or medical expense insurance policy,
or a hospital, or medical service subscriber contract, or a
medical practice or other prepayment plan or by any other
plan or program; those for which the person is eligible,
whether or not covered, under any plan of group coverage on
an insured or uninsured basis; or those available for the person
by or through any state, provincial or federal law.
Converted Policy
If you reside in a state that requires the offering of a
conversion policy, the Converted Policy will be one of Cigna's
current conversion policy offerings available in the state
where you reside, as determined based upon Cigna's rules.
The Converted Policy will be issued to you if you are Entitled
to Convert, insuring you and those Dependents for whom you
may convert. If you are not Entitled to Convert and your
spouse and children are Entitled to Convert, it will be issued to
the spouse, covering all such Dependents. Otherwise, a
Converted Policy will be issued to each Dependent who is
Entitled to Convert. The Converted Policy will take effect on
the day after the person's insurance under this plan ceases. The
premium on its effective date will be based on: class of risk
and age; and benefits.
During the first 12 months the Converted Policy is in effect,
the amount payable under it will be reduced so that the total
amount payable under the Converted Policy and the Medical
Benefits Extension of this plan (if any) will not be more than
the amount that would have been payable under this plan if the
person's insurance had not ceased. After that, the amount
payable under the Converted Policy will be reduced by any
amount still payable under the Medical Benefits Extension of
this plan (if any). Cigna or the Policyholder will give you, on
request, further details of the Converted Policy.
HC-CNV28 04-14
V1-ET
Medical Benefits Extension Upon Policy
Cancellation
If the Medical Benefits under this plan cease for you or your
Dependent due to cancellation of the policy, and you or your
Dependent is Totally Disabled on that date due to an Injury,
Sickness or pregnancy, Medical Benefits will be paid for
Covered Expenses incurred in connection with that Injury,
Sickness or pregnancy. However, no benefits will be paid after
the earliest of:
the date you exceed the Maximum Benefit, if any, shown in
the Schedule;
the date a succeeding carrier agrees to provide coverage
without limitation for the disabling condition;
the date you are no longer Totally Disabled;
12 months from the date the policy is canceled; or
for pregnancy, until delivery.
myCigna.com 14
Totally Disabled
You will be considered Totally Disabled if, because of an
Injury or a Sickness:
you are unable to perform the basic duties of your
occupation; and
you are not performing any other work or engaging in any
other occupation for wage or profit.
Your Dependent will be considered Totally Disabled if,
because of an Injury or a Sickness:
he is unable to engage in the normal activities of a person of
the same age, sex and ability; or
in the case of a Dependent who normally works for wage or
profit, he is not performing such work.
HC-BEX42 04-11
ET
Definitions
Dependent
A child includes a legally adopted child, including that child
from the date of placement in the home or from birth provided
that a written agreement to adopt such child has been entered
into prior to the birth of such child. Coverage for a legally
adopted child will include the necessary care and treatment of
an Injury or a Sickness existing prior to the date of placement
or adoption. Coverage is not required if the adopted child is
ultimately not placed in your home.
A child includes a child born to an insured Dependent child of
yours until such child is 18 months old.
HC-DFS162 07-14
V2-ET
CIGNA HEALTH AND LIFE INSURANCE
COMPANY, a Cigna company (hereinafter called
Cigna)
CERTIFICATE RIDER – Georgia Residents
Rider Eligibility: Each Employee who is located in Georgia
You will become insured on the date you become eligible,
including if you are not in Active Service on that date due to
your health status.
This rider forms a part of the certificate issued to you by
Cigna.
The provisions set forth in this rider comply with the legal
requirements of Georgia group insurance plans covering
insureds located in Georgia. These provisions supersede any
provisions in your certificate to the contrary unless the
provisions in your certificate result in greater benefits.
HC-ETGARDR
When You Have A Complaint Or An
Appeal
For the purposes of this section, any reference to "you," "your"
or "Member" also refers to a representative or provider
designated by you to act on your behalf, unless otherwise
noted.
We want you to be completely satisfied with the care you
receive. That is why we have established a process for
addressing your concerns and solving your problems.
Start With Customer Service
We are here to listen and help. If you have a concern regarding
a person, a service, the quality of care, contractual benefits, or
a rescission of coverage, you can call our toll-free number and
explain your concern to one of our Customer Service
representatives. Please call us at the Customer Service Toll-
Free Number that appears on your Benefit Identification card,
explanation of benefits or claim form.
We will do our best to resolve the matter on your initial
contact. If we need more time to review or investigate your
concern, we will get back to you as soon as possible, but in
any case within 30 days.
If you are not satisfied with the results of a coverage decision,
you can start the appeals procedure.
Appeals Procedure
Cigna has a two step appeals procedure for coverage
decisions. To initiate an appeal, you must submit a request for
an appeal in writing, within 365 days of receipt of a denial
notice, to the following address:
Cigna
National Appeals Organization (NAO)
PO Box 188011
Chattanooga, TN 37422
You should state the reason why you feel your appeal should
be approved and include any information supporting your
appeal. If you are unable or choose not to write, you may ask
to register your appeal by telephone. Call us at the toll-free
number on your Benefit Identification card, explanation of
benefits or claim form.
myCigna.com 15
Level-One Appeal
Your appeal will be reviewed and the decision made by
someone not involved in the initial decision. Appeals
involving Medical Necessity or clinical appropriateness will
be considered by a health care professional.
For level-one appeals, we will respond in writing with a
decision within 15 calendar days after we receive an appeal
for a required preservice or concurrent care coverage
determination (decision). We will respond within 30 calendar
days after we receive an appeal for a postservice coverage
determination. If more time or information is needed to make
the determination, we will notify you in writing to request an
extension of up to 15 calendar days and to specify any
additional information needed to complete the review.
You may request that the appeal process be expedited if, (a)
the time frames under this process would seriously jeopardize
your life, health or ability to regain maximum function or in
the opinion of your Physician would cause you severe pain
which cannot be managed without the requested services; or
(b) your appeal involves nonauthorization of an admission or
continuing inpatient Hospital stay.
If you request that your appeal be expedited based on (a)
above, you may also ask for an expedited external
Independent Review at the same time, if the time to complete
an expedited level-one appeal would be detrimental to your
medical condition.
Cigna's Physician Reviewer, in consultation with the treating
Physician, will decide if an expedited appeal is necessary.
When an appeal is expedited, we will respond orally with a
decision within 72 hours, followed up in writing.
Level Two Appeal
If you are dissatisfied with our level one appeal decision, you
may request a second review. To start a level two appeal,
follow the same process required for a level one appeal.
Requests for a level-two appeal regarding the Medical
Necessity or clinical appropriateness of your issue will be
conducted by a Committee, which consists of at least three
people not previously involved in the prior decision. The
Committee will consult with at least one Physician in the same
or similar specialty as the care under consideration, as
determined by Cigna's Physician Reviewer. You may present
your situation to the Committee in person or by conference
call.
For required preservice and concurrent care coverage
determinations, the Committee review will be completed
within 15 calendar days. For postservice claims, the
Committee review will be completed within 30 calendar days.
If more time or information is needed to make the
determination, we will notify you in writing to request an
extension of up to 15 calendar days and to specify any
additional information needed by the Committee to complete
the review. In the event any new or additional information
(evidence) is considered, relied upon or generated by Cigna in
connection with the level-two appeal, Cigna will provide this
information to you as soon as possible and sufficiently in
advance of the decision, so that you will have an opportunity
to respond. Also, if any new or additional rationale is
considered by Cigna, Cigna will provide the rationale to you
as soon as possible and sufficiently in advance of the decision
so that you will have an opportunity to respond.
You will be notified in writing of the Committee's decision
within five working days after the Committee meeting, and
within the Committee review time frames above if the
Committee does not approve the requested coverage.
You may request that the appeal process be expedited if, the
time frames under this process would seriously jeopardize
your life, health or ability to regain maximum function or in
the opinion of your Physician would cause you severe pain
which cannot be managed without the requested services; or
your appeal involves nonauthorization of an admission or
continuing inpatient Hospital stay. Cigna's Physician
Reviewer, in consultation with the treating Physician will
decide if an expedited appeal is necessary. When an appeal is
expedited, we will respond orally with a decision within 72
hours, followed up in writing.
Independent Review Procedure
If you are not fully satisfied with the decision of Cigna’s
level two appeal review and the appeal involves medical
judgment or a rescission of coverage, you may request that
your appeal be referred to an Independent Review
Organization. The Independent Review Organization is
composed of persons who are not employed by Cigna
HealthCare or any of its affiliates. A decision to request an
appeal to an Independent Review Organization will not
affect the claimant's rights to any other benefits under the
plan.
There is no charge for you to initiate this independent
review process. Cigna will abide by the decision of the
Independent Review Organization.
To request a review, you must notify the Appeals
Coordinator within 180 days of your receipt of Cigna's level
two appeal review denial. Cigna will then forward the file to
the Independent Review Organization.
The Independent Review Organization will render an
opinion within 45 days. When requested and if a delay
would be detrimental to your condition, as determined by
Cigna's Physician Reviewer, or if your appeal concerns an
admission, availability of care, continued stay, or health
care item or service for which you received emergency
services, but you have no yet been discharged from the
facility, the review shall be completed within 72 hours.
myCigna.com 16
Notice of Benefit Determination on Appeal
Every notice of a determination on appeal will be provided in
writing or electronically and, if an adverse determination, will
include: information sufficient to identify the claim; the
specific reason or reasons for the adverse determination;
reference to the specific plan provisions on which the
determination is based; a statement that the claimant is entitled
to receive, upon request and free of charge, reasonable access
to and copies of all documents, records, and other Relevant
Information as defined; a statement describing any voluntary
appeal procedures offered by the plan and the claimant's right
to bring an action under ERISA section 502(a); upon request
and free of charge, a copy of any internal rule, guideline,
protocol or other similar criterion that was relied upon in
making the adverse determination regarding your appeal, and
an explanation of the scientific or clinical judgment for a
determination that is based on a Medical Necessity,
experimental treatment or other similar exclusion or limit; and
information about any office of health insurance consumer
assistance or ombudsman available to assist you in the appeal
process. A final notice of adverse determination will include a
discussion of the decision.
You also have the right to bring a civil action under section
502(a) of ERISA if you are not satisfied with the decision on
review. You or your plan may have other voluntary alternative
dispute resolution options such as Mediation. One way to find
out what may be available is to contact your local U.S.
Department of Labor office and your State insurance
regulatory agency. You may also contact the Plan
Administrator.
Relevant Information
Relevant Information is any document, record, or other
information which was relied upon in making the benefit
determination; was submitted, considered, or generated in the
course of making the benefit determination, without regard to
whether such document, record, or other information was
relied upon in making the benefit determination; demonstrates
compliance with the administrative processes and safeguards
required by federal law in making the benefit determination;
or constitutes a statement of policy or guidance with respect to
the plan concerning the denied treatment option or benefit or
the claimant's diagnosis, without regard to whether such
advice or statement was relied upon in making the benefit
determination.
Legal Action
If your plan is governed by ERISA, you have the right to bring
a civil action under section 502(a) of ERISA if you are not
satisfied with the outcome of the Appeals Procedure. In most
instances, you may not initiate a legal action against Cigna in
federal court until you have completed the level one and level
two Appeal processes. If your Appeal is expedited, there is no
need to complete the level two process prior to bringing legal
action. However, no action will be brought at all unless
brought within 3 years after a claim is submitted for In-
Network Services or within three years after proof of claim is
required under the Plan for Out-of-Network services.
Appeal to the State of Georgia
You have the right to contact the Department of Insurance or
the Department of Human Resources for assistance at any
time. The Department of Insurance or the Department of
Human Resources may be contacted at the following
respective addresses and telephone numbers:
Georgia Department of Insurance
2 Martin Luther King, Jr. Drive
Floyd Memorial Bldg, 704 West Tower
Atlanta, GA 30334
404-656-2056
Georgia Dept. of Human Resources
Two Peachtree Street, NW
Suite 33.250
Atlanta, GA 30303-3167
404-657-5550
HC-APL46 05-14
V2-ET
CIGNA HEALTH AND LIFE INSURANCE
COMPANY, a Cigna company (hereinafter called
Cigna)
CERTIFICATE RIDER – Idaho Residents
Rider Eligibility: Each Employee who is located in Idaho
You will become insured on the date you become eligible,
including if you are not in Active Service on that date due to
your health status.
This rider forms a part of the certificate issued to you by
Cigna.
The provisions set forth in this rider comply with the legal
requirements of Idaho group insurance plans covering insureds
located in Idaho. These provisions supersede any provisions in
your certificate to the contrary unless the provisions in your
certificate result in greater benefits.
HC-ETIDRDR
myCigna.com 17
When You Have A Complaint Or An
Appeal
For the purposes of this section, any reference to "you," "your"
or "Member" also refers to a representative or provider
designated by you to act on your behalf, unless otherwise
noted.
We want you to be completely satisfied with the care you
receive. That is why we have established a process for
addressing your concerns and solving your problems.
Start with Customer Service
We are here to listen and help. If you have a concern regarding
a person, a service, the quality of care, contractual benefits, or
a rescission of coverage, you can call our toll-free number and
explain your concern to one of our Customer Service
representatives. Please call us at the Customer Service toll-free
number that appears on your Benefit Identification card,
explanation of benefits or claim form.
We will do our best to resolve the matter on your initial
contact. If we need more time to review or investigate your
concern, we will get back to you as soon as possible, but in
any case within 30 days.
If you are not satisfied with the results of a coverage decision,
you can start the appeals procedure.
Appeals Procedure
Cigna has a two-step appeals procedure for coverage
decisions. To initiate an appeal, you must submit a request for
an appeal in writing, within 365 days of receipt of a denial
notice, to the following address:
Cigna
National Appeals Organization (NAO)
PO Box 188011
Chattanooga, TN 37422
You should state the reason why you feel your appeal should
be approved and include any information supporting your
appeal. If you are unable or choose not to write, you may ask
to register your appeal by telephone. Call us at the toll-free
number on your Benefit Identification card, explanation of
benefits or claim form.
Level One Appeal
Your appeal will be reviewed and the decision made by
someone not involved in the initial decision. Appeals
involving Medical Necessity or clinical appropriateness will
be considered by a health care professional.
For level one appeals, we will respond in writing with a
decision within 15 calendar days after we receive an appeal
for a required preservice or concurrent care coverage
determination (decision). We will respond within 30 calendar
days after we receive an appeal for a postservice coverage
determination. If more time or information is needed to make
the determination, we will notify you in writing to request an
extension of up to 15 calendar days and to specify any
additional information needed to complete the review.
You may request that the appeal process be expedited if: (a)
the time frames under this process would seriously jeopardize
your life, health or ability to regain maximum function or, in
the opinion of your Physician, would cause you severe pain
which cannot be managed without the requested services; or
(b) your appeal involves non-authorization of an admission or
continuing inpatient Hospital stay.
If you request that your appeal be expedited based on (a)
above, you may also ask for an expedited external
Independent Review at the same time, if the time to complete
an expedited level-one appeal would be detrimental to your
medical condition.
Cigna's Physician Reviewer, in consultation with the treating
Physician, will decide if an expedited appeal is necessary.
When an appeal is expedited, we will respond orally with a
decision within 72 hours, followed up in writing.
Level Two Appeal
If you are dissatisfied with our level one appeal decision, you
may request a second review. To start a level two appeal,
follow the same process required for a level one appeal.
If the appeal involves a coverage decision based on issues of
Medical Necessity, clinical appropriateness or experimental
treatment, a medical review will be conducted by a Physician
Reviewer in the same or similar specialty as the care under
consideration, as determined by Cigna’s Physician Reviewer.
For all other coverage plan-related appeals, a second-level
review will be conducted by someone who was not involved
in any previous decision related to your appeal and who was
not a subordinate of previous decision makers. Provide all
relevant documentation with your second-level appeal request.
For required pre-service and concurrent care coverage
determinations, the review will be completed within 15
calendar days. For post-service claims, the review will be
completed within 30 calendar days. If more time or
information is needed to make the determination, we will
notify you in writing to request an extension of up to 15
calendar days and to specify any additional information
needed to complete the review.
In the event any new or additional information (evidence) is
considered, relied upon or generated by Cigna in connection
with the level-two appeal, Cigna will provide this information
to you as soon as possible and sufficiently in advance of the
decision, so that you will have an opportunity to respond.
Also, if any new or additional rationale is considered by
Cigna, Cigna will provide the rationale to you as soon as
possible and sufficiently in advance of the decision so that you
will have an opportunity to respond.
myCigna.com 18
You will be notified in writing of the decision within five
working days after the decision is made, and within the review
time frames above if Cigna does not approve the requested
coverage.
You may request that the appeal process be expedited if: the
time frames under this process would seriously jeopardize
your life, health or ability to regain maximum function; or in
the opinion of your Physician, would cause you severe pain
which cannot be managed without the requested services; or
your appeal involves non-authorization of an admission or
continuing inpatient Hospital stay. Cigna's Physician
Reviewer, in consultation with the treating Physician will
decide if an expedited appeal is necessary. When an appeal is
expedited, we will respond orally with a decision within 72
hours, followed up in writing.
Your Right To An Independent External Review
Please read this notice carefully. It describes a procedure
for review of a disputed health claim by a qualified
professional who has no affiliation with your health plan.
If you request an independent external review of your
claim, the decision made by the independent reviewer will
be binding and final on the health carrier. Except in
limited circumstances, you will have no further right to
have further review of your claim reviewed by a court,
arbitrator, mediator or other dispute resolution entity only
if your plan is subject to the Employee Retirement Income
Security Act of 1974 (ERISA), as more fully explained
below under “Binding Nature of the External Review
Decision."
If we issue a final adverse benefit determination of your
request to provide or pay for a health care service or supply,
you may have the right to have our decision reviewed by
health care professionals who have no association with us.
You have this right only if our denial decision involved:
The Medical Necessity, appropriateness, health care setting,
level of care, or effectiveness of your health care service or
supply, or
Our determination your health care service or supply was
investigational.
You must first exhaust our internal grievance and appeal
process. Exhaustion of that process includes completing all
levels of appeal, or unless you requested or agreed to a delay,
our failure to respond to a standard appeal within 35 days in
writing or to an urgent appeal within three (3) business days of
the date you filed your appeal. We may also agree to waive the
exhaustion requirement for an external review request. You
may file for an internal urgent appeal with us and for an
expedited external review with the Idaho Department of
Insurance at the same time if your request qualifies as an
“urgent care request” defined below.
You may submit a written request for an external review to:
Idaho Department of Insurance
ATTN: External Review
700 W State St., 3rd Floor
Boise, Idaho 83720-0043
For more information and for an external review request form:
See the department’s website at: http://www.doi.idaho.gov,
or
Call the department’s telephone number, (208) 334-4250, or
toll-free in Idaho, 1-800-721-3272.
You may represent yourself in your request or you may name
another person, including your treating health care provider, to
act as your authorized representative for your request. If you
want someone else to represent you, you must include a signed
“Appointment of an Authorized Representative” form with
your request.
Your written external review request to the Department of
Insurance must include a completed form authorizing the
release of any of your medical records the independent review
organization may require to reach a decision on the external
review, including any judicial review of the external review
decision pursuant to ERISA, if applicable. The department
will not act on an external review request without your
completed authorization form.
If your request qualifies for external review, our final adverse
benefit determination will be reviewed by an independent
review organization selected by the department. We will pay
the costs of the review.
Standard External Review Request: You must file your
written external review request with the department within
four months after the date we issue a final notice of denial.
Within seven (7) days after the department receives your
request, the department will send a copy to us.
Within 14 days after we receive your request from the
department, we will review your request for eligibility.
Within five business days after we complete that review, we
will notify you and the department in writing if your request
is eligible or what additional information is needed. If we
deny your eligibility for review, you may appeal that
determination to the department.
If your request is eligible for review, the department will
assign an independent review organization to your review
within seven days of receipt of our notice. The department
will also notify you in writing.
Within seven (7) days of the date you receive the
department’s notice of assignment to an independent review
organization, you may submit any additional information in
writing to the independent review organization that you
want the organization to consider in its review.
myCigna.com 19
The independent review organization must provide written
notice of its decision to you, to us and to the department
within 42 days after receipt of an external review request.
Expedited External Review Request: You may file a written
“urgent care request” with the department for an expedited
external review of a pre-service or concurrent service denial.
You may file for an internal urgent appeal with us and for an
expedited external review with the department at the same
time.
Urgent care request means a claim relating to an admission,
availability of care, continued stay or health care service for
which the covered person received emergency services but has
not been discharged from a facility, or any pre-service or
concurrent care claim for medical care or treatment for which
application of the time periods for making a regular external
review determination:
Could seriously jeopardize the life or health of the covered
person or the ability of the covered person to regain
maximum function;
In the opinion of the treating health care professional with
knowledge of the covered person’s medical condition,
would subject the covered person to severe pain that cannot
be adequately managed without the disputed care or
treatment; or
The treatment would be significantly less effective if not
promptly initiated.
The department will send your request to us. We will
determine, no later than the second full business day, if your
request is eligible for review. We will notify you and the
department no later than one (1) business day after our
decision if your request is eligible. If we deny your eligibility
for review, you may appeal that determination to the
department.
If your request is eligible for review, the department will
assign an independent review organization to your review
upon receipt of our notice. The department will also notify
you. The independent review organization must provide notice
of its decision to you, to us and to the department within 72
hours after the date of receipt of the external review request.
The independent review organization must provide written
confirmation of its decision within 48 hours of notice of its
decision. If the decision reverses our denial, we will notify
you and the department of the approval of coverage (and our
intent to pay the covered benefit) as soon as reasonably
practicable but not later than one (1) business day after
making the determination receiving notice of the decision.
Binding Nature of the External Review Decision: If your
plan is subject to federal ERISA laws (generally, any plan
offered through an employer to its employees), the external
review decision by the independent review organization will
be final and binding on us. You may have additional review
rights provided under federal ERISA laws.
If your plan is not subject to ERISA requirements, the external
review decision by the independent review organization will
be final and binding on both you and us. This means that if
you elect to request external review, you will be bound by
the decision of the independent review organization. You
will not have any further opportunity for review of our
denial after the independent review organization issues its
final decision. If you choose not to use the external review
process, other options for resolving a disputed claim may
include mediation, arbitration or filing an action in court.
Under Idaho law, the independent review organization is
immune from any claim relating to its opinion rendered or acts
or omissions performed within the scope of its duties unless
performed in bad faith or involving gross negligence.
Notice of Benefit Determination on Appeal
Every notice of a determination on appeal will be provided in
writing or electronically and, if an adverse determination, will
include: information sufficient to identify the claim; the
specific reason or reasons for the adverse determination;
reference to the specific plan provisions on which the
determination is based; a statement that the claimant is entitled
to receive, upon request and free of charge, reasonable access
to and copies of all documents, records, and other Relevant
Information as defined; a statement describing any voluntary
appeal procedures offered by the plan and the claimant's right
to bring an action under ERISA section 502(a); upon request
and free of charge, a copy of any internal rule, guideline,
protocol or other similar criterion that was relied upon in
making the adverse determination regarding your appeal, and
an explanation of the scientific or clinical judgment for a
determination that is based on a Medical Necessity,
experimental treatment or other similar exclusion or limit; and
information about any office of health insurance consumer
assistance or ombudsman available to assist you in the appeal
process. A final notice of adverse determination will include a
discussion of the decision.
You also have the right to bring a civil action under section
502(a) of ERISA if you are not satisfied with the decision on
review. You or your plan may have other voluntary alternative
dispute resolution options such as Mediation. One way to find
out what may be available is to contact your local U.S.
Department of Labor office and your State insurance
regulatory agency. You may also contact the Plan
Administrator.
Relevant Information
Relevant Information is any document, record, or other
information which: was relied upon in making the benefit
determination; was submitted, considered, or generated in the
course of making the benefit determination, without regard to
myCigna.com 20
whether such document, record, or other information was
relied upon in making the benefit determination; demonstrates
compliance with the administrative processes and safeguards
required by federal law in making the benefit determination;
or constitutes a statement of policy or guidance with respect to
the plan concerning the denied treatment option or benefit or
the claimant's diagnosis, without regard to whether such
advice or statement was relied upon in making the benefit
determination.
Legal Action
If your plan is governed by ERISA, you have the right to bring
a civil action under section 502(a) of ERISA if you are not
satisfied with the outcome of the Appeals Procedure. In most
instances, you may not initiate a legal action against Cigna
until you have completed the level one and level two Appeal
processes. If your Appeal is expedited, there is no need to
complete the level two process prior to bringing legal action.
However, no action will be brought at all unless brought
within three years after a claim is submitted for In-Network
services or within three years after proof of claim is required
under the Plan for Out-of-Network services.
HC-APL234 1-15
ET
CIGNA HEALTH AND LIFE INSURANCE
COMPANY, a Cigna company (hereinafter called
Cigna)
CERTIFICATE RIDER – Illinois Residents
Rider Eligibility: Each Employee who is located in Illinois
You will become insured on the date you become eligible,
including if you are not in Active Service on that date due to
your health status.
This rider forms a part of the certificate issued to you by
Cigna.
The provisions set forth in this rider comply with the legal
requirements of Illinois group insurance plans covering
insureds located in Illinois. These provisions supersede any
provisions in your certificate to the contrary unless the
provisions in your certificate result in greater benefits.
HC-ETILRDR
The Schedule
If your medical plan is subject to a Lifetime Maximum or
Preventive Care Maximum, The Schedule is amended to
indicate that Mammogram charges do not accumulate towards
those maximums. In addition, In-Network Preventive Care
Related (i.e. “routine”) Mammograms will be covered at “No
charge”.
SCHEDIL-ETC
Covered Expenses
charges made for or in connection with low-dose
mammography screening for detecting the presence of
breast cancer. Coverage shall include: a baseline
mammogram for women ages 35 to 39; an annual
mammogram for women age 40 and older; and
mammograms at intervals considered Medically Necessary
for women less than age 40 who have a family history of
breast cancer, prior personal history of breast cancer,
positive genetic testing or other risk factors. Coverage also
includes a comprehensive ultrasound screening of an entire
breast or breasts if a mammogram demonstrates
heterogeneous or dense breast tissue, when determined
Medically Necessary by a Physician licensed to practice
medicine in all of its branches.
Low dose mammography means the x-ray examination of
the breast using equipment dedicated specifically for
mammography, including the x-ray tube, compression
device and image receptor, with radiation exposure
delivery of less than one rad per breast for two views of
an average size breast.
charges made for complete and thorough clinical breast
exams performed by a Physician licensed to practice
medicine in all its branches, an advanced practice nurse who
has a collaborative agreement with a collaborating
Physician that authorizes breast examinations, or a
Physician assistant who has been delegated authority to
provide breast examinations. Coverage shall include such an
exam at least once every three years for women ages 20 to
40; and annually for women 40 years of age or older.
HC-COV430 08-15
V1-ET2
myCigna.com 21
CIGNA HEALTH AND LIFE INSURANCE
COMPANY, a Cigna company (hereinafter called
Cigna)
CERTIFICATE RIDER – Kansas Residents
Rider Eligibility: Each Employee who is located in Kansas
You will become insured on the date you become eligible,
including if you are not in Active Service on that date due to
your health status.
This rider forms a part of the certificate issued to you by
Cigna.
The provisions set forth in this rider comply with the legal
requirements of Kansas group insurance plans covering
insureds located in Kansas. These provisions supersede any
provisions in your certificate to the contrary unless the
provisions in your certificate result in greater benefits.
HC-ETKSRDR
Covered Expenses
abortion when a Physician certifies in writing that the
pregnancy would endanger the life of the mother, or when
the expenses are incurred to treat medical complications due
to abortion.
HC-COV103 04-10
V1-ET2
CIGNA HEALTH AND LIFE INSURANCE
COMPANY, a Cigna company (hereinafter called
Cigna)
CERTIFICATE RIDER – Kentucky Residents
Rider Eligibility: Each Employee who is located in Kentucky
You will become insured on the date you become eligible,
including if you are not in Active Service on that date due to
your health status.
This rider forms a part of the certificate issued to you by
Cigna.
The provisions set forth in this rider comply with the legal
requirements of Kentucky group insurance plans covering
insureds located in Kentucky. These provisions supersede any
provisions in your certificate to the contrary unless the
provisions in your certificate result in greater benefits.
HC-ETKYRDR
Covered Expenses
charges for cochlear implants for persons age 2 and over
with the diagnosis of profound sensorineural deafness or
postlingual deafness in adults. Cochlear implants for
children under age 2 will be covered when, upon review,
they are determined to be Medically Necessary.
charges for the diagnosis and treatment of Autism Spectrum
Disorders:
treatment for Autism Spectrum Disorders includes
medical care, habilitative or rehabilitative care, pharmacy
if covered by the plan, psychiatric care, psychological
care, therapeutic care, and applied behavior analysis
prescribed or ordered by a licensed health professional.
coverage is not subject to visit limits. Coverage is not
subject to copayments, deductibles, or coinsurance that is
less favorable than those applied to other covered
services.
Cigna may request utilization review of the treatment
once every 12 months, unless Cigna and the covered
person’s licensed Physician, psychiatrist, or psychologist
agree that a more frequent review is necessary
myCigna.com 22
Liaisons are available to facilitate communication between
You and Cigna regarding Autism Spectrum Disorder
coverage. The responsibilities of the liaison include:
explaining to the member the benefits for the treatment of
autism under the member's health benefit plan and the
specific process to access those benefits;
explaining to the member the process for prior authorization
of treatment, including communicating specific
documentation needed from the member or provider for the
insurer to consider the request;
monitoring the adjudication of a member’s claims for the
treatment of autism services;
explaining to the member the proper coding to use when
submitting claims for applied behavioral analysis therapy
and any supporting documentation required to be attached
to the claim;
explaining to the member, upon request, how claims for the
treatment of autism services were adjudicated, including the
application of any deductibles, copayments, coinsurance,
and benefit limitations; and
explaining to the member, upon request, any appeal rights
the member may have regarding coverage for the treatment
of autism that has been denied or limited.
charges for a telehealth consultation provided the treating
Physician or other provider facilitating the use of telehealth
ensures that: informed consent of the patient or another
person with authority to make the health care treatment
decision for the patient, is obtained before covered services
are provided through telehealth; and that the confidentiality
of the patient's medical information and quality of care
protocols are maintained. Telehealth means the use of
interactive, audio, video or other electronic media to deliver
health care. It includes the use of electronic media for
diagnosis, consultation, treatment, transfer of medical data
and medical education.
charges for the necessary care and treatment of medically
diagnosed inherited metabolic diseases. Coverage must
include amino acid modified preparations and low protein
modified food products for the treatment of inherited
metabolic diseases provided that the amino acid products
are prescribed as Medically Necessary for the therapeutic
treatment of inherited metabolic diseases, and are
administered under the direction of a Physician.
HC-COV523 05-15
ET1
When You Have A Complaint Or An
Appeal
For the purposes of this section, any reference to "you," "your"
or "Member" also refers to a representative or provider
designated by you to act on your behalf, unless otherwise
noted.
We want you to be completely satisfied with the care you
receive. That is why we have established a process for
addressing your concerns and solving your problems.
Start with Customer Service
We are here to listen and help. If you have a concern regarding
a person, a service, the quality of care, contractual benefits, or
a rescission of coverage, you can call our toll-free number and
explain your concern to one of our Customer Service
representatives. Please call us at the Customer Service Toll-
Free Number that appears on your Benefit Identification card,
explanation of benefits or claim form.
We will do our best to resolve the matter on your initial
contact. If we need more time to review or investigate your
concern, we will get back to you as soon as possible, but in
any case within 30 days.
If you are not satisfied with the results of a coverage decision,
you can start the appeals procedure.
Appeals Procedure
Cigna has a one step appeal procedure for coverage decisions.
To initiate an appeal, you must submit a request for an appeal
in writing, within 365 days of receipt of a denial notice, to the
following address:
Cigna
National Appeals Organization (NAO)
PO Box 188011
Chattanooga, TN 37422
You may also initiate an appeal when Cigna has not made and
provided written notice of an initial utilization review
determination within allowable time frames. You should state
the reason why you feel your appeal should be approved and
include any information supporting your appeal. If you are
unable or choose not to write, you may ask to register your
appeal by telephone. Call us at the toll-free number on your
Benefit Identification card, explanation of benefits or claim
form.
Internal Appeals
You, an authorized person, or a provider, acting on your
behalf, may request an internal appeal if you are dissatisfied
with the initial Medical Necessity or clinical appropriateness
decision or a coverage denial decision, or we have failed to
make and communicate in writing an initial Medical Necessity
or clinical appropriateness determination within allowable
time frames.
myCigna.com 23
Under federal law, you are allowed up to four (4) months after
the date of receipt of a notice of adverse determination or final
adverse determination to file a request for external review.
Coverage Denial Appeals
Your appeal of a Coverage Denial determination for which a
service, treatment, prescription drug, or device is specifically
limited, excluded or denied under the plan will be reviewed
and the decision made by someone not involved in the initial
decision and not a subordinate of previous decision makers.
Provide all relevant documentation with your appeal request.
For required preservice and concurrent care coverage
determinations, Cigna’s review will be completed within 30
calendar days of the receipt of your appeal request. For
postservice claims, Cigna’s review will be completed within
30 calendar days. In the event any new or additional
information (evidence) is considered, relied upon or generated
by Cigna in connection with the appeal, Cigna will provide
this information to you as soon as possible and sufficiently in
advance of the decision, so that you will have an opportunity
to respond. Also, if any new or additional rationale is
considered by Cigna, Cigna will provide the rationale to you
as soon as possible and sufficiently in advance of the decision
so that you will have an opportunity to respond.
You will be notified in writing of the decision within five
working days after the decision is made, and within the review
time frames above. Notification of the appeal review decision
will be provided to you and any designated representative and
provider(s) acting on your behalf.
Medical Necessity Appeals
Your appeal of Cigna's adverse determination, decision to
deny, reduce or terminate a medical service based on a
determination that it is not Medically Necessary or is
experimental or investigational, will be considered by a
Physician, or upon your request, by a reviewer, in the same or
similar specialty as the care under consideration, who was not
involved in the initial decision as determined by Cigna's
Physician Reviewer.
For required preservice and concurrent care coverage
determinations, Cigna’s review will be completed within 30
calendar days of the receipt of your appeal request. For
postservice claims, Cigna’s review will be completed within
30 calendar days. In the event any new or additional
information (evidence) is considered, relied upon or generated
by Cigna in connection with your appeal, Cigna will provide
this information to you as soon as possible and sufficiently in
advance of the decision, so that you will have an opportunity
to respond. Also, if any new or additional rationale is
considered by Cigna, Cigna will provide the rationale to you
as soon as possible and sufficiently in advance of the decision
so that you will have an opportunity to respond.
You will be notified in writing of the decision to uphold or
reverse the decision of the Physician Reviewer within five
working days after the decision is made, and within the review
time frames above. Notification of the appeal review decision
will be provided to you and any designated representative and
provider(s) acting on your behalf.
Expedited Internal Appeals
An expedited appeal will be provided when you are
hospitalized or as requested when the treating provider is of
the opinion that review under a standard time frame could, in
the absence of immediate medical attention, result in any of
the effects listed in the following paragraph.
You may request that the appeal process be expedited for an
appeal of a Medical Necessity Adverse Determination or an
appeal of a Coverage Denial if: (a) the time frames under this
process would seriously jeopardize your life or health, or with
respect to a pregnant woman, the life or health of the unborn
child; or the ability to regain maximum function; or result in
serious impairment to bodily functions or serious dysfunction
of a bodily organ or part; or in the opinion of your Physician
would cause you severe pain which cannot be managed
without the requested services; or (b) your appeal involves
nonauthorization of an admission or continuing inpatient
Hospital stay.
If you request that your appeal be expedited based on (a)
above, you may also ask for an expedited external
Independent Review at the same time, if the time to complete
an expedited internal appeal would be detrimental to your
medical condition.
When an appeal is expedited, we will respond orally with a
decision within 72 hours of receipt of the appeal request,
followed up in writing within three working days.
Reconsideration of an Internal Review Medical Necessity
or Clinical Appropriateness Appeal Decision
You may present new clinical information regarding an
adverse internal review appeal determination decision prior to
the initiation of the external review process conducted by an
Independent Review Entity in the process described in the
following paragraph entitled, "External Review by an
Independent Review Entity." If you do, Cigna will provide
written notice of a reconsideration decision within five
working days of receiving additional information related to the
request for reconsideration. If a reconsideration is requested,
the four months time frame for requesting an external review
by an Independent Review Entity shall not begin until Cigna
provides the reconsideration decision. If we do not provide a
written reconsideration decision within the allowable time
frame, then you may request an external review by an
Independent Review Entity. Notification of the
reconsideration of the appeal review decision will be provided
myCigna.com 24
to you and any designated representative or provider(s) acting
on your behalf.
External Review by an Independent Review Entity
If you are not fully satisfied with the decision of Cigna's
internal appeal decision or reconsideration decision regarding
your Medical Necessity or clinical appropriateness issue, you
may request that your appeal be referred to an Independent
Review Entity (IRE).
Your appeal of Cigna's adverse determination, decision to
deny, reduce or terminate a medical service based on a
determination that it is not Medically Necessary or is
experimental or investigational, will be considered by a
Physician or upon your request, by a reviewer, in the same or
similar specialty as the care under consideration, who was not
involved in the initial decision as determined by Cigna's
Physician Reviewer. The Independent Review Entities that
Kentucky Department of Insurance assigns in rotation to
requests for external independent review are: certified by the
Kentucky Department of Insurance, and composed of persons
who are not employed by Cigna HealthCare or any of its
affiliates. A decision to use the voluntary level of appeal will
not affect the claimant's rights of any other benefits under the
plan.
An IRE will provide an expedited review of an external appeal
when requested, and any of the following apply: the treating
Physician believes that independent review under a standard
time frame would seriously jeopardize your life or health, or
with respect to a pregnant woman, the life or health of the
unborn child; or the ability to regain maximum function; or
result in serious impairment to bodily functions or serious
dysfunction of a bodily organ or part; or would cause you
severe pain which cannot be managed without the requested
services; or your appeal involves nonauthorization of an
admission or continuing inpatient Hospital stay.
Cigna will pay the cost of the review of an Independent
Review Entity, however, there is a $25 filing fee for you to
initiate this independent review process, and you will be billed
for this directly by the IRE. The IRE will waive the fee if
financial hardship can be demonstrated and will refund the fee
if their review results in a decision favorable for you. Cigna
will abide by the decision of the IRE, and will provide notice
to the Kentucky Department of Insurance of its
implementation of the decision within 30 days of the IRE's
decision in your favor. Cigna will provide coverage of the
treatment, service, drug or device as required by the binding
decision of the IRE, if you are currently enrolled for coverage
by Cigna or you have disenrolled. If you have disenrolled,
Cigna will only provide the treatment, service, drug, or device
for a period of 30 days.
Call the toll-free number on your Benefit Identification card or
contact the appeals representative indicated on your appeal
decision notification letter for information about how to
request an external review appeal by an IRE.
In order to request a referral to an IRE the following
conditions apply: you must submit your request in writing to
Cigna, within 60 days of the date of this letter (except that
requests for expedited appeals may be requested verbally,
followed up by an abbreviated written request). However,
when a reconsideration of this decision is requested due to the
submission of new clinical information, the 60-day time frame
limit for requesting an external review by an IRE will not
begin until Cigna has provided a reconsideration decision; you
provide a signed copy of the medical release form which
provides permission for the IRE to obtain all of the necessary
medical records in order to complete its review; you were
insured at time of service, or when you or your provider
requested the service you have exhausted the Cigna internal
review process and received an adverse decision regarding
your request involving a Medical Necessity issue; or Cigna
has not completed its review of your internal review appeal
within the required 30 days; or the Kentucky Department of
Insurance has provided notice that Cigna's Coverage Denial
determination is not valid because the requested service or
coverage is available under the plan. If you believe that you
are entitled to an IRE review and Cigna has denied your
request for an IRE review, you may file a complaint with the
Kentucky Department of Insurance, which shall issue a
decision within five days of the receipt of your complaint. If
the Department agrees that you are entitled to an IRE review,
it shall require Cigna to provide one, as noted above.
If both Cigna and you agree to waive the internal appeal
requirement, you may also request that your eligible issue be
referred directly to an IRE without initiating or exhausting the
internal appeals process.
Cigna will not provide an external review by an IRE if the
request for review of the adverse determination has previously
gone through the external review process and the IRE found in
favor of Cigna and no new clinical information has been
submitted since the IRE found in favor of Cigna.
Cigna will forward your request and the file to the IRE, after
the Department of Insurance assigns an IRE to your review
request.
If you believe that you are entitled to an IRE review and Cigna
has denied your request for an IRE review, you may file a
complaint with the Kentucky Department of Insurance, which
shall issue a decision within five days of the receipt of your
complaint. If the Department agrees that you are entitled to an
IRE review, it shall require Cigna to provide one, as noted
above.
The IRE will render an opinion within 21 calendar days,
unless you and Cigna agree to an extension of up to 14
calendar days more. When requested, and when your provider
believes that review under a standard time frame would be
myCigna.com 25
detrimental to your medical condition, Cigna shall forward
your request for an IRE review to the IRE within 24 hours of
receiving it, and the IRE will make a decision within 24 hours
of receipt of all information required from Cigna. If you agree
to a 24-hour extension for the expedited review, then the IRE
will provide an expedited decision of the review request
within 48 hours of receipt of all information required from
Cigna, but no later than 72 hours of receiving your request for
an IRE from Cigna.
The external review process shall be confidential.
External Review of a Coverage Denial by the Kentucky
Department of Insurance
You have the right to ask the Kentucky Department of
Insurance to review a Coverage Denial determination that has
been made following an internal appeal. A Coverage Denial
means a determination that a service, treatment, prescription
drug or device is specifically limited or excluded under the
Plan. You, or an authorized person or provider on your behalf,
may submit a written request for review of a Coverage Denial
to the Kentucky Department of Insurance at the following
address:
Kentucky Department of Insurance
Attn: Coverage Denial Coordinator
P.O. Box 517
Frankfort, KY 40602-0517
Include a copy of the initial Cigna denial notice and the appeal
notice with your written request for review of a Coverage
Denial. Upon Cigna's receipt of the Kentucky Department of
Insurance's (DOI's) determination decision of your Coverage
Denial review request, Cigna will: provide the disputed
coverage if the DOI has concluded that the treatment, service,
drug or device is not specifically limited or excluded by the
plan or offer you the opportunity to seek an external review by
an Independent Review Entity; or not provide the disputed
coverage if the DOI has concluded that the treatment, service,
drug or device is not specifically limited or excluded by the
Plan. When Cigna provides the coverage because the DOI has
determined the treatment, service, drug or device is not
specifically limited or excluded by the plan, it will provide
coverage if you are currently enrolled for coverage by Cigna
or you have disenrolled. If you have disenrolled, Cigna will
only provide coverage for the treatment, service, drug, or
device for a period of 30 days.
Appeal to the State of Kentucky
You have the right to contact the Kentucky Department of
Insurance for assistance at any time. The Kentucky
Department of Insurance may be contacted at the following
address and telephone number:
Kentucky Department of Insurance
P.O. Box 517
Frankfort, KY 40602-0517
1-800-595-6053
Hearing Impaired: 1-800-462-2081
Notice of Benefit Determination on Appeal
Every notice of a determination on appeal will be provided in
writing or electronically and, if an adverse determination, will
include: information sufficient to identify the claim; the
specific reason or reasons for the adverse determination;
reference to the specific plan provisions on which the
determination is based; a statement that the claimant is entitled
to receive, upon request and free of charge, reasonable access
to and copies of all documents, records, and other Relevant
Information as defined; a statement describing any voluntary
appeal procedures offered by the plan and the claimant's right
to bring an action under ERISA section 502(a); upon request
and free of charge, a copy of any internal rule, guideline,
protocol or other similar criterion that was relied upon in
making the adverse determination regarding your appeal; an
explanation of the scientific or clinical judgment for a
determination that is based on a Medical Necessity,
experimental treatment or other similar exclusion or limit; date
of the review decision; name and title of the person making
the review decision and for Medical Necessity determinations,
the name, state of licensure, medical license number and the
title of the person making the determination and, as applicable
to managed care plans, the signature of a Kentucky-licensed
Medical Director; a description of alternative benefits,
supplies or services covered by the plan; instructions for
requesting an external review by either an IRE or the
Kentucky Department of Insurance, as applicable, including
applicable time frames and instructions to complete any
required forms and whether the request for review of the
appeal decision must be in writing; for Medical Necessity
appeal determinations, a release of medical records form for
provision to the IRE; the name and phone number of a contact
person who can provide information about a Coverage Denial
determination or about external review by an IRE, as
applicable; and for Coverage Denial appeal notices,
instructions to include a copy of the initial Coverage Denial
notice and the Coverage Denial notice with the written request
to the Department of Insurance to conduct a review of a
Coverage Denial appeal determination; and information about
any office of health insurance consumer assistance or
ombudsman available to assist you in the appeal process.
myCigna.com 26
You also have the right to bring a civil action under section
502(a) of ERISA if you are not satisfied with the decision on
review. You or your plan may have other voluntary alternative
dispute resolution options such as Mediation. One way to find
out what may be available is to contact your local U.S.
Department of Labor office and your State insurance
regulatory agency. You may also contact the Plan
Administrator.
Relevant Information
Relevant Information is any document, record, or other
information which was relied upon in making the benefit
determination; was submitted, considered, or generated in the
course of making the benefit determination, without regard to
whether such document, record, or other information was
relied upon in making the benefit determination; demonstrates
compliance with the administrative processes and safeguards
required by federal law in making the benefit determination;
or constitutes a statement of policy or guidance with respect to
the plan concerning the denied treatment option or benefit or
the claimant's diagnosis, without regard to whether such
advice or statement was relied upon in making the benefit
determination.
Legal Action
If your plan is governed by ERISA, you have the right to bring
a civil action under section 502(a) of ERISA if you are not
satisfied with the outcome of the Appeals Procedure. In most
instances, you may not initiate a legal action against Cigna
until you have completed the Internal Review Appeal process.
However, no action will be brought at all unless brought
within 3 years after a claim is submitted for In-Network
Services or within three years after proof of claim is required
under the Plan for Out-of-Network services.
HC-APL261 05-15
ET
CIGNA HEALTH AND LIFE INSURANCE
COMPANY, a Cigna company (hereinafter called
Cigna)
CERTIFICATE RIDER – Louisiana Residents
Rider Eligibility: Each Employee who is located in Louisiana
You will become insured on the date you become eligible,
including if you are not in Active Service on that date due to
your health status.
This rider forms a part of the certificate issued to you by
Cigna.
The provisions set forth in this rider comply with the legal
requirements of Louisiana group insurance plans covering
insureds located in Louisiana. These provisions supersede any
provisions in your certificate to the contrary unless the
provisions in your certificate result in greater benefits.
HC-ETLARDR
Covered Expenses
charges for electronic imaging/telemedicine health care
services, including, but not limited to, diagnostic testing and
treatment. The Physician must be physically present with
the patient and communicating with a Physician at the
facility receiving the transmission. Payment shall not be less
than 75% of the reasonable and customary payment
received for an intermediate office visit. These
electronic/telemedicine benefits are subject to utilization
review requirements.
charges for treatment of severe mental illness, on the same
basis as other sickness covered under the plan. “Severe
mental illness” includes any of the following:
schizophrenia or schizoaffective disorder;
bipolar disorder;
panic disorder;
obsessive-compulsive disorder;
major depressive disorder;
anorexia/bulimia;
intermittent explosive disorder;
post-traumatic stress disorder;
myCigna.com 27
psychosis NOS (not otherwise specified) when diagnosed
in a child under age 17;
Rett’s Disorder;
Tourette’s Disorder.
Autism Spectrum Disorder
Charges for the diagnosis and treatment of Autism Spectrum
Disorders, including applied behavioral analysis, in
individuals less than 17 years of age. Such coverage shall
include the following care prescribed, provided or ordered by
a physician or a psychologist who is licensed in this state who
shall supervise provision of such care:
Medically Necessary assessments, evaluations, or tests to
diagnose an Autism Spectrum Disorder;
Habilitative or rehabilitative care;
Pharmacy care;
Psychiatric care;
Psychological care;
Therapeutic care.
Autism Spectrum Disorders include any of the pervasive
developmental disorders as defined by the most recent edition
of the Diagnostic and Statistical Manual of Mental Disorders
(DSM), including Autistic Disorder, Asperger’s Disorder and
Pervasive Developmental Disorder – Not Otherwise Specified.
Benefits for the diagnosis and treatment of Autism Spectrum
Disorders are payable on the same basis as any other sickness
covered under the plan.
HC-COV190 04-10
V1-ET1
Termination of Insurance
Continuation
Continuation of Medical Insurance during Active Military
Duty
If your coverage would otherwise cease because you are a
Reservist in the United States Armed Forces and are called to
active duty, the insurance for you and your Dependents will be
continued during your active duty only if you elect it in
writing, and will continue until the earliest of the following
dates:
90 days from the date your military service ends;
the last day for which you made any required contribution
for the insurance; or
the date the group policy cancels.
Additionally, a Dependent who is called to active duty will not
cease to qualify for Dependent coverage due to his/her active
duty status if he or she has elected to continue coverage in
writing. Coverage will be continued for that Dependent during
his or her active duty until the earliest of the following dates:
the date insurance ceases.
the last day for which the Dependent has made any required
contribution for the insurance;
the date the Dependent no longer qualifies as a Dependent;
or
the date Dependent Insurance is canceled.
Reinstatement of Medical Insurance
If your coverage ceases because you are a Reservist in the
United States Armed Forces and are called to active duty, the
insurance for you and your Dependents will be automatically
reinstated after your deactivation, provided that you return to
Active Service within 90 days.
If coverage for your Dependent has ceased because he or she
was called to active duty, the insurance for that Dependent
will be automatically reinstated after his or her deactivation, provided that he or she otherwise continues to qualify for
coverage.
Such reinstatement will be without the application of: a new
waiting period, or a new Pre-existing Condition Limitation. A
new Pre-existing Condition Limitation will not be applied to
any condition that you or your Dependent developed while
coverage was interrupted. The remainder of a Pre-existing
Condition Limitation which existed prior to interruption of
coverage may still be applied.
HC-TRM81 04-10
V1-ET1
Definitions
Dependent
The term child includes any grandchild of yours provided such
child is under 26 years of ag e and is in your legal custody and
resides with you or any grandchild of yours who is in your
legal custody and resides with you, and is incapable of self-
sustaining employment by reason of mental or physical
handicap which existed prior to the child’s 26th
birthday.
HC-DFS427 04-10
V1-ET1
myCigna.com 28
CIGNA HEALTH AND LIFE INSURANCE
COMPANY, a Cigna company (hereinafter called
Cigna)
CERTIFICATE RIDER – Maine Residents
Rider Eligibility: Each Employee who is located in Maine
You will become insured on the date you become eligible,
including if you are not in Active Service on that date due to
your health status.
This rider forms a part of the certificate issued to you by
Cigna.
The provisions set forth in this rider comply with the legal
requirements of Maine group insurance plans covering
insureds located in Maine. These provisions supersede any
provisions in your certificate to the contrary unless the
provisions in your certificate result in greater benefits.
HC-ETMERDR
Short-Term Rehabilitative Therapy and Chiropractic
Care Services
charges made for Short-term Rehabilitative Therapy that is
part of a rehabilitative program, including physical, speech,
occupational, cognitive, osteopathic manipulative, cardiac
rehabilitation and pulmonary rehabilitation therapy, when
provided in the most medically appropriate setting. Also
included are services that are provided by a chiropractic
Physician when provided in an outpatient setting. Services
of a chiropractic Physician include the conservative
management of acute neuromusculoskeletal conditions
through manipulation and ancillary physiological treatment
that is rendered to restore motion, reduce pain and improve
function.
The following limitation applies to Short-term Rehabilitative
Therapy and Chiropractic Care Services:
occupational therapy is provided only for purposes of
enabling persons to perform the activities of daily living
after an Injury or Sickness.
Short-term Rehabilitative Therapy and Chiropractic Care
services that are not covered include but are not limited to:
sensory integration therapy, group therapy; treatment of
dyslexia; behavior modification or myofunctional therapy
for dysfluency, such as stuttering or other involuntarily
acted conditions without evidence of an underlying medical
condition or neurological disorder;
treatment for functional articulation disorder such as
correction of tongue thrust, lisp, or verbal apraxia or
swallowing dysfunction that is not based on an underlying
diagnosed medical condition or Injury;
maintenance or preventive treatment consisting of routine,
long term or non-Medically Necessary care provided to
prevent recurrences or to maintain the patient’s current
status.
The following are specifically excluded from Chiropractic
Care Services:
services of a chiropractor which are not within his scope of
practice, as defined by state law;
charges for care not provided in an office setting;
vitamin therapy.
If multiple outpatient services are provided on the same day
they constitute one day.
The following applies to Network and Network Point of
Service plans, and to Preferred Provider, Exclusive Provider
and Open Access Provider copay plans:
A separate Copayment will apply to the services provided by
each provider.
HC-COV112 04-10
V1-ET
Medical Conversion Privilege
The provision in your certificate, if any, entitled "Medical
Conversion Privilege" will not apply to Maine residents.
HC-CNV 04-10
ET
When You Have A Complaint Or An
Appeal
For the purposes of this section, any reference to "you", "your"
or "Member" also refers to a representative or provider
designated by you to act on your behalf, unless otherwise
noted.
We want you to be completely satisfied with the care you
receive. That is why we have established a process for
addressing your concerns and solving your problems.
Start with Customer Service
We are here to listen and help. If you have a concern regarding
a person, a service, the quality of care, contractual benefits, or
myCigna.com 29
a rescission of coverage, you can call our toll-free number and
explain your concern to one of our Customer Service
representatives. Please call us at the Customer Service Toll-
Free Number that appears on your Benefit Identification
card, explanation of benefits or claim form.
We will do our best to resolve the matter on your initial
contact. If we need more time to review or investigate your
concern, we will get back to you as soon as possible, but in
any case within 20 days.
If you are not satisfied with the results of a coverage decision,
you can start the appeals procedure.
Appeals Procedure
Cigna has a two step appeals procedure for coverage
decisions. To initiate an appeal, you must submit a request for
an appeal in writing, after receipt of a denial notice, to the
following address:
Cigna
National Appeals Unit (NAU)
PO Box 188011
Chattanooga, TN 37422
You should state the reason why you feel your appeal should
be approved and include any information supporting your
appeal. If you are unable or choose not to write, you may ask
to register your appeal by telephone. Call us at the toll-free
number on your Benefit Identification card, explanation of
benefits or claim form.
Level One Appeal
Your appeal will be reviewed and the decision made by
someone not involved in the initial decision. Appeals
involving Medical Necessity or clinical appropriateness will
be considered by a health care professional.
For level one appeals, we will respond in writing with a
decision within 15 calendar days after we receive an appeal
for a required preservice or concurrent care coverage
determination (decision). We will respond within 20 working
days after we receive an appeal for a postservice coverage
determination. If more time or information is needed to make
the determination, we will notify you in writing to request an
extension of up to 15 calendar days and to specify any
additional information needed to complete the review.
You may request that the appeal process be expedited if, (a)
the time frames under this process would seriously jeopardize
your life, health or ability to regain maximum function or in
the opinion of your Physician would cause you severe pain
which cannot be managed without the requested services; or
(b) your appeal involves nonauthorization of an admission or
continuing inpatient Hospital stay.
If you request that your appeal be expedited based on (a)
above, you may also ask for an expedited external
Independent Review at the same time, if the time to complete
an expedited level-one appeal would be detrimental to your
medical condition.
Cigna's Physician reviewer, in consultation with the treating
Physician, will decide if an expedited appeal is necessary.
When an appeal is expedited, we will respond orally with a
decision within 72 hours, followed up in writing within two
working days of the oral response.
Level Two Appeal
If you are dissatisfied with our level one appeal decision, you
may request a second review. To start a level two appeal,
follow the same process required for a level one appeal.
Most requests for a second review will be conducted by the
Appeals Committee, which consists of at least three people.
Anyone involved in the prior decision may not vote on the
Committee. For appeals involving Medical Necessity or
clinical appropriateness, the Committee will consult with at
least one Physician reviewer in the same or similar specialty
as the care under consideration, as determined by Cigna's
Physician reviewer. You may present your situation to the
Committee in person or by conference call.
For level two appeals we will acknowledge in writing that we
have received your request and schedule a Committee review.
For required preservice and concurrent care coverage
determinations, the Committee review will be completed
within 15 calendar days. For postservice claims, the
Committee review will be completed within 20 working days.
If more time or information is needed to make the
determination, we will notify you in writing to request an
extension of up to 15 calendar days and to specify any
additional information needed by the Committee to complete
the review. In the event any new or additional information
(evidence) is considered, relied upon or generated by Cigna in
connection with the level-two appeal, Cigna will provide this
information to you as soon as possible and sufficiently in
advance of the decision, so that you will have an opportunity
to respond. Also, if any new or additional rationale is
considered by Cigna, Cigna will provide the rationale to you
as soon as possible and sufficiently in advance of the decision
so that you will have an opportunity to respond.
You will be notified in writing of the Committee's decision
within five working days after the Committee meeting, and
within the Committee review time frames above if the
Committee does not approve the requested coverage.
You may request that the appeal process be expedited if the
time frames under this process would seriously jeopardize
your life, health or ability to regain maximum function or in
the opinion of your Physician would cause you severe pain
which cannot be managed without the requested services; or
your appeal involves nonauthorization of an admission or
continuing inpatient Hospital stay. Cigna's Physician reviewer,
in consultation with the treating Physician will decide if an
myCigna.com 30
expedited appeal is necessary. When an appeal is expedited,
we will respond orally with a decision within 72 hours,
followed up in writing within two working days of the oral
response.
Independent Review Procedure
You also have the right to appeal an unfavorable decision,
including denials based on experimental or pre-existing
conditions, by way of the State of Maine's independent review
process. Your request must be in writing and sent to the State
of Maine, Bureau of Insurance, 34 State House Station,
Augusta, ME 04330. A request for an independent review
must be submitted within 12 months of the date that you
receive an adverse determination (decision) under Cigna's
complaint and appeals process. When you request an
independent review from the Maine's Bureau of Insurance,
you may submit additional information for consideration. You
may attend the review in person, by telephone, by
teleconference or other appropriate electronic means, ask
questions of the representatives and have outside assistance.
The Independent Review Organization will issue a written
decision within 30 days of receipt of a completed review from
Maine's Bureau of Insurance.
You may request an expedited independent review of your
appeal prior to exhausting all levels of Cigna's appeals
procedure if: Cigna has failed to make a decision on a
complaint or an appeal within the time period required; you
and Cigna mutually agreed to bypass the appeals procedure;
the time frames under this process would seriously jeopardize
your life, health or ability to regain maximum function or in
the opinion of your Physician would cause you severe pain
which cannot be managed without the requested services; or
the patient has died.
You may call Cigna at the toll-free telephone number on your
ID card for assistance in filing a request for an independent
review with the Maine's Bureau of Insurance. There is no
charge for you to initiate this independent review process.
Cigna will abide by the decision of the Independent Review
Organization. The Independent Review Program is a voluntary
program arranged by Cigna.
You may also call Maine's Bureau of Insurance at 1-800-300-
5000 for assistance.
Appeal to the State of Maine
You have the right to contact the Superintendent of Insurance
for assistance at any time. The Superintendent of Insurance
may be contacted at the following address and telephone
number:
State of Maine
Maine Bureau of Insurance
Superintendent of Insurance
34 State House Station
Augusta, ME 04333
1-800-300-5000
Notice of Benefit Determination on Appeal
Every notice of a determination on appeal will be provided in
writing or electronically and, if an adverse determination, will
include: information sufficient to identify the claim; the
specific reason or reasons for the adverse determination;
reference to the specific plan provisions on which the
determination is based; a statement that the claimant is entitled
to receive, upon request and free of charge, reasonable access
to and copies of all documents, records, and other Relevant
Information as defined; a statement describing any voluntary
appeal procedures offered by the plan and the claimant's right
to bring an action under ERISA section 502(a); upon request
and free of charge, a copy of any internal rule, guideline,
protocol or other similar criterion that was relied upon in
making the adverse determination regarding your appeal, and
an explanation of the scientific or clinical judgment for a
determination that is based on a Medical Necessity,
experimental treatment or other similar exclusion or limit; and
information about any office of health insurance consumer
assistance or ombudsman available to assist you in the appeal
process. A final notice of adverse determination will include a
discussion of the decision.
You also have the right to bring a civil action under Section
502(a) of ERISA if you are not satisfied with the decision on
review. You or your plan may have other voluntary alternative
dispute resolution options such as Mediation. One way to find
out what may be available is to contact your local U.S.
Department of Labor office and your State insurance
regulatory agency. You may also contact the Plan
Administrator.
Relevant Information
Relevant Information is any document, record, or other
information which was relied upon in making the benefit
determination; was submitted, considered, or generated in the
course of making the benefit determination, without regard to
whether such document, record, or other information was
relied upon in making the benefit determination; demonstrates
compliance with the administrative processes and safeguards
required by federal law in making the benefit determination;
or constitutes a statement of policy or guidance with respect to
myCigna.com 31
the plan concerning the denied treatment option or benefit or
the claimant's diagnosis, without regard to whether such
advice or statement was relied upon in making the benefit
determination.
Legal Action
If your plan is governed by ERISA, you have the right to bring
a civil action under Section 502(a) of ERISA if you are not
satisfied with the outcome of the Appeals Procedure. In most
instances, you may not initiate a legal action against Cigna
until you have completed the Level One and Level Two
Appeal processes. If your Appeal is expedited, there is no
need to complete the Level Two process prior to bringing
legal action.
HC-APL56 04-10
V1-ET
CIGNA HEALTH AND LIFE INSURANCE
COMPANY, a Cigna company (hereinafter called
Cigna)
CERTIFICATE RIDER – Maryland Residents
Rider Eligibility: Each Employee who is located in Maryland
You will become insured on the date you become eligible,
including if you are not in Active Service on that date due to
your health status.
This rider forms a part of the certificate issued to you by
Cigna.
The provisions set forth in this rider comply with the legal
requirements of Maryland group insurance plans covering
insureds located in Maryland. These provisions supersede any
provisions in your certificate to the contrary unless the
provisions in your certificate result in greater benefits.
HC-ETMDRDR
Important Notices
Qualified Medical Child Support Order (QMCSO)
Eligibility for Coverage Under a QMCSO
If a Qualified Medical Child Support Order (QMCSO) is
issued for your child, that child will be eligible for coverage as
required by the order and you will not be considered a Late
Entrant for Dependent Insurance.
You, your child’s noninsuring parent, a state child support
enforcement agency or the Maryland Department of Health
and Mental Hygiene must notify your Employer and elect
coverage for that child. If you yourself are not already
enrolled, you must elect coverage for both yourself and your
child. We will enroll both you and your child within 20
business days of our receipt of the QMCSO from your
Employer.
Eligibility for coverage will not be denied on the grounds that
the child: was born out of wedlock; is not claimed as a
dependent on the Employee’s federal income tax return; does
not reside with the Employee or within the plan’s service area;
or is receiving, or is eligible to receive, benefits under the
Maryland Medical Assistance Program.
Qualified Medical Child Support Order Defined
A Qualified Medical Child Support Order is a judgment,
decree or order (including approval of a settlement agreement)
or administrative notice, which is issued pursuant to a state
domestic relations law (including a community property law),
or to an administrative process, which provides for child
support or provides for health benefit coverage to such child
and relates to benefits under the group health plan, and
satisfies all of the following:
the order recognizes or creates a child’s right to receive
group health benefits for which a participant or beneficiary
is eligible;
the order specifies your name and last known address, and
the child’s name and last known address, except that the
name and address of an official of a state or political
subdivision may be substituted for the child’s mailing
address;
the order provides a description of the coverage to be
provided, or the manner in which the type of coverage is to
be determined;
the order states the period to which it applies; and
if the order is a National Medical Support Notice completed
in accordance with the Child Support Performance and
Incentive Act of 1998, such Notice meets the requirements
above.
The QMCSO may not require the health insurance policy to
provide coverage for any type or form of benefit or option not
otherwise provided under the policy, except that an order may
require a plan to comply with State laws regarding health care
coverage.
Claims
Claims will be accepted from the noninsuring parent, from the
child’s health care provider or from the state child support
myCigna.com 32
enforcement agency. Payment will be directed to whomever
submits the claim.
Payment of Benefits
Any payment of benefits in reimbursement for Covered
Expenses paid by the child, or the child’s custodial parent or
legal guardian, shall be made to the child, the child’s custodial
parent or legal guardian, or a state official whose name and
address have been substituted for the name and address of the
child.
Termination of Coverage Under a QMCSO
Coverage required by a QMCSO will continue until we
receive written evidence that: the order is no longer in effect;
the child is or will be enrolled under a comparable health plan
which takes effect not later than the effective date of
disenrollment; dependent coverage has been eliminated for all
Employees; or you are no longer employed by the Employer,
except that if you elect to exercise the provisions of the federal
Consolidated Omnibus Budget Reconciliation Act of 1985
(COBRA), coverage will be provided for the child consistent
with the Employer’s plan for postemployment health
insurance coverage for Dependents.
HC-IMP89 04-10
V1-ET3
The Schedule
The Medical Schedule is amended to remove any of the
following OB/GYN notes if included:
Note: OB/GYN provider is considered a Specialist.
Note: OB/GYN providers will be considered either as a PCP
or Specialist, depending on how the provider contracts with
the Insurance Company.
Note: Well-Woman OB/GYN visits will be considered a
Specialist visit.
Note: Well-Woman OB/GYN visits will be considered either
a PCP or Specialist depending on how the provider contracts
with the Insurance Company.
The “Outpatient Facility Services” entry in the Medical
Schedule is amended to read as follows:
Outpatient Facility Services
Operating Room, Recovery Room, Procedures Room,
Treatment Room and Observation Room and when provided
instead of an inpatient service, when an attending physician’s
request for an inpatient admission has been denied.
The Medical Schedule is amended to include the following
note in the “Delivery – Facility” provision of the “Maternity
Care Services” section:
Note: Benefit levels will be the same as the benefit levels for
Inpatient Hospital Facility Services for any other covered
Sickness.
The Medical Schedule is amended to include the following
provision, covered at “No charge”, in the “Maternity Care
Services” section:
Home Visits, as required by law and as recommended by the
Physician
SCHEDMD-ET3
Covered Expenses
charges made for an outpatient service provided instead of
an inpatient service, when an attending physician’s request
for an inpatient admission is denied after utilization review
has been conducted.
charges for an objective second opinion, when required by a
utilization review program.
charges made for inpatient hospitalization services for a
mother and newborn child for a minimum of: 48 hours on
inpatient hospitalization care after an uncomplicated vaginal
delivery; and 96 hours of inpatient hospitalization care after
an uncomplicated cesarean section. A mother may request a
shorter length of stay than that provided if the mother
decides, in consultation with her attending provider, that
less time is needed for recovery.
If the mother and newborn child have a shorter hospital stay
than that provided, coverage is provided for: one home visit
scheduled to occur within 24 hours after hospital discharge;
and an additional home visit if prescribed by the attending
provider. The home visit must: be provided in accordance
with generally accepted standards of nursing practice for
home care of a mother and newborn child; be provided by a
registered nurse with at least one year of experience in
maternal and child health nursing or community health
nursing with an emphasis on maternal and child health; and
include any services required by the attending provider.
Unless you are enrolled in a Health Savings Account or a
High Deductible Health Plan, coverage for the home visits
described in this section are not subject to any deductible.
If the mother and newborn child remain in the hospital for at
least the minimum length of time provided, coverage is
provided for a home visit if prescribed by the attending
provider. The home visit must: be provided in accordance
with generally accepted standards of nursing practice for
home care of a mother and newborn child; be provided by a
registered nurse with at least one year of experience in
myCigna.com 33
maternal and child health nursing or community health
nursing with an emphasis on maternal and child health; and
included any services required by the attending provider.
Unless you are enrolled in a Health Savings Account or a
High Deductible Health Plan, coverage for the home visits
described in this section are not subject to any deductible.
Additionally, whenever a mother is required to remain
hospitalized after childbirth for medical reasons and the
mother requests that the newborn also remain in the
hospital, coverage will be provided for additional
hospitalization for the newborn for up to four days.
HC-COV27 04-10
V1-ET3
HC-COV211
CIGNA HEALTH AND LIFE INSURANCE
COMPANY, a Cigna company (hereinafter called
Cigna)
CERTIFICATE RIDER – Massachusetts Residents
Rider Eligibility: Each Employee who is located in
Massachusetts
You will become insured on the date you become eligible,
including if you are not in Active Service on that date due to
your health status.
This rider forms a part of the certificate issued to you by
Cigna.
The provisions set forth in this rider comply with the legal
requirements of Massachusetts group insurance plans covering
insureds located in Massachusetts. These provisions supersede
any provisions in your certificate to the contrary unless the
provisions in your certificate result in greater benefits.
HC-ETMARDR
Eligibility - Effective Date
Dependent Insurance
Exception for Newborns
Any Dependent child including the newborn infant of a
Dependent, an adopted child or foster child born while you are
insured will become insured on the date of his birth if you
elect Dependent Insurance no later than 31 days after his birth.
If you do not elect to insure your newborn child within such
31 days, coverage for that child will end on the 31st day. No
benefits for expenses incurred beyond the 31st day will be
payable.
HC-ELG12 04-10
V1-ET
Covered Expenses
Covered Expenses include expenses incurred at any of the
Approximate Intervals shown below for a Dependent child
who is age 5 or less for charges made for Child Preventive
Care Services consisting of the following services delivered or
supervised by a Physician, in keeping with prevailing medical
standards:
a history; physical examination; development assessment;
anticipatory guidance; and appropriate immunizations and
laboratory tests;
measurements; sensory screening; neuropsychiatric
evaluation; hereditary and metabolic screening at birth; TB
test; hematocrit; other appropriate blood tests and urinalysis;
special medical formulas approved by the Commissioner of
Public Health, prescribed by a Physician, and Medically
Necessary for treatment of PKU, tyrosinemia,
homocystinuria, maple syrup urine disease, and propionic
acidemia or methylmalonic acidemia in infants and children
or Medically Necessary to protect the unborn fetuses of
pregnant women with PKU.
excluding any charges for:
more than one visit to one provider for Child Preventive
Care Services at each of the Approximate Intervals up to a
total of 12 visits for each Dependent child;
services for which benefits are otherwise provided under
this medical benefits section;
services for which benefits are not payable according to the
Expenses Not Covered section.
Approximate Intervals are:
six times during the first year of life;
three times during the second year of life;
annually each year thereafter through the fifth year of life.
Covered Expenses also include expenses incurred for
Dependent children from birth until the child's third birthday
for Early Intervention Services, up to the Medically Necessary
Early Intervention Services Maximum shown in The
Schedule, to include: occupational, physical and speech
therapy, nursing care and psychological counseling.
myCigna.com 34
These services must be delivered by certified early
intervention specialists, as defined by the early intervention
operational standards by the Massachusetts Department of
Public Health and in accordance with applicable certification
requirements.
charges made for or in connection with mammograms for
breast cancer screening, not to exceed: one baseline
mammogram for women age 35 but less than 40, and a
mammogram annually for women age 40 and over.
charges made for screening for lead poisoning of a
Dependent child from birth until 6 years of age.
charges for treatment of an Injury or Sickness of an eligible
newborn or adopted child, including the necessary care and
treatment of medically-diagnosed congenital defects and
birth abnormalities or premature birth.
charges for a minimum of 48 hours of inpatient care
following a vaginal delivery and a minimum of 96 hours of
inpatient care following a caesarean section for a mother
and her newborn child. Any decision to shorten such
minimum coverage will be made in accordance with rules
and regulations promulgated by the Massachusetts
Department of Public Health relative to early discharge (less
than 48 hours for a vaginal delivery and 96 hours for a
caesarean delivery) and postdelivery care, including but not
limited to: home visits; parent education; assistance and
training in breast or bottle feeding; and the performance of
any necessary and appropriate clinical tests. The first home
visit may be conducted by a registered nurse, Physician or
certified nurse-midwife. Any subsequent home visit
determined to be clinically necessary must be provided by a
licensed health care provider.
charges made for cardiac rehabilitation, according to
standards developed by the Massachusetts Department of
Public Health. Cardiac rehabilitation means a
multidisciplinary, Medically Necessary treatment of persons
with documented cardiovascular disease, provided in either
a Hospital or other setting and meeting standards set forth
by the Massachusetts Commissioner of Public Health.
HC-COV250 01-14
V3-ET1
Short-Term Rehabilitative Therapy and Chiropractic
Care Services
charges made for Short-term Rehabilitative Therapy that is
part of a rehabilitative program, including physical, speech,
occupational, cognitive, osteopathic manipulative, and
pulmonary rehabilitation therapy, when provided in the
most medically appropriate setting. Also included are
services that are provided by a chiropractic Physician when
provided in an outpatient setting. Services of a chiropractic
Physician include the conservative management of acute
neuromusculoskeletal conditions through manipulation and
ancillary physiological treatment that is rendered to restore
motion, reduce pain and improve function.
The following limitation applies to Short-term
Rehabilitative Therapy and Chiropractic Care Services:
occupational therapy is provided only for purposes of
enabling persons to perform the activities of daily living
after an Injury or Sickness.
Short-term Rehabilitative Therapy and Chiropractic Care
services that are not covered include but are not limited to:
sensory integration therapy, group therapy; treatment of
dyslexia; behavior modification or myofunctional therapy
for dysfluency, such as stuttering or other involuntarily
acted conditions without evidence of an underlying medical
condition or neurological disorder;
treatment for functional articulation disorder such as
correction of tongue thrust, lisp, verbal apraxia or
swallowing dysfunction that is not based on an underlying
diagnosed medical condition or Injury;
maintenance or preventive treatment consisting of routine,
long term or non-Medically Necessary care provided to
prevent recurrences or to maintain the patient’s current
status.
The following are specifically excluded from Chiropractic
Care Services:
services of a chiropractor which are not within his scope of
practice, as defined by state law;
vitamin therapy.
If your plan is subject to Copayments, a separate Copayment
will apply to the services provided by each provider.
HC-COV86 04-10
V1-ET
Definitions
Dependent
Dependents include:
your former spouse, unless the divorce decree provides
otherwise.
A child includes:
a legally adopted child. Coverage for an adopted child will
begin: on the date of the filing of a petition to adopt such a
child, provided the child has been residing in your home as
a foster child, and for whom you have been receiving foster
care payments; or when a child has been placed in your
myCigna.com 35
home by a licensed placement agency for purposes of
adoption;
a child born to one of your Dependent children, as long as
your grandchild is living with you and: your Dependent
child is insured; or your grandchild is primarily supported
by you.
HC-DFS644 01-14
V1-ET1
CIGNA HEALTH AND LIFE INSURANCE
COMPANY, a Cigna company (hereinafter called
Cigna)
CERTIFICATE RIDER – Minnesota Residents
Rider Eligibility: Each Employee who is located in Minnesota
You will become insured on the date you become eligible,
including if you are not in Active Service on that date due to
your health status.
This rider forms a part of the certificate issued to you by
Cigna.
The provisions set forth in this rider comply with the legal
requirements of Minnesota group insurance plans covering
insureds located in Minnesota. These provisions supersede any
provisions in your certificate to the contrary unless the
provisions in your certificate result in greater benefits.
HC-ETMNRDR
Expenses For Which A Third Party May
Be Responsible
This plan does not cover:
expenses for which another party may be responsible as a
result of having caused or contributed to the Injury or
Sickness. If you incur a Covered Expense for which, in the
opinion of Cigna, another party may be liable, Cigna may,
at its sole discretion, pay the benefits otherwise payable
under the Policy. However, you must first agree in writing
to refund to Cigna the lesser of:
The amount actually paid for such Covered Expenses by
Cigna; or
The amount you actually receive from the third party for
such Covered Expenses;
at the time that the third party’s liability for medical
expenses is determined and satisfied, whether by settlement,
judgment, arbitration or award or otherwise.
Expenses incurred by a Participant to the extent any
payment is received for them either directly or indirectly
from a third party tortfeasor or as a result of a settlement,
judgment or arbitration award in connection with any
automobile medical, automobile no-fault, uninsured or
underinsured motorist, homeowners, workers'
compensation, government insurance (other than Medicaid),
or similar type of insurance or coverage.
Cigna's claim rights under this provision will be valid only if
you are fully compensated for your loss. Your costs,
disbursements, attorney fees and other expenses incurred to
obtain recovery from the third party will be subtracted from
the amount of Cigna's claim right.
Cigna will only exercise its claim rights if the amount received
by you is specifically identified in the settlement or judgment
as amounts paid for medical expenses.
Subrogation/Right Of Reimbursement
If a Participant incurs a Covered Expense for which, in the
opinion of the plan or its claim administrator, another party
may be responsible or for which the Participant may receive
payment as described above:
1. Subrogation: The plan shall, to the extent permitted by law,
be subrogated to all rights, claims or interests that a
Participant may have against such party and shall
automatically have a lien upon the proceeds of any recovery
by a Participant from such party to the extent of any benefits
paid under the plan. A Participant or his/her representative
shall execute such documents as may be required to secure
the plan’s subrogation rights.
2. Right of Reimbursement: The plan is also granted a right of
reimbursement from the proceeds of any recovery whether
by settlement, judgment, or otherwise. This right of
reimbursement is cumulative with and not exclusive of the
subrogation right granted in paragraph 1, but only to the
extent of the benefits provided by the plan.
Cigna's claim rights under this provision will be valid only if
you are fully compensated for your loss. Your costs,
disbursements, attorney fees and other expenses incurred to
obtain recovery from the third party will be subtracted from
the amount of Cigna's claim right.
Lien Of The Plan
By accepting benefits under this plan, a Participant:
grants a lien and assigns to the plan an amount equal to the
benefits paid under the plan against any recovery made by
or on behalf of the Participant which is binding on any
myCigna.com 36
attorney or other party who represents the Participant
whether or not an agent of the Participant or of any
insurance company or other financially responsible party
against whom a Participant may have a claim provided said
attorney, insurance carrier or other party has been notified
by the plan or its agents;
agrees that this lien shall constitute a charge against the
proceeds of any recovery and the plan shall be entitled to
assert a security interest thereon;
agrees to hold the proceeds of any recovery in trust for the
benefit of the plan to the extent of any payment made by the
plan.
Additional Terms
No adult Participant hereunder may assign any rights that it
may have to recover medical expenses from any third party
or other person or entity to any minor Dependent of said
adult Participant without the prior express written consent
of the plan. The plan’s right to recover shall apply to
decedents’, minors’, and incompetent or disabled persons’
settlements or recoveries.
No Participant shall make any settlement, which specifically
reduces or excludes, or attempts to reduce or exclude, the
benefits provided by the plan.
The plan’s right of recovery shall be a prior lien against any
proceeds recovered by the Participant. This right of
recovery shall not be defeated nor reduced by the
application of any so-called “Made-Whole Doctrine”,
“Rimes Doctrine”, or any other such doctrine purporting to
defeat the plan’s recovery rights by allocating the proceeds
exclusively to non-medical expense damages.
No Participant hereunder shall incur any expenses on behalf
of the plan in pursuit of the plan’s rights hereunder,
specifically; no court costs, attorneys' fees or other
representatives' fees may be deducted from the plan’s
recovery without the prior express written consent of the
plan. This right shall not be defeated by any so-called “Fund
Doctrine”, “Common Fund Doctrine”, or “Attorney’s Fund
Doctrine”.
The plan shall recover the full amount of benefits provided
hereunder without regard to any claim of fault on the part of
any Participant, whether under comparative negligence or
otherwise.
In the event that a Participant shall fail or refuse to honor its
obligations hereunder, then the plan shall be entitled to
recover any costs incurred in enforcing the terms hereof
including, but not limited to, attorney’s fees, litigation, court
costs, and other expenses. The plan shall also be entitled to
offset the reimbursement obligation against any entitlement
to future medical benefits hereunder until the Participant has
fully complied with his reimbursement obligations
hereunder, regardless of how those future medical benefits
are incurred.
Any reference to state law in any other provision of this
plan shall not be applicable to this provision, if the plan is
governed by ERISA. By acceptance of benefits under the
plan, the Participant agrees that a breach hereof would cause
irreparable and substantial harm and that no adequate
remedy at law would exist. Further, the Plan shall be
entitled to invoke such equitable remedies as may be
necessary to enforce the terms of the plan, including, but not
limited to, specific performance, restitution, the imposition
of an equitable lien and/or constructive trust, as well as
injunctive relief.
HC-SUB1 04-10
V3-ET
Termination of Insurance and Special
Continuation
Reinstatement of Insurance
If your coverage ceases because of active duty in: the armed
forces of the United States, or the National Guard, the
insurance for you and your Dependents will be reinstated after
your deactivation, provided that:
you apply for such reinstatement within 90 days after
deactivation; and
you are otherwise eligible.
Such reinstatement will be without the application of: a new
waiting period, or a new Pre-existing Condition Limitation. A
new Pre-existing Condition Limitation will not be applied to a
condition that you or your Dependent may have developed
while coverage was interrupted, excluding any condition that
the Veterans Administration has determined to be military
related. The remainder of a Pre-existing Condition Limitation
which existed prior to interruption of coverage may still be
applied.
HC-TRM70 09-14
V2-ET1
myCigna.com 37
CIGNA HEALTH AND LIFE INSURANCE
COMPANY, a Cigna company (hereinafter called
Cigna)
CERTIFICATE RIDER – Missouri Residents
Rider Eligibility: Each Employee who is located in Missouri
You will become insured on the date you become eligible,
including if you are not in Active Service on that date due to
your health status.
This rider forms a part of the certificate issued to you by
Cigna.
The provisions set forth in this rider comply with the legal
requirements of Missouri group insurance plans covering
insureds located in Missouri. These provisions supersede any
provisions in your certificate to the contrary unless the
provisions in your certificate result in greater benefits.
HC-ETMORDR
Missouri First Steps Program
Cigna participates in Missouri’s Part C Early Intervention
System, “First Steps.” “First Steps” provides coverage for
Early Intervention Services described in this section that are
delivered by early intervention specialists who are health care
professionals licensed by the state of Missouri and acting
within the scope of their professions for children from birth to
age three identified by the Part C Early Intervention System as
eligible services for persons under Part C of the Individuals
with Disabilities Education Act.
Early Intervention Services means Medically Necessary
speech and language therapy, occupational therapy, physical
therapy, and assistive technology devices for children from
birth to age three who are identified by the Part C Early
Intervention System as eligible for services under Part C of the
Individuals with Disabilities Education Act and shall include
services under an active individualized family service plan
that enhances functional ability without effecting a cure. An
individualized family service plan is a written plan for
providing early intervention services to an eligible child and
the child's family that is adopted in accordance with 20 U.S.C.
Section 1436.
Important Information About Your
Medical Plan
Direct Access for OB/GYN Services
Female insureds covered by this plan are allowed direct access
to a licensed/certified Participating Provider for covered
OB/GYN services. There is no requirement to obtain an
authorization of care from your Primary Care Physician (if
you have selected one) for visits to the Participating Provider
of your choice for those services defined by the published
recommendations of the accreditation council for graduate
medical education for training an obstetrician, gynecologist or
obstetrician/gynecologist, including but not limited to
diagnosis, treatment and referral for such services.
Direct Access for Chiropractic Care Services
Insureds covered by this plan are allowed direct access to a
licensed/certified Participating Provider for In-Network
covered Chiropractic Care services. There is no requirement to
obtain an authorization of care from your Primary Care
Physician (if you have selected one) for visits to the
Participating Provider of your choice for Chiropractic Care.
Covered Expenses
charges made by a Hospital or an Ambulatory Surgical
Facility for anesthesia for inpatient Hospital dental
procedures for: a child under the age of five; a person with a
severe disability; or a person with a behavioral or medical
condition that requires hospitalization or general anesthesia
when dental care is provided. Cigna may require prior
authorization for hospitalization for dental procedures.
charges for immunizations (including the associated office
visit) for children from birth to age 5 will include
poliomyelitis, rubella, rubeola, mumps, tetanus, pertussis,
diphtheria, hepatitis B, Haemophilus influenzae type b
(Hib), and varicella. This includes the office visit in
connection with immunizations. There will be no deductible
and no copay.
charges for or in connection with the diagnosis, treatment
and appropriate management of osteoporosis for persons
with a condition or medical history for which bone mass
measurement is Medically Necessary, provided such
services are received by a Physician licensed to practice
medicine and surgery in Missouri.
charges for a colorectal examination and laboratory tests for
cancer in accordance with current American Cancer Society
guidelines for any nonsymptomatic person covered under
the Plan.
charges for a pelvic examination and Pap smear in
accordance with current American Cancer Society
myCigna.com 38
guidelines for any nonsymptomatic woman covered under
the Plan.
charges for telehealth (telemedicine) will be covered on the
same basis as covered services provided through a face to
face consultation or contact with participating provider.
Coverage does not include telehealth site origination fees or
costs for the provision of telehealth services. Utilization
may be utilized to determine the appropriateness of
telehealth as a means of delivering a health care service on
the same basis as when the same services is delivered in
person.
charges for prostate cancer examinations and laboratory
tests for any insured nonsymptomatic male, in accordance
with current American Cancer Society guidelines. Men age
50 and older should discuss getting an annual PSA blood
test and a digital rectal exam with their Physician. Men who
are at risk, which includes African American or men who
have a family history of prostate cancer, should consider
being tested at a younger age.
charges made by a Hospital or other facility that provides
obstetrical care for inpatient Hospital services will include
Covered Expenses for a mother and her newborn child for
48 hours following a vaginal delivery or for 96 hours
following a cesarean delivery. A longer stay will be covered
if deemed Medically Necessary. The mother may request an
earlier discharge if, after consulting with her Physician, it is
determined that less time is needed for recovery. If
discharged early, at least 2 post discharge visits will be
covered, one of which will be a home visit by either a
registered nurse with experience in maternal and child
health nursing or a Physician. These visits will include, but
are not limited to, a physical assessment of the mother and
the newborn; parent education; assistance and training in
breast and bottle feeding; education and services for
complete childhood immunizations; Medically Necessary
clinical tests; and the submission of a metabolic specimen to
the state laboratory.
Autism Spectrum Disorder and Applied Behavior Analysis
Coverage is provided for the diagnosis and treatment of autism
spectrum disorders, and care prescribed or ordered for a
Member diagnosed with an autism spectrum disorder by a
licensed Physician or licensed psychologist, including
equipment Medically Necessary for such care, pursuant to the
powers granted under such licensed Physician’s or licensed
psychologist’s license, including but not limited to:
psychiatric care; psychological care; habilitative or
rehabilitative care, including behavior analysis therapy;
therapeutic care; and pharmacy care. Coverage cannot be
denied on the basis that it is educational or habilitative in
nature.
The terms used above are defined as follows:
Autism spectrum disorders means a neurobiological
disorder, an illness of the nervous system, which includes
Autistic Disorder, Asperger's Disorder, Pervasive
Developmental Disorder Not Otherwise Specified, Rett's
Disorder, and Childhood Disintegrative Disorder, as defined
in the most recent edition of the Diagnostic and Statistical
Manual of Mental Disorders of the American Psychiatric
Association.
Diagnosis of autism spectrum disorders means Medically
Necessary assessments, evaluations, or tests in order to
diagnose whether an individual has an autism spectrum
disorder.
Treatment for autism spectrum disorders means care
prescribed or ordered for an individual diagnosed with an
autism spectrum disorder by a licensed Physician or
licensed psychologist, including equipment Medically
Necessary for such care, pursuant to the powers granted
under such licensed Physician's or licensed psychologist's
license, including, but not limited to: psychiatric care;
psychological care; habilitative or rehabilitative care,
including applied behavior analysis therapy; therapeutic
care; and pharmacy care.
Autism service provider means any person, entity, or
group that provides diagnostic or treatment services for
autism spectrum disorders who is licensed or certified by
the state of Missouri; or any person who is licensed under
chapter 337 as a board-certified behavior analyst by the
behavior analyst certification board or licensed under
chapter 337 as an assistant board-certified behavior analyst.
Applied behavior analysis means the design,
implementation, and evaluation of environmental
modifications, using behavioral stimuli and consequences,
to produce socially significant improvement in human
behavior, including the use of direct observation,
measurement, and functional analysis of the relationships
between environment and behavior.
Habilitative or rehabilitative care is professional,
counseling, and guidance services and treatment programs,
including applied behavior analysis, that are necessary to
develop the functioning of an individual.
Line therapist means an individual who provides
supervision of an individual diagnosed with an autism
diagnosis and other neurodevelopmental disorders pursuant
to the prescribed treatment, and implements specific
behavioral interventions as outlined in the behavior plan
under the direct supervision of a licensed behavior analyst.
Pharmacy care means medications used to address
symptoms of an autism spectrum disorder prescribed by a
licensed Physician, and any health-related services deemed
Medically Necessary to determine the need or effectiveness
myCigna.com 39
of the medications, only to the extent that such medications
are included in the insured's health benefit plan.
Psychiatric care means direct or consultative services
provided by a psychiatrist licensed in the state in which the
psychiatrist practices.
Psychological care means direct or consultative services
provided by a psychologist licensed in the state in which the
psychologist practices.
Therapeutic care means services provided by licensed
speech therapists, occupational therapists, or physical
therapists.
CIGNA HEALTH AND LIFE INSURANCE
COMPANY, a Cigna company (hereinafter called
Cigna)
CERTIFICATE RIDER – Nebraska Residents
Rider Eligibility: Each Employee who is located in Nebraska
You will become insured on the date you become eligible,
including if you are not in Active Service on that date due to
your health status.
This rider forms a part of the certificate issued to you by
Cigna.
The provisions set forth in this rider comply with the legal
requirements of Nebraska group insurance plans covering
insureds located in Nebraska. These provisions supersede any
provisions in your certificate to the contrary unless the
provisions in your certificate result in greater benefits.
HC-ETNERDR
Covered Expenses
charges made for one screening test for hearing loss for a
Dependent child from birth through 30 days old.
charges for the screening, diagnosis, and treatment of
autism spectrum disorder.
Treatment means evidence-based care, including related
equipment, that is prescribed or ordered for a covered
person diagnosed with an autism spectrum disorder by a
licensed Physician or a licensed Psychologist including:
Behavioral health treatment; pharmacy care; psychiatric
care; psychological care, and therapeutic care.
Behavioral health treatment means counseling and treatment
programs, including applied behavior analysis, that are:
necessary to develop, maintain, or restore, to the maximum
extent practicable, the functioning of an individual; and
provided by a certified behavior analyst or a licensed
Psychologist if the services performed are within the
boundaries of the Psychologist's competency.
Pharmacy care means a medication that is prescribed by a
licensed Physician and any health related service deemed
Medically Necessary to determine the need or effectiveness
of the medication.
Psychiatric care means a direct or consultative service
provided by a psychiatrist licensed in the state in which he
or she practices.
Psychological care means a direct or consultative service
provided by a Psychologist licensed in the state in which he
or she practices.
Therapeutic care means a service provided by a licensed
speech-language pathologist, occupational therapist, or
physical therapist.
HC-COV469 05-15
V1-ET
CIGNA HEALTH AND LIFE INSURANCE
COMPANY, a Cigna company (hereinafter called
Cigna)
CERTIFICATE RIDER – New Hampshire Residents
Rider Eligibility: Each Employee who is located in New
Hampshire
You will become insured on the date you become eligible,
including if you are not in Active Service on that date due to
your health status.
This rider forms a part of the certificate issued to you by
Cigna.
myCigna.com 40
The provisions set forth in this rider comply with the legal
requirements of New Hampshire group insurance plans
covering insureds located in New Hampshire. These
provisions supersede any provisions in your certificate to the
contrary unless the provisions in your certificate result in
greater benefits.
HC-ETNHRDR
Continuation of Coverage Under New
Hampshire State Law
High Risk Pool
If you or your Dependents have been covered for 60 days, you
or your Dependent may apply to the New Hampshire High
Risk Pool within 31 days after termination of coverage,
without having to provide evidence of insurability.
HC-TRM45 04-10
V1-ET1
CIGNA HEALTH AND LIFE INSURANCE
COMPANY, a Cigna company (hereinafter called
Cigna)
CERTIFICATE RIDER – New Jersey Residents
Rider Eligibility: Each Employee who is located in New
Jersey
You will become insured on the date you become eligible,
including if you are not in Active Service on that date due to
your health status.
This rider forms a part of the certificate issued to you by
Cigna.
The provisions set forth in this rider comply with the legal
requirements of New Jersey group insurance plans covering
insureds located in New Jersey. These provisions supersede
any provisions in your certificate to the contrary unless the
provisions in your certificate result in greater benefits.
HC-ETNJRDR
Definitions
Dependent
Dependents include:
your lawful spouse or civil union partner; or
any child of yours who is:
less than 26 years old.
26 years old, but less than 26, not married nor in a civil
union partnership nor in a Domestic Partnership, enrolled
in school as a full-time student and primarily supported
by you.
26 or more years old, not married nor in a civil union
partnership nor in a Domestic Partnership, and primarily
supported by you and incapable of self-sustaining
employment by reason of mental or physical disability
which arose while the child was covered as a Dependent
under this Plan, or while covered as a dependent under a
prior plan with no break in coverage.
Proof of the child's condition and dependence must be
submitted to Cigna within 31 days after the date the child
ceases to qualify above. From time to time, but not more
frequently than once a year, Cigna may require proof of
the continuation of such condition and dependence.
The term child means a child born to you or a child legally
adopted by you. It also includes a stepchild. If your civil union
partner has a child, that child will also be included as a
Dependent.
HC-DFS646 01-15
V1-ET
CIGNA HEALTH AND LIFE INSURANCE
COMPANY, a Cigna company (hereinafter called
Cigna)
CERTIFICATE RIDER – New Mexico Residents
Rider Eligibility: Each Employee who is located in New
Mexico
You will become insured on the date you become eligible,
including if you are not in Active Service on that date due to
your health status.
This rider forms a part of the certificate issued to you by
Cigna.
myCigna.com 41
The provisions set forth in this rider comply with the legal
requirements of New Mexico group insurance plans covering
insureds located in New Mexico. These provisions supersede
any provisions in your certificate to the contrary unless the
provisions in your certificate result in greater benefits.
HC-ETNMRDR
When You Have a Complaint or an
Appeal (Grievance)
For the purposes of this section, any reference to "you," "your"
or "Member" also refers to Grievant.
Information about Appeals (Grievance) Procedures
Cigna is responsible for:
including a clear and concise description of all grievance
procedures, both internal and external, in boldface type in
the enrollment materials, including in member handbooks or
evidence of coverage issued to Grievants;
for a person who has been denied coverage, providing him
or her with a copy of the grievance procedures;
notifying Grievants that a representative of Cigna and the
Managed Health Care Bureau of the insurance division are
available upon request to assist with grievance procedures
by including such information, and a toll-free telephone
number for obtaining such assistance, in the enrollment
materials and Summary of Benefits issued to Grievants;
providing a copy of its grievance procedures and all
necessary grievance forms at each decision point in the
grievance process and immediately upon request, at any
time, to a Grievant, Provider, or other interested person;
providing a detailed written explanation of the appropriate
grievance procedures and a copy of the grievance form to a
Grievant or Provider when Cigna makes either an adverse
determination or adverse administrative decision. The
written explanation will describe how Cigna reviews and
resolves grievances and provide a toll-free number,
facsimile number, e-mail address, and mailing address of
Cigna's consumer assistance office;
providing consumer education brochures and materials
developed and approved by the superintendent, annually, or
as directed by the superintendent in consultation with Cigna
for distribution;
providing notice to enrollees in a Culturally and
Linguistically Appropriate Manner;
providing continued coverage for an ongoing course of
treatment pending the outcome of an internal appeal;
not reducing or terminating an ongoing course of treatment
without first notifying the Grievant sufficiently in advance
of the reduction or termination to allow the Grievant to
appeal and obtain a determination on review of the proposed
reduction or termination;
allowing individuals in urgent care situations and receiving
an ongoing course of treatment to proceed with an expedited
external review at the same time as the internal review
process.
Timeframes for Initial Utilization Management
Determinations
For initial Utilization Management Determinations, we will
respond in writing with a decision within 5 working days. If
more time or information is needed to make the determination,
and the delay is due to a reasonable cause beyond our control,
and does not result in increased medical risk to you we will
notify you in writing as to the reason for the delay, and to
request an extension of up to 10 working days. If there is a
delay, you will be provided a written progress report within
the original five (5) working day review period.
You may request, either verbally or in writing, that the initial
determination be expedited, and we will make a determination
within 24 hours after receiving your request, if the time frames
under this process would seriously jeopardize your life, health
or ability to regain maximum function; or your Physician
makes a reasonable request; or it is the opinion of your
Physician, who has knowledge of your medical condition, that
you would be subject to severe pain that cannot be adequately
managed without the care or treatment in question; or the
medical exigencies of your case require an expedited
determination; or your claim involves urgent care.
When considering whether to certify a Health Care Service
requested by a Provider or Grievant, Cigna will determine
whether the requested Health Care Service is covered by the
Health Benefits Plan. Before denying a Health Care Service
requested by a Provider or Grievant on grounds of a lack of
coverage, Cigna will determine that there is no provision of
the Health Benefits Plan under which the requested Health
Care Service could be covered. If Cigna finds that the
requested Health Care Service is not covered by the Health
Benefits Plan, Cigna need not address the issue of Medical
Necessity.
If Cigna finds that the requested Health Care Service is
covered by the Health Benefits Plan, then when considering
whether to certify a Health Care Service requested by a
Provider or Grievant, a physician, registered nurse, or other
Health Care Professional shall, within the timeframe required
by the medical exigencies of the case, determine whether the
requested Health Care Service is Medically Necessary.
Before Cigna denies a Health Care Service requested by a
Provider or Grievant on grounds of a lack of Medical
Necessity, a physician shall render an opinion as to Medical
Necessity, either after consultation with specialists who are
myCigna.com 42
experts in the area that is the subject of review, or after
application of Uniform Standards used by Cigna. The
physician shall be under the clinical authority of the medical
director responsible for Health Care Services provided to
Grievants.
Notice of Initial Utilization Management Determination
You and your Provider will be notified within two (2) working
days of the date a Health Care Service has been certified,
unless earlier notice is required due to the medical exigencies
of your case.
You will be notified by telephone, or as required by the
medical exigencies of your case, no later than twenty-four
hours after an adverse determination decision has been made,
followed by a written or electronic communication within one
(1) working day of the telephone notice, unless you fail to
provide sufficient information to determine whether, or to
what extent, benefits are covered under the plan. If you fail to
provide such information, you will be afforded a reasonable
amount of time, but not less than forty-eight (48) hours to
provide the specified information.
If the adverse determination is based on Medical Necessity,
the notice will include a clear and complete explanation as to
why the requested service is not Medically Necessary. If the
adverse determination is based on lack of coverage, the notice
will identify all plan provisions relied upon, and include a
clear and complete explanation as to why the requested service
is not covered by the plan provisions. A statement that the
requested Health Care Service is not covered under the Health
Benefits Plan will not be sufficient. The notice will include the
date of service, the health care Provider, the claim amount (if
applicable) and a statement describing the availability (upon
request) of the diagnosis code and its corresponding meaning,
and the treatment code and its corresponding meaning. It will
also include a description of the Cigna standard that was used
in denying the claim and provide a summary of the discussion
which triggered the final determination. The notice will also
advise you of your rights to request an internal or external
review of the adverse determination. Appeals procedures and
any required forms will be sent along with the notice.
Customer Service
We want you to be completely satisfied with the care you
receive. If you have a concern regarding a person, a service,
the quality of care, contractual benefits, or a Rescission of
Coverage, you may call our toll-free number 1-888-992-4462
and explain your concern to one of our Customer Service
representatives.
When You Have a Complaint or an Appeal (Grievance)
If you are not satisfied with the results of a coverage decision,
you can start the appeals procedure, without being subject to
retaliation for any reason related to the appeal.
You must submit a request for an appeal in writing. If you
need help completing the forms required to initiate an internal
review, we will assist you. If you are unable or choose not to
write, you may ask to register your appeal by telephone. Call
us at the toll-free number 1-888-992-4462 or write to:
Cigna
National Appeals Organization (NAO)
PO Box 188011
Chattanooga, TN 37422
The New Mexico Managed Health Care Bureau is also
available for assistance:
Office of Superintendent of Insurance
Managed Health Care Bureau
Post Office Box 1689
Santa Fe, New Mexico 87504-1689
E-mail: [email protected]
Phone: 1-855-427-5674
Fax: (505) 827-3833
Website: http://www.osi.state.nm.us/managed-
healthcare/contact-us.html.
Once we receive your appeal, we will determine whether it is
an adverse determination appeal, or an administrative appeal.
If your appeal involves both an administrative appeal and an
adverse determination appeal, we will initiate separate
complaints, which will be explained to you in one
acknowledgement letter.
Under federal law, you are allowed up to four (4) months after
the date of receipt of a notice of adverse determination or final
adverse determination to file a request for external review.
Adverse Determination Appeal
An adverse determination means any of the following: any
Rescission of Coverage (whether or not a rescission has any
adverse effect on any particular benefit at the time); a denial,
reduction, or termination of, or a failure to provide or make
payment (in whole or in part) for a benefit, including any such
denial, reduction, termination, or failure to provide or make
payments, that is based on a determination of a participant’s or
beneficiary’s eligibility to participate in a plan, and including
a denial, reduction, or termination of, or a failure to provide or
make payment (in whole or in part) for, a benefit resulting
from the application of any utilization review, as well as a
failure to cover an item or service for which benefits are
otherwise provided because it is determined to be
Experimental or Investigational or not Medically Necessary or
appropriate.
An adverse determination appeal means an oral or written
complaint submitted by or on behalf of a Grievant regarding
an adverse determination.
We will review your appeal in accordance with the procedures
for adverse determination appeals outlined below and as
myCigna.com 43
required by 13.10.17.17 NMAC through 13.10.17.22 NMAC.
The adverse determination appeals procedures include an
internal appeal, an appeal to Cigna, an internal panel review,
and an external appeal.
Administrative Appeal
If the appeal is not based on an adverse determination of a pre-
or post- Health Care Service, it is an administrative appeal.
An administrative appeal means an oral or written complaint
submitted by or on behalf of a Grievant regarding any aspect
of a Health Benefits Plan other than a request for Health Care
Services, including but not limited to:
administrative practices of Cigna that affects the
availability, delivery, or quality of Health Care Services;
claims payment, handling or reimbursement for Health Care
Services; and
Terminations of Coverage; including Rescissions of
Coverage.
Administrative appeals procedures will be reviewed in
accordance with the procedures outlined below in the section,
“Administrative Appeal (Grievance) Procedures” and as
required by 13.10.17.33 NMAC through 13.10.17.36
NMAC.
Internal Appeal of an Adverse Determination
You have the right to request an internal review (appeal) of an
adverse determination if you are dissatisfied.
Upon receipt of a request for internal review of an adverse
determination, Cigna will date and time stamp the request and,
within one (1) working day from receipt, send you an
acknowledgment that the request has been received. The
acknowledgment will contain the name, address, and direct
telephone number of a Cigna representative who may be
contacted regarding the appeal.
To ensure that you receive a full and fair internal review, we
will allow you to review the claim file and present evidence
and testimony as part of the internal claims and appeals
process, and we will provide you, free of charge, with any new
or additional evidence, and any new or additional rationale,
considered, relied upon, or generated by Cigna, as soon as
possible and sufficiently in advance of the date of the notice of
final internal adverse benefit determination to allow you a
reasonable opportunity to respond before the final internal
adverse determination is made.
We will ensure that all internal claims and appeals are
adjudicated in a manner designed to ensure the independence
and impartiality of the persons involved in making the
decisions in such a way that decisions regarding hiring,
compensation, termination, promotion, or other similar matters
with respect to any individual (such as a claims adjudicator or
medical expert), must not be made based upon the likelihood
that the individual will support the denial of benefits.
We will complete your Internal Appeal of an Adverse
Determination and if utilized, your Internal Panel Appeal of
Adverse Determination within 20 working days after we
receive a request for an internal review for a required
preservice, or concurrent care coverage determination
(decision) that is not expedited. We will respond within 40
working days after we receive an appeal for a postservice
coverage determination. If more time or information is needed
to make the determination, and the delay is due to a reasonable
cause beyond our control, and does not result in increased
medical risk to you, we will notify you in writing as to the
reason for the delay, and to request an extension of up to 10
working days for pre-service claims, and 20 working days for
post service claims. If there is a delay, you will be provided a
written progress report within the original thirty (30) day
review period for pre-service and concurrent appeals; or the
sixty (60) day review period for post service appeals.
We will expedite your appeal if appropriate based on the
medical exigencies of your case and make a decision no later
than seventy-two (72) hours from the time your appeal is
received, whenever: the standard time frames under this
process would seriously jeopardize the life, health or ability to
regain maximum function of the Grievant; the Provider
reasonably requests an expedited decision; in the opinion of
the physician with knowledge of the Grievant’s medical
condition, would subject the Grievant to severe pain that
cannot be adequately managed without the care or treatment
that is the subject of the claim; or the medical exigencies of
the case require an expedited decision.
If you request that your appeal be expedited, you may also ask
for an expedited external Independent Review at the same
time, if the time to complete an expedited level-one appeal
would be detrimental to your medical condition.
If we fail to comply with the appeal deadlines outlined above,
the requested Health Care Service will be deemed approved,
unless you, after being informed of your rights, have agreed in
writing to extend the deadline.
Adverse Determination Appeal
Cigna will complete the review of the adverse determination
within the timeframes required by the medical exigencies of
your case.
If the initial adverse determination was based on a lack of
coverage, Cigna will review the Health Benefits Plan and
determine whether there is any provision in the plan under
which the requested Health Care Service could be certified.
If the initial adverse determination was based on a lack of
Medical Necessity, Cigna will render an opinion as to Medical
Necessity, either after consultation with specialists who are
experts in the area that is the subject of review, or after
application of Uniform Standards used by Cigna.
myCigna.com 44
If Cigna reverses the initial adverse determination and certifies
the service, we will notify you within the timeframes
discussed above.
If Cigna upholds the initial adverse determination to deny the
requested Health Care Service, within the timeframes
discussed above, we will notify you, and ascertain if you wish
to pursue an Internal Panel Appeal.
If you do not want to appeal further, we will mail you written
notification of our decision, along with confirmation of your
decision within three (3) working days of our decision.
If we are unable to contact you by phone within seventy-two
hours of making the decision to uphold the determination, we
will notify you by mail of our decision, along with a self-
addressed stamped response form with a box for checking
“yes”, and a box for checking “no”, which you may use to
indicate whether or not you want to appeal further. If you do
not return the response form within 10 working days, we will
again attempt to contact you by phone.
If you respond via telephone or response form, that you do
wish to appeal further, we will select a medical panel to
further review your adverse determination.
If you do not respond by telephone; or return the response
form:
for expedited reviews, we will select a medical panel to
further review your adverse determination.
If you do not make an immediate decision to pursue the
appeal, or you have requested additional time to supply
supporting documents or information, or postponement, the
required timeframe outlined above will be extended to include
the additional time you require.
Internal Panel Appeal of Adverse Determination
If we uphold the initial adverse determination to deny the
requested Health Care Service, we will notify you of your
right to an internal panel review (appeal) within the time
frames described in the internal appeal of an adverse
determination section.
If you choose to pursue the appeal, we will notify you of the
date, time, and place of the internal panel review. If Cigna will
be represented by an attorney, the notice will advise you that
you may want to also seek legal representation.
We will select one or more of Cigna’s representatives and one
or more health care or other professionals who have not been
previously involved in the adverse determination being
reviewed to serve on the internal panel. At least one of the
Health Care Professionals selected shall practice in a specialty
that would typically manage the case that is the subject of the
appeal, unless we mutually agree otherwise.
The internal review panel shall review the Health Benefits
Plan and determine whether there is any provision in the plan
under which the requested Health Care Service could be
certified.
The internal review panel shall render an opinion as to
Medical Necessity, either after consultation with specialists
who are experts in the area that is the subject of review, or
after application of Uniform Standards used by Cigna.
No fewer than three (3) working days prior to the internal
panel review, we will provide you copies of:
pertinent medical records;
the treating Provider’s recommendation;
Health Benefits Plan;
Cigna’s notice of adverse determination;
Uniform Standards relevant to your medical condition that
is used by the internal panel in reviewing the adverse
determination;
questions sent to or reports received from any medical
consultants retained by Cigna; and
all other evidence or documentation relevant to reviewing
the adverse determination, including any new or additional
rationale considered by Cigna.
We will not unreasonably deny your request for postponement
of the internal panel review. The timeframes for internal panel
review will be extended during the period of any
postponement.
You have the right to:
attend and participate in the internal panel review;
present your case to the internal panel;
submit supporting material both before and at the internal
panel review;
ask questions of any of Cigna’s representatives;
ask questions of any Health Care Professionals on the
internal panel;
be assisted or represented by a person of your choice,
including legal representation; and
hire a specialist to participate in the internal review panel
review at your own expense, but such specialist may not
participate in making the decision.
The internal panel will complete its review of the adverse
determination as required by the medical exigencies of your
case and within the timeframes described in the internal appeal
of an adverse determination section. Internal review panel
members must be present physically or by video or telephone
conferencing to hear the appeal. An internal review panel
member who is not present to hear the grievance either
physically or by video or telephone conferencing cannot
participate in the decision.
myCigna.com 45
In an expedited review, we will transmit required information
to you using the most expeditious method available.
If an expedited review is conducted during a patient’s hospital
stay or course of treatment, Health Care Services shall be
continued without cost (except for applicable co-payments and
deductibles) to the Grievant until Cigna makes a final decision
and notifies you of that decision.
Cigna will not conduct an expedited review of an adverse
determination made after Health Care Services have been
provided to a Grievant.
Within the time period allotted for completion of its internal
review, we will notify you of the internal panel’s decision by
telephone within twenty-four (24) hours of the panel’s
decision and in writing or by electronic means within one (1)
working day of the telephone notice.
The written notice will contain:
information sufficient for you to identify the claim;
the names, titles, and qualifying credentials of the persons
on the internal review panel;
a statement of the internal panel's understanding of the
nature of the appeal and all pertinent facts;
a description of the evidence relied on by the internal
review panel in reaching its decision;
a clear and complete explanation of the rationale for the
internal review panel's decision;
every provision of your Health Benefits Plan relevant to the
issue of coverage in the case under review, and an
explanation as to why each provision did or did not support
the panel’s decision regarding coverage of the requested
Health Care Service;
the notice shall cite the Uniform Standards relevant to your
medical condition and explain whether each supported or
did not support the panel’s decision regarding the Medical
Necessity of the requested Health Care Service;
notice of your right to request an external review by the
superintendent, including the address and telephone number
of the Managed Health Care Bureau of the insurance
division, a description of all procedures and time deadlines
necessary to pursue external review, and copies of any
forms required to initiate external review;
information about the New Mexico Managed Health Care
Bureau available to assist you in the appeal process.
External Review of Adverse Determination Procedure
If you are dissatisfied with the results of an internal panel
review, you may request, at no cost to you, an external review
by the superintendent. There is no minimum claim dollar
amount that must be met before you exercise this right to
external review.
The superintendent may require that you exhaust any of
Cigna’s appeals procedures, as appropriate, before accepting a
request for external review.
If exhaustion of internal appeals is required prior to external
review, exhaustion will be unnecessary and the internal
appeals process will be deemed exhausted if: Cigna waives the
exhaustion requirement; or if we are considered to have
exhausted the internal appeals process by failing to comply
with the requirements of the internal appeals process; or you
simultaneously request an expedited internal appeal and an
expedited external review.
An exception to the exhaustion requirement is as follows. The
internal claims and appeals process will not be deemed
exhausted based on violations of Cigna that are minor and do
not cause, and are not likely to cause prejudice or harm to you,
so long as Cigna demonstrates that the violation was for good
cause or due to matters beyond its control, and the violation
occurred in the context of an ongoing, good faith exchange of
information between Cigna and you, the Grievant, unless the
violation is part of a pattern or practice of violations by Cigna.
You may request a written explanation of the violation by
Cigna and we will provide it within ten (10) days, including a
specific description of its basis, if any, for asserting that the
violation should not cause the internal claims and appeals
process to be deemed exhausted. If an external reviewer or
court rejects your request for immediate review on the basis
that Cigna met the standards for an exception, you have the
right to resubmit and pursue the internal appeal of the claim.
In such a case, within a reasonable amount of time, not to
exceed ten (10) days, Cigna will provide you with notice of
the opportunity to resubmit and pursue the internal appeal of
the claim. Time periods for re-filing the claim will begin to
run upon your receipt of such notice.
If required by the medical exigencies of your case, you may
telephonically request an expedited review by calling the
Managed Health Care Bureau at 1-855-427-5674.
In all other cases, to initiate an external review, you must file a
written request for external review with the superintendent
within one hundred and twenty (120) calendar days from
receipt of the written notice of internal review decision unless
extended by the superintendent for good cause shown, or
unless a longer time frame is permitted under federal law.
Cigna will bear the cost of the external review.
The request shall be:
mailed to the Office of Superintendent of Insurance, Attn:
Managed Health Care Bureau - External Review Request,
New Mexico Public Regulation Commission, Post Office
Box 1689, Santa Fe, New Mexico 87504-1689; or
e-mailed to [email protected], subject External
Review Request; or
myCigna.com 46
faxed to the Office of Superintendent of Insurance, Attn:
Managed Health Care Bureau - External Review Request, at
(505) 827-3833; or
completed on-line with a NM PRC, Division of Insurance
Complaint Form available at
http://www.osi.state.nm.us/managed-healthcare/contact-
us.html.
You must file the request for external review on the forms
provided by Cigna, and you must also file:
a copy of the notice of internal review decision;
a fully executed release form authorizing the superintendent
to obtain any necessary medical records from Cigna or any
other relevant Provider; and
if the appeal involves an experimental or investigational
treatment adverse determination, the Provider’s
Certification and recommendation.
You may also file any other supporting documents or
information you wish to submit to the superintendent for
review.
If you wish to supply supporting documents or information
subsequent to the filing of the request for external review, the
timeframes for external review shall be extended up to 90 days
from the receipt of the complaint form, or until you submit all
supporting documents, whichever occurs first.
Upon receipt of a request for external review, the
superintendent will immediately send:
you an acknowledgment that the request has been received;
Cigna a copy of the request for external review.
Upon receipt of the copy of the request for external review,
Cigna will, within five (5) working days for standard review
or the time limit set by the superintendent for expedited
review, provide to you and the superintendent, by any
available expeditious method:
the Summary of Benefits;
the complete Health Benefits Plan, which may be in the
form of a member handbook/evidence of coverage;
all pertinent medical records, internal review decisions and
rationales, consulting physician reports, and documents and
information submitted by you or Cigna;
Uniform Standards relevant to your medical condition that
were used by the internal panel in reviewing the adverse
determination; and
any other documents, records, and information relevant to
the adverse determination and the internal review decision
or intended to be relied on at the external review hearing.
If Cigna fails to comply with the requirements of this section,
the superintendent may reverse the adverse determination. The
superintendent may waive the requirements of this section if
necessitated by the medical exigencies of the case.
The superintendent shall conduct either a standard or
expedited external review of the adverse determination, as
required by the medical exigencies of the case.
The superintendent shall complete an external review as
required by the medical exigencies of the case but in no case
later than seventy-two (72) hours of receipt of the external
review request whenever:
the Grievant’s life would be jeopardized; or
the Grievant’s ability to regain maximum function would be
jeopardized.
If the superintendent’s initial decision is made orally, written
notice of the decision must be provided within forty-eight (48)
hours of the oral notification.
The superintendent shall conduct a standard review in all cases
not requiring expedited review. Insurance division staff shall
complete the initial review within ten (10) working days from
receipt of the request for external review and the information
required by you and Cigna. If a hearing is held, the
superintendent will complete the external review within forty-
five (45) working days from receipt of the complete request
for external review. The superintendent may extend the
external review period for up to an additional ten (10) working
days when the superintendent has been unable to schedule the
hearing within the required timeframe and the delay will not
result in increased medical risk to the Covered Person.
Upon receipt of the request for external review, insurance
division staff shall review the request to determine whether:
you have provided the documents required;
the individual is or was insured by Cigna at the time the
Health Care Service was requested or provided;
the Grievant has exhausted Cigna’s internal review
procedure and any applicable appeal review procedure; and
the Health Care Service that is the subject of the appeal
reasonably appears to be a covered benefit under the Health
Benefits Plan.
If the request is for external review of an experimental or
investigational treatment adverse determination, insurance
division staff shall also consider whether the recommended or
requested Health Care Service:
reasonably appears to be a covered benefit under the
Grievant’s Health Benefit Plan except for Cigna’s
determination that the Health Care Service is experimental
or investigational for a particular medical condition; and
myCigna.com 47
is not explicitly listed as an excluded benefit under the
Grievant’s Health Benefit Plan; and the Grievant’s treating
Provider has certified that:
standard Health Care Services have not been effective in
improving the Grievant’s condition; or
standard Health Care Services are not medically
appropriate for the Grievant; or
there is no standard Health Care Service covered by
Cigna that is as beneficial or more beneficial than the
Health Care Service:
recommended by the Grievant’s treating Provider that
the treating Provider certifies in writing is likely to be
more beneficial to the Grievant, in the treating
Provider’s opinion, than standard Health Care Services;
or
requested by the Grievant regarding which the
Grievant’s treating Provider, who is a licensed, board
certified or board eligible physician qualified to
practice in the area of medicine appropriate to treat the
Grievant’s condition, has certified in writing that
scientifically valid studies using accepted protocols
demonstrate that the Health Care Service requested by
the Grievant is likely to be more beneficial to the
Grievant than available standard Health Care Services.
If the request for external review is incomplete, insurance
division staff will immediately notify you and Cigna and
require that you submit the required information within the
specified period of time.
If the request for external review does not meet the prescribed
criteria and, if applicable, insurance division staff will so
inform the superintendent. The superintendent will notify you
and Cigna that the request does not meet the criteria for
external review and is thereby denied, and that you have the
right to request a hearing within thirty-three (33) days from
the date the notice was mailed.
If the request for external review is complete and meets the
required criteria and, if applicable, insurance division staff
shall so inform the superintendent. The superintendent shall
notify you and Cigna that the request meets the criteria for
external review and that an informal hearing has been set to
determine whether, as a result of Cigna’s adverse
determination, you were deprived of Medically Necessary
covered services. Prior to the hearing, insurance division staff
shall attempt to informally resolve the appeal.
The notice of hearing shall be mailed no later than eight (8)
working days prior to the hearing date. The notice shall state
the date, time, and place of the hearing and the matters to be
considered and shall advise the Grievant and Cigna of the
rights. The superintendent shall not unreasonably deny a
request for postponement of the hearing made by you or
Cigna.
The superintendent may designate a Hearing Officer who shall
be an attorney licensed to practice in New Mexico. The
hearing may be conducted by telephone conference call, video
conferencing, or other appropriate technology at the insurance
division’s expense.
The superintendent may designate two (2) Independent Co-
Hearing Officers (ICOs) who must be licensed Health Care
Professionals and who must maintain independence and
impartiality in the process. If the superintendent designates
two (2) ICOs, at least one of them shall practice in a specialty
that would typically manage the case that is the subject of the
appeal.
The superintendent or attorney Hearing Officer shall regulate
the proceedings and perform all acts and take all measures
necessary or proper for the efficient conduct of the hearing.
The superintendent or attorney Hearing Officer may:
require the production of additional records, documents, and
writings relevant to the subject of the appeal;
exclude any irrelevant, immaterial, or unduly repetitious
evidence; and
if you or Cigna fails to appear, proceed with the hearing or
adjourn the proceedings to a future date, giving notice of the
adjournment to the absent party.
Staff may attend the hearing, ask questions, and otherwise
solicit evidence from the parties, but shall not be present
during deliberations among the superintendent or his
designated Hearing Officer and any ICOs.
Testimony at the hearing shall be taken under oath. The
superintendent or Hearing Officers may call and examine you,
Cigna, and other witnesses.
The hearing shall be stenographically recorded at the
insurance division’s expense.
Both you and Cigna have the right to:
attend the hearing; Cigna shall designate a person to attend
on its behalf and you may designate a person to attend on
your behalf if you choose not to attend personally;
be assisted or represented by an attorney or other person;
and
call, examine and cross-examine witnesses; and
submit to the ICO, prior to the scheduled hearing, in
writing, additional information that the ICO must consider
when conducting the internal review hearing and require
that the information be submitted to Cigna and the MHCB
staff..
You and Cigna must each stipulate on the record that the
Hearing Officers shall be released from civil liability for all
communications, findings, opinions, and conclusions made in
the course and scope of the external review. The
superintendent shall consult with appropriate professional
myCigna.com 48
societies, organizations, or associations to identify licensed
health care and other professionals who are willing to serve as
ICOs in external reviews.
The superintendent will provide for maintenance of a list of
licensed professionals qualified to serve as Independent Co-
Hearing Officers. The superintendent will select appropriate
professional societies, organizations or associations to identify
licensed health care and other professionals willing to serve as
Independent Co-Hearing Officers in external reviews who
maintain independent and impartiality of the process.
Prior to accepting designation as an ICO, each potential ICO
shall provide to the superintendent a list identifying all Health
Care Insurers and Providers with whom the potential ICO
maintains any health care related or other professional
business arrangements and briefly describe the nature of each
arrangement. Each potential ICO shall disclose to the
superintendent any other potential conflict of interest that may
arise in hearing a particular case, including any personal or
professional relationship to the Grievant or Cigna or Providers
involved in a particular external review.
The superintendent shall consult with appropriate professional
societies, organizations, or associations in New Mexico to
determine reasonable compensation for health care and other
professionals who are appointed as ICOs for external appeal
reviews and shall annually publish a schedule of ICO
compensation in a bulletin.
Upon completion of an external review, the attorney and ICO
shall each complete a statement of ICO compensation form
prescribed by the superintendent detailing the amount of time
spent participating in the external review and submit it to the
superintendent for approval. The superintendent shall send the
approved statement of ICO compensation to Cigna. Within
thirty (30) days of receipt of the statement of ICO
compensation, Cigna will remit the approved compensation
directly to the ICO.
If the parties provide written notice of a settlement up to three
(3) working days prior to the date set for external review
hearing, compensation will be unavailable to the Hearing
Officers or ICOs.
The Hearing Officer and ICOs must maintain written records
for a period of three (3) years and make them available upon
request.
At the close of the hearing, the Hearing Officers shall review
and consider the entire record and prepare findings of fact,
conclusions of law, and a recommended decision. Any
Hearing Officer may submit a supplementary or dissenting
opinion to the recommended decision.
Within the time period allotted for external review, the
superintendent shall issue an appropriate order. If the order
requires action by Cigna, the order shall specify the timeframe
for compliance.
The order shall be binding on you and Cigna and shall state
that you and Cigna have the right to judicial review and that
state and federal law may provide other remedies.
Neither you nor Cigna may file a subsequent request for
external review of the same adverse determination that was the
subject of the superintendent’s order.
Administrative Appeal (Grievance) Procedures
If you are dissatisfied with a decision, action or inaction by
Cigna, including Termination of Coverage, you have the right
to request an internal review of an administrative appeal orally
or in writing.
Within three (3) working days after receipt of an
administrative appeal, we will send you a written
acknowledgment that we have received the administrative
appeal. The acknowledgment shall contain the name, address,
and direct telephone number of a Cigna representative you
may contact regarding the administrative appeal.
Cigna will promptly review the administrative appeal. The
initial review will:
be conducted by a Cigna representative authorized to take
corrective action on the administrative appeal; and
allow you to present any information pertinent to the
administrative appeal.
Cigna will mail a written decision to you within fifteen (15)
calendar days after we receive an appeal for a required
preservice administrative appeal. Cigna will mail a written
decision to you within fifteen (15) working days of receipt of
the postservice administrative appeal. The fifteen (15) day
period may be extended when there is a delay in obtaining
documents or records necessary for the review of the
administrative appeal, provided we notify you in writing of the
need and reasons for the extension and the expected date of
resolution, or by our mutual written agreement.
The written decision shall contain:
information sufficient for you to identify the claim;
the name, title, and qualifications of the person conducting
the initial review;
a statement of the reviewer’s understanding of the nature of
the administrative appeal and all pertinent facts;
a clear and complete explanation of the rationale for the
reviewer’s decision;
identification of the Health Benefits Plan provisions relied
upon in reaching the decision;
reference to evidence or documentation considered by the
reviewer in making the decision;
a statement that the initial decision will be binding unless
you submit a request for reconsideration within twenty (20)
working days of receipt of the initial decision;
myCigna.com 49
a description of the procedures and deadlines for requesting
reconsideration of the initial decision, including any
necessary forms; and
information about the New Mexico Managed Health Care
Bureau available to assist you in the appeal process.
Upon receipt of a request for reconsideration, we appoint a
reconsideration committee consisting of one or more Cigna
employees who have not participated in the initial decision.
We may include one or more employees other than the
Grievant to participate on the reconsideration committee.
The reconsideration committee shall schedule and hold a
hearing within fifteen (15) calendar days after receiving a
request for a reconsideration of a preservice administrative
appeal, and within fifteen (15) working days after receipt of a
request for reconsideration of a postservice administrative
appeal. The hearing shall be held during regular business
hours at a location reasonably accessible to you, and we will
offer you the opportunity to communicate with the committee,
at our expense, by conference call, video conferencing, or
other appropriate technology. We will not unreasonably deny
any request you make for postponement of the hearing. If
Cigna will be represented by an attorney, the notice will
advise you that you may want to also seek legal
representation.
We will notify you in writing of the hearing date, time and
place at least ten (10) working days in advance. The notice
shall advise you of your rights.
No fewer than three (3) working days prior to the hearing, we
will provide you all documents and information that the
committee will rely on in reviewing the case. Specifically, in
the event any new or additional information (evidence) is
considered, relied upon or generated by Cigna in connection
with the reconsideration, Cigna will provide this information
to you as soon as possible and sufficiently in advance of the
decision, so that you will have an opportunity to respond.
Also, if any new or additional rationale is considered by
Cigna, Cigna will provide the rationale to you as soon as
possible and sufficiently in advance of the decision so that you
will have an opportunity to respond.
You have the right to:
attend the reconsideration committee hearing;
present your case to the reconsideration committee;
submit supporting material both before and at the
reconsideration committee hearing;
ask questions of any Cigna representative; and
be assisted or represented by a person of your choice.
We will mail a written decision to you within seven (7)
working days after the reconsideration committee hearing. The
written decision shall include:
information sufficient for you to identify the claim;
the names, titles, and qualifications of the persons on the
reconsideration committee;
the reconsideration committee’s statement of the issues
involved in the administrative appeal;
a clear and complete explanation of the rationale for the
reconsideration committee's decision;
the Health Benefits Plan provision relied on in reaching the
decision;
references to the evidence or documentation relied on in
reaching the decision;
a statement that the initial decision will be binding unless
you submit a request for external review by the
superintendent within twenty (20) working days of receipt
of the reconsideration decision; and
a description of the procedures and deadlines for requesting
external review by the superintendent, including any
necessary forms.
The notice will also contain the toll free telephone number and
address of the superintendent’s office.
External Review of Administrative Appeal by
Superintendent
If you are dissatisfied with the results of the internal review of
an administrative decision you have the right to request
external review by the superintendent. The superintendent
may require that you exhaust any of Cigna’s appeal
procedures before accepting an administrative appeal for
external review.
If exhaustion of internal appeals is required prior to external
review, exhaustion will be unnecessary and the internal
appeals process will be deemed exhausted if: Cigna waives the
exhaustion requirement; or if we are considered to have
exhausted the internal appeals process by failing to comply
with the requirements of the internal appeals process; or you
simultaneously request an expedited internal appeal and an
expedited external review.
An exception to the exhaustion requirement is as follows. The
internal claims and appeals process will not be deemed
exhausted based on violations of Cigna that are minor and do
not cause, and are not likely to cause prejudice or harm to you,
so long as Cigna demonstrates that the violation was for good
cause or due to matters beyond its control, and the violation
occurred in the context of an ongoing, good faith exchange of
information between Cigna and you, the Grievant, unless the
violation is part of a pattern or practice of violations by Cigna.
myCigna.com 50
You may request a written explanation of the violation by
Cigna and we will provide it within ten (10) days, including a
specific description of its basis, if any, for asserting that the
violation should not cause the internal claims and appeals
process to be deemed exhausted. If an external reviewer or
court rejects your request for immediate review on the basis
that Cigna met the standards for an exception, you have the
right to resubmit and pursue the internal appeal of the claim.
In such a case, within a reasonable amount of time, not to
exceed ten (10) days, Cigna will provide you with notice of
the opportunity to resubmit and pursue the internal appeal of
the claim. Time periods for re-filing the claim will begin to
run upon your receipt of such notice.
To initiate an external review, you must file a written request
for external review with the superintendent within twenty (20)
working days from receipt of the written notice of
reconsideration decision.
The request shall either be:
mailed to the Office of Superintendent of Insurance, Attn:
Managed Health Care Bureau – External Review Request,
New Mexico Public Regulation Commission, Post Office
Box 1689, Santa Fe, New Mexico 87504-1689; or
e-mailed to [email protected], subject External
Review Request; or
faxed to the Office of Superintendent of Insurance, Attn:
Managed Health Care Bureau - External Review Request,
(505) 827-3833; or
completed on-line using a NM PRC, Division of Insurance
Complaint Form available at
http://www.osi.state.nm.us/managed-healthcare/contact-
us.html.
You must file the request for external review on the forms
Cigna provides to you. You may also file any other supporting
documents or information you wish to submit to the
superintendent for review. If you wish to supply supporting
documents or information subsequent to the filing of the
request for external review, the timeframes for external review
will be extended up to 90 days from the receipt of the
complaint form, or until you submit all supporting documents,
whichever occurs first.
Upon receipt of a request for external review, the
superintendent will immediately send:
you an acknowledgment that the request has been received;
Cigna a copy of the request for external review.
Upon receipt of the copy of the request for external review,
Cigna will provide you and the superintendent, by any
available expeditious method within five (5) working days all
necessary documents and information considered in arriving at
the administrative appeal decision.
The superintendent shall review the documents submitted by
you or Cigna, and may conduct an investigation or inquiry or
consult with you, as appropriate. The superintendent shall
issue a written decision on the administrative appeal within
twenty (20) working days of receipt of the complete request
for external review.
Confidentiality
Health Care Insurers, the superintendent, Independent Co-
Hearing Officers, and all others who acquire access to
identifiable medical records and information of Grievants
when reviewing grievances shall treat and maintain such
records and information as confidential except as otherwise
provided by federal and New Mexico law.
HC-APL105 05-12
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Definitions
Certification
The term Certification means a decision by Cigna that a
Health Care Service requested by a Provider or Grievant has
been reviewed and, based upon the information available,
meets Cigna’s requirements for coverage and Medical
Necessity, and the requested Health Care Service is therefore
approved.
HC-DFS476V2 05-12
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Covered Person
The term Covered Person means a policyholder, subscriber,
enrollee, or other individual entitled to receive health care
benefits provided by a Health Benefits Plan, and includes
Medicaid recipients enrolled in a Health Care Insurer's
Medicaid plan and individuals whose health insurance
coverage is provided by an entity that purchases or is
authorized to purchase health care benefits pursuant to the
New Mexico Health Care Purchasing Act.
HC-DFS478 04-10
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myCigna.com 51
Culturally and Linguistically Appropriate Manner of
Notice
The term Culturally and Linguistically Appropriate Manner of
Notice means:
A grievance related notice that meets the following
requirements:
oral language services provided by Cigna (such as a
telephone customer assistance hotline) that includes
answering questions in any applicable non-English
language and providing assistance with filing claims and
appeals (including external review) in any applicable non-
English language;
a grievance related notice provided by Cigna, upon
request, in any applicable non-English language;
included in the English versions of all grievance related
notices provided by Cigna, a statement prominently
displayed in any applicable non-English language clearly
indicating how to access the language services provided
by Cigna; and
for purposes of this definition, with respect to an address
in any New Mexico county to which a grievance related
notice is sent, a non-English language is an applicable
non-English language if ten percent (10%) or more of the
population residing in the county is literate only in the
same non-English language, as determined by the
department of health and human services (HHS); the
counties that meet this ten percent (10%) standard, as
determined by HHS, are found at
http://cciio.cms.gov/resources/factsheets/clas-data.html
and any necessary changes to this list are posted by HHS
annually.
HC-DFS609 05-12
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Grievant
The term Grievant means any of the following:
A policyholder, subscriber, enrollee, or other individual, or
that person’s authorized representative or provider, acting
on behalf of that person with that person’s consent, entitled
to receive health care benefits provided by Cigna;
An individual, or that person’s authorized representative,
who may be entitled to receive health care benefits provided
by Cigna;
Medicaid recipients enrolled in a Cigna Medicaid plan, if
Cigna offers such a plan.
If Cigna purchases or is authorized to purchase health care
coverage pursuant to the New Mexico Health Care Purchasing
Act, a Grievant includes individuals whose health insurance
coverage is provided by such coverage.
HC-DFS477V2 05-12
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Health Benefits Plan
The term Health Benefit Plan means a health plan or a policy,
contract, certificate or agreement offered or issued by a Health
Care Insurer or plan administrator to provide, deliver, arrange
for, pay for, or reimburse the costs of Health Care Services;
this includes a Traditional Fee-For-Service Health Benefits
Plan.
HC-DFS479V2 05-12
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Health Care Insurer
The term Health Care Insurer means a person that has a valid
certificate of authority in good standing issued pursuant to the
Insurance Code to act as an insurer, health maintenance
organization, nonprofit health care plan, fraternal benefit
society, vision plan, or pre-paid dental plan.
HC-DFS480 04-10
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Health Care Professional
The term Health Care Professional means a Physician or other
health care practitioner, including a pharmacist, who is
licensed, certified or otherwise authorized by the state to
provide Health Care Services consistent with state law.
HC-DFS488 04-10
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Health Care Services
The term Health Care Services means services, supplies, and
procedures for the diagnosis, prevention, treatment, cure or
relief of a health condition, illness, injury, or disease, and
includes, to the extent offered by the Health Benefits Plan,
physical and mental health services, including community-
based mental health services, and services for developmental
disability or developmental delay.
HC-DFS481 04-10
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Hearing Officer, Independent Co-Hearing Officer or ICO
The terms Hearing Officer, Independent Co-Hearing Officer
or ICO mean a health care or other professional licensed to
practice medicine or another profession who is willing to
assist the superintendent as a Hearing Officer in understanding
and analyzing Medical Necessity and coverage issues that
arise in external review hearings.
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Medical Necessity or Medically Necessary
The terms Medical Necessity or Medically Necessary mean
Health Care Services determined by a Provider, in
consultation with the Health Care Insurer, to be appropriate or
necessary, according to any applicable generally accepted
principles and practices of good medical care or practice
guidelines developed by the federal government, national or
professional medical societies, boards and associations, or any
applicable clinical protocols or practice guidelines developed
by the Health Care Insurer consistent with such federal,
national, and professional practice guidelines, for the
diagnosis or direct care and treatment of a physical,
behavioral, or mental health condition, illness, injury, or
disease.
HC-DFS483 04-10
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Provider
The term Provider means a duly licensed Hospital or other
licensed facility, Physician, or other Health Care Professional
authorized to furnish Health Care Services within the scope of
their license.
HC-DFS484 04-10
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Rescission of Coverage
The term Rescission of Coverage means a cancellation or
discontinuance of coverage that has retroactive effect; a
cancellation or discontinuance of coverage is not a rescission
if:
the cancellation or discontinuance of coverage has only a
prospective effect; or
the cancellation or discontinuance of coverage is effective
retroactively to the extent it is attributable to a failure to
timely pay required premiums or contributions towards the
cost of coverage.
HC-DFS608 05-12
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Termination of Coverage
The term Termination of Coverage means the cancellation or
non-renewal of coverage provided by Cigna to a Grievant but
does not include a voluntary termination by a Grievant or
termination of a Health Benefits Plan that does not contain a
renewal provision.
HC-DFS485V2 05-12
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Traditional Fee-For-Service Indemnity Benefit
The term Traditional Fee-For-Service Indemnity Benefit
means a fee-for-service indemnity benefit, not associated with
any financial incentives that encourage Grievants to utilize
preferred Providers, to follow pre-authorization rules, to
utilize prescription drug formularies or other cost-saving
procedures to obtain prescription drugs, or to otherwise
comply with a plan's incentive program to lower cost and
improve quality, regardless of whether the benefit is based on
an indemnity form of reimbursement for services.
HC-DFS486V2 05-12
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Uniform Standards
The term Uniform Standards means all generally accepted
practice guidelines, evidence-based practice guidelines or
practice guidelines developed by the federal government or
national and professional medical societies, boards and
associations, and any applicable clinical review criteria,
policies, practice guidelines, or protocols developed by the
Health Care Insurer consistent with the federal, national, and
professional practice guidelines that are used by a Health Care
Insurer in determining whether to certify or deny a requested
Health Care Service.
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Utilization Management Determinations
The term Utilization Management Determinations means the
outcome, including Certification and adverse determination, of
myCigna.com 53
the review and evaluation of Health Care Services and settings
for Medical Necessity, appropriateness, efficacy, and
efficiency.
HC-DFS475 04-10
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CIGNA HEALTH AND LIFE INSURANCE
COMPANY, a Cigna company (hereinafter called
Cigna)
CERTIFICATE RIDER – North Carolina Residents
Rider Eligibility: Each Employee who is located in North
Carolina
You will become insured on the date you become eligible,
including if you are not in Active Service on that date due to
your health status.
This rider forms a part of the certificate issued to you by
Cigna.
The provisions set forth in this rider comply with the legal
requirements of North Carolina group insurance plans
covering insureds located in North Carolina. These provisions
supersede any provisions in your certificate to the contrary
unless the provisions in your certificate result in greater
benefits.
HC-ETNCRDR
Important Information About Your
Medical Plan
Direct Access for OB/GYN Services
Female insureds covered by this plan are allowed direct access
to a licensed/certified Participating Provider for covered
OB/GYN services. There is no requirement to obtain an
authorization of care from your Primary Care Physician for
visits to the Participating Provider of your choice for
pregnancy, well-woman gynecological exams, primary and
preventive gynecological care, and acute gynecological
conditions.
Primary Care Physician
Choice of Primary Care Physician:
If you are diagnosed with a serious or chronic degenerative,
disabling, or life-threatening disease or condition, which
requires specialized medical care, you can select a Specialist
with expertise in treating the disease or condition to serve as
your PCP. Cigna will consult with you or your designee and
the Specialist to determine if your care would appropriately
be coordinated by that Specialist.
An extended or standing authorization of care for a
Participating Specialist Physician may be obtained from the
PCP. The extended authorization can be obtained if the
insured has a serious or chronic degenerative, disabling, or
life-threatening disease or condition which, in the opinion of
the PCP who consults with the Specialist, requires ongoing
specialty care. The extended period for access to the
Participating Specialist shall not exceed 12 months.
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Covered Expenses
charges made for Family Planning, including medical
history, physical exam, related laboratory tests, medical
supervision in accordance with generally accepted medical
practices, other medical services, information and
counseling on contraception, implanted/injected
contraceptives, after appropriate counseling, medical
services connected with surgical therapies (tubal ligations,
vasectomies).
charges made by a Hospital or Ambulatory Surgical Facility
for anesthesia and facility charges for services performed in
the facility in connection with dental procedures for:
Dependent children below age 9; covered persons with
serious mental or physical conditions; or covered persons
with significant behavioral problems. The treating provider
must certify that hospitalization or general anesthesia is
required in order to safely and effectively perform the
procedure because of the person's age, condition or
problem.
charges made for or in connection with: the treatment of
congenital defects and abnormalities, including those
charges for your newborn child from the moment of birth;
and with the treatment of cleft lip or cleft palate.
charges for prescription contraceptives and devices
approved by the U.S. Food and Drug Administration and
charges for the insertion and/or removal of a prescription
contraceptive device and any Medically Necessary exam
associated with use of the prescription contraceptive device.
myCigna.com 54
charges made for surgical and nonsurgical care of
Temporomandibular Joint Dysfunction (TMJ) excluding
appliances and orthodontic treatment.
HC-COV119 04-10
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Definitions
Dependent
A child includes an adopted child or foster child including that
child from the first day of placement in your home regardless
of whether the adoption has become final.
HC-DFS700 07-14
V1-ET
CIGNA HEALTH AND LIFE INSURANCE
COMPANY, a Cigna company (hereinafter called
Cigna)
CERTIFICATE RIDER – Ohio Residents
Rider Eligibility: Each Employee who is located in Ohio
You will become insured on the date you become eligible,
including if you are not in Active Service on that date due to
your health status.
This rider forms a part of the certificate issued to you by
Cigna.
The provisions set forth in this rider comply with the legal
requirements of Ohio group insurance plans covering insureds
located in Ohio. These provisions supersede any provisions in
your certificate to the contrary unless the provisions in your
certificate result in greater benefits.
HC-ETOHRDR
Covered Expenses
charges made for or in connection with: an annual cytologic
screening (Pap smear) for detection of cervical cancer; a
single baseline mammogram for women ages 35 to 39; a
mammogram every two years for women ages 40 through
49, or an annual mammogram if a licensed Physician has
determined the woman to be at risk; and an annual
mammogram for women ages 50 through 64.
charges for any drug approved by the Food and Drug
Administration (FDA) which has not been approved by the
FDA for the treatment of the particular indication for which
the drug has been prescribed, provided the drug has been
recognized as safe and effective for treatment of that
indication in one or more of the standard medical reference
compendia adopted by the Department of Health and
Human Services (HHS) under 42 U.S.C. 1395x(t)(2), as
amended, or in medical literature only if all of the following
apply:
Two articles from major peer-reviewed professional
medical journals have recognized, based on scientific or
medical criteria, the drug's safety and effectiveness for
treatment of the indication for which it has been
prescribed;
No article from a major peer-reviewed professional
medical journal has concluded, based on scientific or
medical criteria, that the drug is unsafe or ineffective or
that the drug's safety and effectiveness cannot be
determined for the treatment of the indication for which it
has been prescribed;
Each article meets the uniform requirements for
manuscripts submitted to biomedical journals established
by the international committee of medical journal editors
or is published in a journal specified by the HHS pursuant
to section 1861(t)(2)(B) of the "Social Security Act," 107
Stat. 591 (1993), 42 U.S.C. 1395x(t)(2)(B), as amended,
as acceptable peer-reviewed medical literature.
Coverage includes Medically Necessary services associated
with the administration of the drug.
Such coverage shall not be construed to do any of the
following:
Require coverage for any drug if the FDA has
determined its use to be contraindicated for the
treatment of the particular indication for which the drug
has been prescribed;
Require coverage for experimental drugs not approved
for any indication by the FDA;
Alter any law with regard to provisions limiting the
coverage of drugs that have not been approved by the
FDA;
Require reimbursement or coverage for any drug not
included in the drug formulary or list of covered drugs
specified in the policy;
myCigna.com 55
Prohibit Cigna from limiting or excluding coverage of a
drug, provided that the decision to limit or exclude
coverage of the drug is not based primarily on the
coverage of drugs described in this provision.
HC-COV123
HC-COV124 04-10
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Termination of Insurance
Special Continuation of Medical Insurance for Military
Reservists and Their Dependents
If you are a Reservist, and if your Medical Insurance would
otherwise cease because you are called or ordered to active
military duty, you may continue Medical Insurance for
yourself and your Dependents, upon payment of the required
premium to your Employer, until the earliest of the following
dates:
18 months from the date your insurance would otherwise
cease, except that coverage for a Dependent may be
extended to 36 months as provided in the section below
entitled “Extension of Continuation to 36 months”;
the last day for which the required premium has been paid;
the date you or your Dependent becomes eligible for
insurance under another group policy that does not contain
any pre-existing condition limitation, other than the Civilian
Health and Medical Program of the Uniformed Services;
the date the group policy is cancelled.
The continuation of Medical Insurance will provide the same
benefits as those provided to any similarly situated person
insured under the policy who has not been called to active
duty.
“Reservist” means a member of a reserve component of the
armed forces of the United States. “Reservist” includes a
member of the Ohio National Guard and the Ohio Air
National Guard.
Extension of Continuation to 36 Months
If your Dependent’s insurance is being continued as outlined
above, such Dependent may extend the 18-month continuation
to a total of 36 months if any of the following occur during the
original 18-month period:
you die;
you are divorced or legally separated from your spouse; or
your Dependent ceases to qualify as an eligible Dependent
under the policy.
Provisions Regarding Notification and Election of Special
Continuation
Your Employer will notify you of your right to elect
continuation of Medical Insurance. To elect the continuation,
you or your Dependent must notify the Employer and pay the
required premium within 31 days after the date your insurance
would otherwise cease, or within 31 days after the date you
are notified of your right to continue, if later.
Special Continuation of Medical Insurance
If your Active Service ends because of involuntary
termination of employment, and if:
you have been insured under the policy (or under the policy
and any similar group coverage replaced by the policy)
during the entire 3 months prior to the date your Active
Service ends; and
you pay the Employer the required premium;
your Medical Insurance will be continued until:
you become eligible for similar group medical benefits or
for Medicare;
the last day for which you have made the required payment;
12 months from the date your Active Service ends; or
the date the policy cancels;
whichever occurs first.
At the time you are given notice of termination of
employment, your Employer will give you written notice of
your right to continue the insurance. To elect this option, you
must apply in writing and make the required monthly payment
to the Employer within 31 days after the date your Active
Service ends.
If your insurance is being continued under this section, the
Medical Insurance for Dependents insured on the date your
insurance would otherwise cease may be continued, subject to
the provisions of this section. The insurance for your
Dependents will be continued until the earlier of:
the date your insurance for yourself ceases; or
with respect to any one Dependent, the date that Dependent
no longer qualifies as a Dependent.
This option will not reduce any continuation of insurance
otherwise provided.
Dependent Medical Insurance After Divorce
In the case of divorce, annulment, dissolution of marriage or
legal separation you may be required to continue the insurance
for any one of your Dependents.
myCigna.com 56
Conversion Available After Continuation
The provisions of the “Medical Conversion Privilege” section
will apply when the insurance ceases.
HC-TRM48 04-10
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When You Have A Complaint Or An
Appeal
Definitions
“Adverse benefit determination” means a decision by a
health plan issuer:
To deny, reduce, or terminate a requested health care
service or payment in whole or in part, including all of the
following:
A determination that the health care service does not meet
the health plan issuer’s requirements for medical
necessity, appropriateness, health care setting, level of
care, or effectiveness, including experimental or
investigational treatments;
A determination of an individual’s eligibility for
individual health insurance coverage, including coverage
offered to individuals through a non-employer group, to
participate in a plan or health insurance coverage;
A determination that a health care service is not a covered
benefit;
The imposition of an exclusion, including exclusions for
pre-existing conditions, source of injury, network, or any
other limitation on benefits that would otherwise be
covered.
Not to issue individual health insurance coverage to an
applicant, including coverage offered to individuals through
a non-employer group;
To rescind coverage on a health benefit plan.
“Authorized representative” means an individual who
represents a covered person in an internal appeal or external
review process of an adverse benefit determination who is any
of the following:
A person to whom a covered individual has given express,
written consent to represent that individual in an internal
appeals process or external review process of an adverse
benefit determination;
A person authorized by law to provide substituted consent
for a covered individual;
A family member or a treating health care professional, but
only when the covered person is unable to provide consent.
“Covered person” means a policyholder, subscriber, enrollee,
member, or individual covered by a health benefit plan.
“Covered person” does include the covered person’s
authorized representative with regard to an internal appeal or
external review.
“Covered benefits” or “benefits” means those health care
services to which a covered person is entitled under the terms
of a health benefit plan.
“Final adverse benefit determination” means an adverse
benefit determination that is upheld at the completion of a
health plan issuer’s internal appeals process.
“Health benefit plan” means a policy, contract, certificate, or
agreement offered by a health plan issuer to provide, deliver,
arrange for, pay for, or reimburse any of the costs of health
care services.
“Health care services” means services for the diagnosis,
prevention, treatment, cure, or relief of a health condition,
illness, injury, or disease.
“Health plan issuer” means an entity subject to the insurance
laws and rules of this state, or subject to the jurisdiction of the
superintendent of insurance, that contracts, or offers to
contract to provide, deliver, arrange for, pay for, or reimburse
any of the costs of health care services under a health benefit
plan, including a sickness and accident insurance company, a
health insuring corporation, a fraternal benefit society, a self-
funded multiple employer welfare arrangement, or a
nonfederal, government health plan. “Health plan issuer”
includes a third party administrator to the extent that the
benefits that such an entity is contracted to administer under a
health benefit plan are subject to the insurance laws and rules
of this state or subject to the jurisdiction of the superintendent.
“Independent review organization” means an entity that is
accredited to conduct independent external reviews of adverse
benefit determinations.
“Rescission” or “to rescind” means a cancellation or
discontinuance of coverage that has a retroactive effect.
“Rescission” does not include a cancellation or discontinuance
of coverage that has only a prospective effect or a cancellation
or discontinuance of coverage that is effective retroactively to
the extent it is attributable to a failure to timely pay required
premiums or contributions towards the cost of coverage.
“Stabilize” means the provision of such medical treatment as
may be necessary to assure, within reasonable medical
probability that no material deterioration of a covered person’s
medical condition is likely to result from or occur during a
transfer, if the medical condition could result in any of the
following:
Placing the health of the covered person or, with respect to a
pregnant woman, the health of the woman or her unborn
child, in serious jeopardy;
myCigna.com 57
Serious impairment to bodily functions;
Serious dysfunction of any bodily organ or part.
In the case of a woman having contractions, “stabilize” means
such medical treatment as may be necessary to deliver,
including the placenta.
“Superintendent” means the superintendent of insurance.
When You Have a Complaint
For the purposes of this section, any reference to "you," "your"
or "Member" also refers to a representative or provider
designated by you to act on your behalf, unless otherwise
noted.
We want you to be completely satisfied with the care you
receive. That is why we have established a process for
addressing your concerns and solving your problems.
Start With Customer Service
We are here to listen and to help. If you have a concern
regarding a person, a service, the quality of care, contractual
benefits, or a rescission of coverage, you may call our toll-free
number and explain your concern to one of our Customer
Service representatives. Please call us at the Customer Service
Toll-Free Number that appears on your Benefit Identification
card, explanation of benefits or claim form.
We will do our best to resolve the matter on your initial
contact. If we need more time to review or investigate your
concern, we will get back to you as soon as possible, but in
any case within 30 days.
If you are not satisfied with the results of a coverage decision,
you can start the appeals procedure.
Internal Appeals Procedure
Cigna has a two-step appeals procedure for coverage
decisions. To initiate an appeal, you must submit a request for
an appeal in writing, within 365 days of receipt of a denial
notice, to the following address:
Cigna HealthCare, Inc.
National Appeals Unit
P.O. Box 188011
Chattanooga, TN 37422
You should state the reason why you feel your appeal should
be approved and include any information supporting your
appeal. If you are unable or choose not to write, you may ask
to register your appeal by telephone. Call us at the toll-free
number on your Benefit Identification card, explanation of
benefits or claim form.
Level One Appeal
Your appeal will be reviewed and the decision made by
someone not involved in the initial decision. Appeals
involving Medical Necessity or clinical appropriateness will
be considered by a health care professional.
For level one appeals, we will respond in writing with a
decision within 15 calendar days after we receive an appeal
for a required preservice or concurrent care coverage
determination (decision).
We will respond within 30 calendar days after we receive an
appeal for a postservice coverage determination. If more time
or information is needed to make the determination, we will
notify you in writing to request an extension of up to 15
calendar days and to specify any additional information
needed to complete the review.
You may request that the appeal process be expedited if, (a)
the time frames under this process would seriously jeopardize
your life, health or ability to regain maximum function or in
the opinion of your Physician would cause you severe pain
which cannot be managed without the requested services; or
(b) your appeal involves nonauthorization of an admission or
continuing inpatient Hospital stay.
If you request that your appeal be expedited based on (a)
above, you may also ask for an expedited external
Independent Review at the same time, if the time to complete
an expedited level-one appeal would be detrimental to your
medical condition.
Cigna's Physician reviewer, in consultation with the treating
Physician, will decide if an expedited appeal is necessary.
When an appeal is expedited, we will respond orally with a
decision within 72 hours, followed up in writing.
Level Two Appeal
If you are dissatisfied with our level one appeal decision, you
may request a second review. To start a level two appeal,
follow the same process required for a level one appeal.
If the appeal involves a coverage decision based on issues of
medical necessity, clinical appropriateness or experimental
treatment, a medical review will be conducted by a Physician
reviewer in the same or similar specialty as the care under
consideration, as determined by Cigna’s Physician reviewer.
For all other coverage plan-related appeals, a second-level
review will be conducted by someone who was not involved
in any previous decision related to your appeal, and not a
subordinate of previous decision makers. Provide all relevant
documentation with your second-level appeal request.
For required preservice and concurrent care coverage
determinations, the review will be completed within 15
calendar days. For postservice claims, the review will be
completed within 30 calendar days. If more time or
information is needed to make the determination, we will
notify you in writing to request an extension of up to 15
calendar days and to specify any additional information
needed by us to complete the review.
In the event any new or additional information (evidence) is
considered, relied upon or generated by Cigna in connection
with the level-two appeal, Cigna will provide this information
myCigna.com 58
to you as soon as possible and sufficiently in advance of the
decision, so that you will have an opportunity to respond.
Also, if any new or additional rationale is considered by
Cigna, Cigna will provide the rationale to you as soon as
possible and sufficiently in advance of the decision so that you
will have an opportunity to respond.
You will be notified in writing of the decision within five
working days after the decision is made, and within the review
time frames above if Cigna does not approve the requested
coverage.
You may request that the appeal process be expedited if, the
time frames under this process would seriously jeopardize
your life, health or ability to regain maximum function or in
the opinion of your Physician would cause you severe pain
which cannot be managed without the requested services; or
your appeal involves nonauthorization of an admission or
continuing inpatient Hospital stay. Cigna's Physician reviewer
or your treating Physician will decide if an expedited appeal is
necessary. When an appeal is expedited, we will respond
orally with a decision within 72 hours, followed up in writing.
Understanding the External Review Process
Under Chapter 3922 of the Ohio Revised Code all health plan
issuers must provide a process that allows a person covered
under a health benefit plan or a person applying for health
benefit plan coverage to request an independent external
review of an adverse benefit determination. This is a summary
of that external review process. An adverse benefit
determination is a decision by Cigna to deny benefits because
services are not covered, are excluded, or limited under the
plan, or the covered person is not eligible to receive the
benefit.
The adverse benefit determination may involve an issue of
medical necessity, appropriateness, health care setting, or level
of care or effectiveness. An adverse benefit determination can
also be a decision to deny health benefit plan coverage or to
rescind coverage.
Opportunity for External Review
An external review may be conducted by an Independent
Review Organization (IRO) or by the Ohio Department of
Insurance. The covered person does not pay for the external
review. There is no minimum cost of health care services
denied in order to qualify for an external review. However, the
covered person must generally exhaust the health plan issuer’s
internal appeal process before seeking an external review.
Exceptions to this requirement will be included in the notice
of the adverse benefit determination.
External Review by an IRO - A covered person is entitled to
an external review by an IRO in the following instances:
The adverse benefit determination involves a medical
judgment or is based on any medical information.
The adverse benefit determination indicates the requested
service is experimental or investigational, the requested
health care service is not explicitly excluded in the covered
person’s health benefit plan, and the treating physician
certifies at least one of the following:
Standard health care services have not been effective in
improving the condition of the covered person.
Standard health care services are not medically
appropriate for the covered person.
No available standard health care service covered by
Cigna is more beneficial than the requested health care
service.
There are two types of IRO reviews, standard and expedited.
A standard review is normally completed within 30 days. An
expedited review for urgent medical situations is normally
completed within 72 hours and can be requested if any of the
following applies:
The covered person’s treating physician certifies that the
adverse benefit determination involves a medical condition
that could seriously jeopardize the life or health of the
covered person or would jeopardize the covered person’s
ability to regain maximum function if treatment is delayed
until after the time frame of an expedited internal appeal.
The covered person’s treating physician certifies that the
final adverse benefit determination involves a medical
condition that could seriously jeopardize the life or health of
the covered person or would jeopardize the covered
person’s ability to regain maximum function if treatment is
delayed until after the time frame of a standard external
review.
The final adverse benefit determination concerns an
admission, availability of care, continued stay, or health
care service for which the covered person received
emergency services, but has not yet been discharged from a
facility.
An expedited internal appeal is already in progress for an
adverse benefit determination of experimental or
investigational treatment and the covered person’s treating
physician certifies in writing that the recommended health
care service or treatment would be significantly less
effective if not promptly initiated.
NOTE: An expedited external review is not available for
retrospective final adverse benefit determinations (meaning
the health care service has already been provided to the
covered person).
myCigna.com 59
External Review by the Ohio Department of Insurance - A
covered person is entitled to an external review by the
Department in the either of the following instances:
The adverse benefit determination is based on a contractual
issue that does not involve a medical judgment or medical
information.
The adverse benefit determination for an emergency
medical condition indicates that medical condition did not
meet the definition of emergency AND Cigna’s decision has
already been upheld through an external review by an IRO.
Request for External Review
Regardless of whether the external review case is to be
reviewed by an IRO or the Department of Insurance, the
covered person, or an authorized representative, must request
an external review through Cigna within 180 days of the date
of the notice of final adverse benefit determination issued by
Cigna.
All requests must be in writing, except for a request for an
expedited external review. Expedited external reviews may be
requested electronically or orally; however written
confirmation of the request must be submitted to Cigna no
later than five (5) days after the initial request. The covered
person will be required to consent to the release of applicable
medical records and sign a medical records release
authorization.
If the request is complete Cigna will initiate the external
review and notify the covered person in writing, or
immediately in the case of an expedited review, that the
request is complete and eligible for external review. The
notice will include the name and contact information for the
assigned IRO or the Ohio Department of Insurance (as
applicable) for the purpose of submitting additional
information. When a standard review is requested, the notice
will inform the covered person that, within 10 business days
after receipt of the notice, they may submit additional
information in writing to the IRO or the Ohio Department of
Insurance (as applicable) for consideration in the review.
Cigna will also forward all documents and information used to
make the adverse benefit determination to the assigned IRO or
the Ohio Department of Insurance (as applicable).
If the request is not complete Cigna will inform the covered
person in writing and specify what information is needed to
make the request complete. If Cigna determines that the
adverse benefit determination is not eligible for external
review, Cigna must notify the covered person in writing and
provide the covered person with the reason for the denial and
inform the covered person that the denial may be appealed to
the Ohio Department of Insurance.
The Ohio Department of Insurance may determine the request
is eligible for external review regardless of the decision by
Cigna and require that the request be referred for external
review. The Department’s decision will be made in
accordance with the terms of the health benefit plan and all
applicable provisions of the law.
IRO Assignment
When Cigna initiates an external review by an IRO, the Ohio
Department of Insurance web based system randomly assigns
the review to an accredited IRO that is qualified to conduct the
review based on the type of health care service. An IRO that
has a conflict of interest with Cigna, the covered person, the
health care provider or the health care facility will not be
selected to conduct the review.
IRO Review and Decision
The IRO must consider all documents and information
considered by Cigna in making the adverse benefit
determination, any information submitted by the covered
person and other information such as; the covered person’s
medical records, the attending health care professional’s
recommendation, consulting reports from appropriate health
care professionals, the terms of coverage under the health
benefit plan, the most appropriate practice guidelines, clinical
review criteria used by the health plan issuer or its utilization
review organization, and the opinions of the IRO’s clinical
reviewers.
The IRO will provide a written notice of its decision within 30
days of receipt by Cigna of a request for a standard review or
within 72 hours of receipt by Cigna of a request for an
expedited review. This notice will be sent to the covered
person, Cigna and the Ohio Department of Insurance and must
include the following information:
A general description of the reason for the request for
external review.
The date the independent review organization was assigned
by the Ohio Department of Insurance to conduct the
external review.
The dates over which the external review was conducted.
The date on which the independent review organization's
decision was made.
The rationale for its decision.
References to the evidence or documentation, including any
evidence-based standards, that was used or considered in
reaching its decision.
NOTE: Written decisions of an IRO concerning an adverse
benefit determination that involves a health care treatment or
service that is stated to be experimental or investigational also
includes the principle reason(s) for the IRO’s decision and the
written opinion of each clinical reviewer including their
recommendation and their rationale for the recommendation.
myCigna.com 60
Binding Nature of External Review Decision
An external review decision is binding on Cigna except to the
extent Cigna has other remedies available under state law. The
decision is also binding on the covered person except to the
extent the covered person has other remedies available under
applicable state or federal law.
A covered person may not file a subsequent request for an
external review involving the same adverse benefit
determination that was previously reviewed unless new
medical or scientific evidence is submitted to Cigna.
If You Have Questions About Your Rights or Need
Assistance
You may contact Cigna:
Cigna HealthCare Inc.
National Appeals Organization (NAO)
PO Box 188011
Chattanooga, TN 37422
1-800-Cigna24
www.Cigna.com
You may also contact the Ohio Department of Insurance:
Ohio Department of Insurance
ATTN: Consumer Affairs
50 West Town Street, Suite 300, Columbus, OH 43215
800-686-1526 / 614-644-2673
614-644-3744 (fax)
614-644-3745 (TDD)
Contact ODI Consumer Affairs:
https://secured.insurance.ohio.gov/ConsumServ/ConServCo
mments.asp
File a Consumer Complaint:
http://insurance.ohio.gov/Consumer/OCS/Pages/ConsComp
l.aspx
Notice of Benefit Determination on Appeal
Every notice of a determination on appeal will be provided in
writing or electronically and, if an adverse benefit
determination, will include: information sufficient to identify
the claim; the specific reason or reasons for the adverse
benefit determination; reference to the specific plan provisions
on which the determination is based; a statement that the
claimant is entitled to receive, upon request and free of charge,
reasonable access to and copies of all documents, records, and
other Relevant Information as defined; a statement describing
any voluntary appeal procedures offered by the plan and the
claimant's right to bring an action under ERISA section
502(a); and upon request and free of charge, a copy of any
internal rule, guideline, protocol or other similar criterion that
was relied upon in making the adverse benefit determination
regarding your appeal, and an explanation of the scientific or
clinical judgment for a determination that is based on a
Medical Necessity, experimental treatment or other similar
exclusion or limit; limit; and information about any office of
health insurance consumer assistance or ombudsman available
to assist you in the appeal process. A final notice of adverse
determination will include a discussion of the decision.
You also have the right to bring a civil action under Section
502(a) of ERISA if you are not satisfied with the decision on
review. You or your plan may have other voluntary alternative
dispute resolution options such as Mediation. One way to find
out what may be available is to contact your local U.S.
Department of Labor office and your State insurance
regulatory agency. You may also contact the Plan
Administrator.
Relevant Information
Relevant Information is any document, record, or other
information which was relied upon in making the benefit
determination; was submitted, considered, or generated in the
course of making the benefit determination, without regard to
whether such document, record, or other information was
relied upon in making the benefit determination; demonstrates
compliance with the administrative processes and safeguards
required by federal law in making the benefit determination;
or constitutes a statement of policy or guidance with respect to
the plan concerning the denied treatment option or benefit or
the claimant's diagnosis, without regard to whether such
advice or statement was relied upon in making the benefit
determination.
Legal Action
If your plan is governed by ERISA, you have the right to bring
a civil action under Section 502(a) of ERISA if you are not
satisfied with the outcome of the Appeals Procedure. In most
instances, you may not initiate a legal action against Cigna
until you have completed the Level One and Level Two
Appeal processes. If your Appeal is expedited, there is no
need to complete the Level Two process prior to bringing
legal action.
HC-APL66
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myCigna.com 61
Definitions
Dependent
A child includes an adopted child including that child from the
first day of placement in your home regardless of whether the
adoption has become final.
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CIGNA HEALTH AND LIFE INSURANCE
COMPANY, a Cigna company (hereinafter called
Cigna)
CERTIFICATE RIDER – Oregon Residents
Rider Eligibility: Each Employee who is located in Oregon
You will become insured on the date you become eligible,
including if you are not in Active Service on that date due to
your health status.
This rider forms a part of the certificate issued to you by
Cigna.
The provisions set forth in this rider comply with the legal
requirements of Oregon group insurance plans covering
insureds located in Oregon. These provisions supersede any
provisions in your certificate to the contrary unless the
provisions in your certificate result in greater benefits.
HC-ORM-04-11 HC-ETORRDR
Eligibility – Effective Date
Exception to Late Entrant Definition
A person will not be considered a Late Entrant when enrolling
outside a designated enrollment period if: he had existing
coverage, and he certified in writing, if applicable, that he
declined coverage due to other available coverage; Employer
contributions toward the other coverage have been terminated;
he no longer qualifies in an eligible class for prior coverage; or
if such prior coverage was continuation coverage and the
continuation period has been exhausted; and he enrolls for this
coverage within 30 days after losing or exhausting prior
coverage; or if he is a Dependent spouse or minor child
enrolled due to court order, within 30 days after the order is
issued.
If you acquire a new Dependent through marriage, birth,
adoption or placement for adoption, you may enroll your
eligible Dependents and yourself, if you are not already
enrolled, within 30 days of such event. Coverage will be
effective, on the date of marriage, birth, adoption, or
placement for adoption.
An adopted child, or a child placed for adoption before age 19
will not be subject to any Pre-existing Condition limitation if
such child was covered within 30 days of adoption or
placement for adoption. Such waiver will not apply if 63 days
elapse between coverage during a prior period of Creditable
Coverage and coverage under this plan.
Any applicable Pre-existing Condition limitation will apply to
you and your Dependents upon enrollment, reduced by prior
Creditable Coverage, but will not be extended as for a Late
Entrant.
Pre-Existing Condition Limitation for Late Entrant
For plans which include a Pre-existing Condition limitation,
the 6-month waiting period before coverage begins for such
conditions, will be increased to 12 months for a Late Entrant.
For plans which do not include a Pre-existing Condition
limitation, you may be required to wait until the next plan
enrollment period, but no longer than 12 months, to enroll for
coverage under the plan, if you are a Late Entrant.
For plans which do not standardly include a Pre-existing
Condition limitation and which do not include an annual open
enrollment period, a Pre-existing condition limitation of 12
months will apply for a Late Entrant.
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Certification Requirements
For You and Your Dependents
Pre-Admission Certification/Continued Stay Review for
Hospital Confinement
Any PAC determination will be binding on Cigna for:
the lesser of: 5 business days; or in the event your coverage
will terminate sooner than 5 business days, the period your
coverage remains in effect, provided that when PAC is
authorized:
Cigna has specific knowledge that your coverage will
terminate sooner than 5 business days; and
the termination date is specified in the PAC; or
the time period your coverage remains in effect, subject to a
maximum of 30 calendar days.
myCigna.com 62
For purposes of counting days, day 1 occurs on the first
business or calendar day, as applicable, following the day on
which Cigna issues a PAC.
Cigna will respond to a PAC request for a non-emergency
admission within two business days of the date of the request.
Qualified health care personnel will be available for same-day
telephone responses to CSR inquiries.
HC-PAC4 11-14
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When You Have a Complaint or Appeal
For the purposes of this section, any reference to "you," "your"
or "Member" also refers to a representative or provider
designated by you to act on your behalf, unless otherwise
noted; and "Physician reviewers" are licensed Physicians.
We want you to be completely satisfied with the care you
receive. That is why we have established a process for
addressing your concerns and solving your problems.
Start with Member Services
We are here to listen and help. If you have a concern regarding
a person, a service, the quality of care, or contractual benefits,
you can call our toll-free number and explain your concern to
one of our Customer Service representatives. You can also
express that concern in writing. Please call or write to us at the
following:
Customer Services Toll-free Number or address that appears
on your Benefit Identification card, explanation of benefits
or claim form.
We will do our best to resolve the matter on your initial
contact. If we need more time to review or investigate your
concern, we will get back to you as soon as possible, but in
any case within 30 days.
If you are not satisfied with the results of a coverage decision,
you can start the appeals procedure.
Appeals Procedure
Cigna has a two-step appeals procedure for coverage
decisions. To initiate an appeal, you must submit a request for
an appeal in writing within 365 days of receipt of a denial
notice. You should state the reason why you feel your appeal
should be approved and include any information supporting
your appeal. If you are unable or choose not to write, you may
ask to register your appeal by telephone. Call or write to us at
the toll-free number or address on your Benefit Identification
card, explanation of benefits or claim form.
Level One Appeal
Your appeal will be reviewed and the decision made by
someone not involved in the initial decision. Appeals
involving Medical Necessity or clinical appropriateness will
be considered by a health care professional.
For level one appeals, we will acknowledge receipt of an
appeal within 7 days of its receipt and respond in writing with
a decision within 15 calendar days after we receive an appeal
for a required preservice or concurrent care coverage
determination (decision). We will respond within 30 calendar
days after we receive an appeal for a postservice coverage
determination. However, for postservice appeals involving
Medical Necessity, we will respond in writing within 20
working days. If more time or information is needed to make
the determination, we will notify you in writing to request an
extension of up to 15 calendar days and to specify any
additional information needed to complete the review.
You may request that the appeal process be expedited if: the
time frames under this process would seriously jeopardize
your life, health or ability to regain maximum function or in
the opinion of your Physician would cause you severe pain
which cannot be managed without the requested services; or
your appeal involves nonauthorization of an admission or
continuing inpatient Hospital stay. Cigna's Physician reviewer,
in consultation with the treating Physician, will decide if an
expedited appeal is necessary. When an appeal is expedited,
we will respond orally with a decision within 72 hours,
followed up in writing.
Level Two Appeal
If you are dissatisfied with our level one appeal decision, you
may request a second review. To start a level two appeal,
follow the same process required for a level one appeal.
Most requests for a second review will be conducted by the
Appeals Committee, which consists of at least three people.
Anyone involved in the prior decision may not vote on the
Committee. For appeals involving Medical Necessity or
clinical appropriateness, the Committee will consult with at
least one Physician reviewer in the same or similar specialty
as the care under consideration, as determined by Cigna’s
Physician reviewer. You may present your situation to the
Committee in person or by conference call.
For level two appeals we will acknowledge in writing that we
have received your request within 7 days of its receipt and
schedule a Committee review. For required preservice and
concurrent care coverage determinations, the Committee
review will be completed within 15 calendar days. For
postservice claims, the Committee review will be completed
within 30 calendar days. If more time or information is needed
to make the determination, we will notify you in writing to
request an extension of up to 15 calendar days and to specify
any additional information needed by the Committee to
complete the review. You will be notified in writing of the
Committee's decision within five working days after the
Committee meeting, and within the Committee review time
myCigna.com 63
frames above if the Committee does not approve the requested
coverage.
You may request that the appeal process be expedited if: the
time frames under this process would seriously jeopardize
your life, health or ability to regain maximum function or in
the opinion of your Physician would cause you severe pain
which cannot be managed without the requested services; or
your appeal involves nonauthorization of an admission or
continuing inpatient Hospital stay. Cigna's Physician reviewer,
in consultation with the treating Physician will decide if an
expedited appeal is necessary. Cigna’s Physician reviewer will
consult with a Physician reviewer in the same or similar
specialty as the care under consideration to make a decision.
When an appeal is expedited, we will respond orally with a
decision within 72 hours, followed up in writing.
Independent Review Procedure
You have the right to apply for external review by an
Independent Review Organization if you are not fully
satisfied with the decision of Cigna's level two appeal
review regarding your Medical Necessity or clinical
appropriateness issue. The Independent Review
Organization is composed of persons who are not employed
by Cigna HealthCare or any of it’s affiliates. A decision to use
the voluntary level of appeal will not affect the claimant's
rights to any other benefits under the plan.
There is no charge for you to initiate this independent review
process. Cigna agrees to be bound by the Independent
Review Organization's decision notwithstanding the
definition of Medical Necessity in the plan.
In order to request a referral to an Independent Review
Organization, certain conditions apply. The reason for the
denial by Cigna must be based on a Medical Necessity
determination, issues of clinical appropriateness, or whether a
course or plan of treatment that an insured is undergoing is an
active course of treatment for the purpose of continuity of
care. Administrative, eligibility or benefit coverage limits or
exclusions are not eligible for an independent review under
this process.
To request a review, you must notify the Appeals Coordinator
in writing within 180 days of your receipt of Cigna's level two
appeal review denial. You must also sign a waiver granting the
Independent Review Organization access to your medical
records.
The Independent Review Organization will render an opinion
within 30 days. When requested and when a delay would be
detrimental to your condition, as determined by a provider
with an established clinical relationship to the insured, the
review shall be completed within three days.
The Independent Review Program is a voluntary program
arranged by Cigna.
Appeal to the State of Oregon
You have the right to file a complaint or seek other assistance
from the Oregon agency. Assistance is available:
by calling (503) 947-7984 or the toll free message line at
(888) 877-4894;
by writing to the Oregon agency, Consumer Protection Unit,
350 Winter Street NE, Room 440-2, Salem, OR 97301-
3883;
through the Internet at
http://www.cbs.state.or.us/external/ins/; or
by e-mail at: [email protected]
Notice of Benefit Determination on Appeal
Every notice of a determination on appeal will be provided in
writing or electronically and, if an adverse determination, will
include: the specific reason or reasons for the adverse
determination; reference to the specific plan provisions on
which the determination is based; a statement that the claimant
is entitled to receive, upon request and free of charge,
reasonable access to and copies of all documents, records, and
other Relevant Information as defined; upon request and free
of charge, a copy of any internal rule, guideline, protocol or
other similar criterion that was relied upon in making the
adverse determination regarding your appeal, and an
explanation of the scientific or clinical judgment for a
determination that is based on a Medical Necessity,
experimental treatment or other similar exclusion or limit.
You or your plan may have other voluntary alternative dispute
resolution options such as Mediation. One way to find out
what may be available is to contact your local U.S.
Department of Labor office and your state insurance
regulatory agency. You may also contact the Plan
Administrator.
Relevant Information
Relevant Information is any document, record, or other
information which: was relied upon in making the benefit
determination; was submitted, considered, or generated in the
course of making the benefit determination, without regard to
whether such document, record, or other information was
relied upon in making the benefit determination; demonstrates
compliance with the administrative processes and safeguards
required by federal law in making the benefit determination;
or constitutes a statement of policy or guidance with respect to
the plan concerning the denied treatment option or benefit or
the claimant's diagnosis, without regard to whether such
advice or statement was relied upon in making the benefit
determination.
Legal Action
In most instances, you may not initiate a legal action against
Cigna until you have completed the Level One and Level Two
Appeal processes. If your Appeal is expedited, there is no
myCigna.com 64
need to complete the Level Two process prior to bringing
legal action.
HC-APL4 04-10
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Definitions
Dependent
The term child means a child born to you or a child legally
adopted by you including that child from the date of
placement. Coverage for such child will include the necessary
care and treatment of medical conditions existing prior to the
date of placement including medically diagnosed congenital
defects or birth abnormalities. It also includes a stepchild.
HC-DFS74 04-10
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CIGNA HEALTH AND LIFE INSURANCE
COMPANY, a Cigna company (hereinafter called
Cigna)
CERTIFICATE RIDER – Pennsylvania Residents
Rider Eligibility: Each Employee who is located in
Pennsylvania
You will become insured on the date you become eligible,
including if you are not in Active Service on that date due to
your health status.
This rider forms a part of the certificate issued to you by
Cigna.
The provisions set forth in this rider comply with the legal
requirements of Pennsylvania group insurance plans covering
insureds located in Pennsylvania. These provisions supersede
any provisions in your certificate to the contrary unless the
provisions in your certificate result in greater benefits.
HC-ETPARDR
Covered Expenses
charges made for or in connection with mammograms for
breast cancer screening and diagnosis, not to exceed: a
baseline mammogram annually for women age 40 and over;
and a mammogram upon a Physician’s recommendation for
women under age 40.
charges for childhood immunizations, including the
immunizing agents and Medically Necessary booster doses.
Immunizations provided in accordance with Advisory
Committee on Immunization Practices (ACIP) standards are
covered for any insured person under age 21 and are exempt
from deductibles or dollar limits.
HC-COV136 04-10
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When You Have A Complaint Or An
Appeal
For the purposes of this section, any reference to "you", "your"
or "Member" also refers to a representative or provider
designated by you to act on your behalf, unless otherwise
noted.
We want you to be completely satisfied with the care you
receive. That is why we have established a process for
addressing your concerns and solving your problems.
Start with Customer Service
We are here to listen and help. If you have a concern regarding
a person, a service, the quality of care, contractual benefits, or
a rescission of coverage, you can call our toll-free number and
explain your concern to one of our Customer Service
representatives. Please call us at the Customer Service Toll-
Free Number that appears on your Benefit Identification card,
explanation of benefits or claim form.
We will do our best to resolve the matter on your initial
contact. If we need more time to review or investigate your
concern, we will get back to you as soon as possible, but in
any case within 30 days.
If you are not satisfied with the results of a coverage decision,
you can start the appeals procedure.
Appeals Procedure
Cigna has a two step appeals procedure for coverage
decisions. To initiate an appeal, you must submit a request for
an appeal in writing, within 365 days of receipt of a denial
notice, to the following address:
Cigna
National Appeals Organization (NAO)
PO Box 188011
Chattanooga, TN 37422
You should state the reason why you feel your appeal should
be approved and include any information supporting your
appeal. If you are unable or choose not to write, you may ask
myCigna.com 65
to register your appeal by telephone. Call us at the toll-free
number on your Benefit Identification card, explanation of
benefits or claim form.
Level One Appeal
Your appeal will be reviewed and the decision made by
someone not involved in the initial decision. Appeals
involving Medical Necessity or clinical appropriateness will
be considered by a health care professional.
For level one appeals, we will respond in writing with a
decision within 15 calendar days after we receive an appeal
for a required preservice or concurrent care coverage
determination (decision). We will respond within 30 calendar
days after we receive an appeal for a postservice coverage
determination. If more time or information is needed to make
the determination, we will notify you in writing to request an
extension of up to 15 calendar days and to specify any
additional information needed to complete the review.
You may request that the appeal process be expedited if: (a)
the time frames under this process would seriously jeopardize
your life, health or ability to regain maximum function or in
the opinion of your Physician would cause you severe pain
which cannot be managed without the requested services; or
(b) your appeal involves nonauthorization of an admission or
continuing inpatient Hospital stay.
If you request that your appeal be expedited based on (a)
above, you may also ask for an expedited external
Independent Review at the same time, if the time to complete
an expedited level-one appeal would be detrimental to your
medical condition.
Cigna's Physician reviewer, or your treating Physician, will
decide if an expedited appeal is necessary. When an appeal is
expedited, we will respond orally with a decision within 72
hours, followed up in writing.
Level Two Appeal
If you are dissatisfied with our level one appeal decision, you
may request a second review. To start a level two appeal,
follow the same process required for a level one appeal.
If the appeal involves a coverage decision based on issues of
medical necessity, clinical appropriateness or experimental
treatment, a medical review will be conducted by a Physician
reviewer in the same or similar specialty as the care under
consideration, as determined by Cigna’s Physician reviewer.
For all other coverage plan-related appeals, a second-level
review will be conducted by someone who was: not involved
in any previous decision related to your appeal; and not a
subordinate of previous decision makers. Provide all relevant
documentation with your second-level appeal request.
For required preservice and concurrent care coverage
determinations, the review will be completed within 15
calendar days. For postservice claims, the review will be
completed within 30 calendar days. If more time or
information is needed to make the determination, we will
notify you in writing to request an extension of up to 15
calendar days and to specify any additional information
needed by us to complete the review.
In the event any new or additional information (evidence) is
considered, relied upon or generated by Cigna in connection
with the level-two appeal, Cigna will provide this information
to you as soon as possible and sufficiently in advance of the
decision, so that you will have an opportunity to respond.
Also, if any new or additional rationale is considered by
Cigna, Cigna will provide the rationale to you as soon as
possible and sufficiently in advance of the decision so that you
will have an opportunity to respond.
You will be notified in writing of the decision within five
working days after the decision is made, and within the
review time frames above if Cigna does not approve the
requested coverage.
You may request that the appeal process be expedited if: the
time frames under this process would seriously jeopardize
your life, health or ability to regain maximum function or in
the opinion of your Physician would cause you severe pain
which cannot be managed without the requested services; or
your appeal involves nonauthorization of an admission or
continuing inpatient Hospital stay. Cigna's Physician reviewer,
or your treating Physician will decide if an expedited appeal is
necessary. When an appeal is expedited, we will respond
orally with a decision within 72 hours, followed up in writing.
Independent Review Procedure
If you are not fully satisfied with the decision of Cigna's level
two appeal review regarding your Medical Necessity or
clinical appropriateness issue, you may request that your
appeal be referred to an Independent Review Organization.
The Independent Review Organization is composed of persons
who are not employed by Cigna HealthCare or any of its
affiliates. A decision to use the voluntary level of appeal will
not affect the claimant's rights to any other benefits under the
plan.
There is no charge for you to initiate this independent review
process. Cigna will abide by the decision of the Independent
Review Organization.
In order to request a referral to an Independent Review
Organization, certain conditions apply. The reason for the
denial must be based on a Medical Necessity or clinical
appropriateness determination by Cigna. Administrative,
eligibility or benefit coverage limits or exclusions are not
eligible for appeal under this process.
To request a review, you must notify the Appeals Coordinator
within 180 days of your receipt of Cigna's level two appeal
review denial. Cigna will then forward the file to the
Independent Review Organization.
myCigna.com 66
The Independent Review Organization will render an opinion
within 30 days. When requested and when a delay would be
detrimental to your condition, as determined by Cigna's
Physician reviewer, the review shall be completed within three
days.
The Independent Review Program is a voluntary program
arranged by Cigna.
Appeal to the State of Pennsylvania
You have the right to contact the Pennsylvania Insurance
Department for assistance at any time. The Pennsylvania
Insurance Department may be contacted at the following
address and telephone number:
Pennsylvania Insurance Department
Bureau of Consumer Services
1321 Strawberry Square
Harrisburg, PA 17120
717-787-5193
Toll-Free Number: 888-466-2787
Notice of Benefit Determination on Appeal
Every notice of a determination on appeal will be provided in
writing or electronically and, if an adverse determination, will
include: information sufficient to identify the claim; the
specific reason or reasons for the adverse determination;
reference to the specific plan provisions on which the
determination is based; a statement that the claimant is entitled
to receive, upon request and free of charge, reasonable access
to and copies of all documents, records, and other Relevant
Information as defined; a statement describing any voluntary
appeal procedures offered by the plan and the claimant's right
to bring an action under ERISA section 502(a); upon request
and free of charge, a copy of any internal rule, guideline,
protocol or other similar criterion that was relied upon in
making the adverse determination regarding your appeal, and
an explanation of the scientific or clinical judgment for a
determination that is based on a Medical Necessity,
experimental treatment or other similar exclusion or limit; and
information about any office of health insurance consumer
assistance or ombudsman available to assist you in the appeal
process. A final notice of adverse determination will include a
discussion of the decision.
You also have the right to bring a civil action under Section
502(a) of ERISA if you are not satisfied with the decision on
review. You or your plan may have other voluntary alternative
dispute resolution options such as Mediation. One way to find
out what may be available is to contact your local U.S.
Department of Labor office and your State insurance
regulatory agency. You may also contact the Plan
Administrator.
Relevant Information
Relevant Information is any document, record, or other
information which: was relied upon in making the benefit
determination; was submitted, considered, or generated in the
course of making the benefit determination, without regard to
whether such document, record, or other information was
relied upon in making the benefit determination; demonstrates
compliance with the administrative processes and safeguards
required by federal law in making the benefit determination;
or constitutes a statement of policy or guidance with respect to
the plan concerning the denied treatment option or benefit or
the claimant's diagnosis, without regard to whether such
advice or statement was relied upon in making the benefit
determination.
Legal Action
If your plan is governed by ERISA, you have the right to bring
a civil action under Section 502(a) of ERISA if you are not
satisfied with the outcome of the Appeals Procedure. In most
instances, you may not initiate a legal action against Cigna
until you have completed the Level One and Level Two
Appeal processes. If your Appeal is expedited, there is no
need to complete the Level Two process prior to bringing
legal action.
HC-APL71 04-10
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Definitions
Dependent
The term child means a child born to you or a child legally
adopted by you including that child, from the date of
placement in your home, regardless of whether the adoption
has become final.
HC-DFS276 01-15
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myCigna.com 67
CIGNA HEALTH AND LIFE INSURANCE
COMPANY, a Cigna company (hereinafter called
Cigna)
CERTIFICATE RIDER – South Carolina Residents
Rider Eligibility: Each Employee who is located in South
Carolina
You will become insured on the date you become eligible,
including if you are not in Active Service on that date due to
your health status.
This rider forms a part of the certificate issued to you by
Cigna.
The provisions set forth in this rider comply with the legal
requirements of South Carolina group insurance plans
covering insureds located in South Carolina. These provisions
supersede any provisions in your certificate to the contrary
unless the provisions in your certificate result in greater
benefits.
HC-ETSCRDR
Definitions
Dependent
A child includes a legally adopted child, including that child
from the first day of placement in your home regardless of
whether the adoption has become final, or an adopted child of
whom you have custody according to the decree of the court
provided you have paid premiums. Adoption proceedings
must be instituted by you, and completed within 31 days after
the child's birth date, and a decree of adoption must be entered
within one year from the start of proceedings, unless extended
by court order due to the child's special needs.
HC-DFS273 04-10
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CIGNA HEALTH AND LIFE INSURANCE
COMPANY, a Cigna company (hereinafter called
Cigna)
CERTIFICATE RIDER – Texas Residents
Rider Eligibility: Each Employee who is located in Texas
You will become insured on the date you become eligible,
including if you are not in Active Service on that date due to
your health status.
This rider forms a part of the certificate issued to you by
Cigna.
The provisions set forth in this rider comply with the legal
requirements of Texas group insurance plans covering
insureds located in Texas. These provisions supersede any
provisions in your certificate to the contrary unless the
provisions in your certificate result in greater benefits.
HC-ETTXRDR
Important Notice
Notice of Coverage for Acquired Brain Injury
Your health benefit plan coverage for an acquired brain injury
includes the following services:
cognitive rehabilitation therapy;
cognitive communication therapy;
neurocognitive therapy and rehabilitation;
neurobehavioral, neurophysiological, neuropsychological
and psychophysiological testing and treatment;
neurofeedback therapy and remediation;
post-acute transition services and community reintegration
services, including outpatient day treatment services or
other post-acute care treatment services; and
reasonable expenses related to periodic reevaluation of the
care of an individual covered under the plan who has
incurred an acquired brain injury, has been unresponsive to
treatment, and becomes responsive to treatment at a later
date, at which time the cognitive rehabilitation services
would be a covered benefit.
The fact that an acquired brain injury does not result in
hospitalization or acute care treatment does not affect the right
of the insured or the enrollee to receive the preceding
treatments or services commensurate with their condition.
myCigna.com 68
Post-acute care treatment or services may be obtained in any
facility where such services may legally be provided,
including acute or post-acute rehabilitation hospitals and
assisted living facilities regulated under the Health and Safety
Code.
The following words and terms shall have the following
meanings:
Acquired brain injury - A neurological insult to the brain,
which is not hereditary, congenital, or degenerative. The
injury to the brain has occurred after birth and results in a
change in neuronal activity, which results in an impairment of
physical functioning, sensory processing, cognition, or
psychosocial behavior.
Cognitive communication therapy - Services designed to
address modalities of comprehension and expression,
including understanding, reading, writing, and verbal
expression of information.
Cognitive rehabilitation therapy - Services designed to
address therapeutic cognitive activities, based on an
assessment and understanding of the individual's brain-
behavioral deficits.
Community reintegration services - Services that facilitate
the continuum of care as an affected individual transitions into
the community.
Enrollee - A person covered by a health benefit plan.
Health benefit plan - As described in the Insurance Code §
1352.001 and § 1352.002.
Issuer - Those entities identified in the Insurance Code §
1352.001.
Neurobehavioral testing - An evaluation of the history of
neurological and psychiatric difficulty, current symptoms,
current mental status, and premorbid history, including the
identification of problematic behavior and the relationship
between behavior and the variables that control behavior. This
may include interviews of the individual, family, or others.
Neurobehavioral treatment - Interventions that focus on
behavior and the variables that control behavior.
Neurocognitive rehabilitation - Services designed to assist
cognitively impaired individuals to compensate for deficits in
cognitive functioning by rebuilding cognitive skills and/or
developing compensatory strategies and techniques.
Neurocognitive therapy - Services designed to address
neurological deficits in informational processing and to
facilitate the development of higher level cognitive abilities.
Neurofeedback therapy - Services that utilize operant
conditioning learning procedure based on
electroencephalography (EEG) parameters, and which are
designed to result in improved mental performance and
behavior, and stabilized mood.
Neurophysiological testing - An evaluation of the functions
of the nervous system.
Neurophysiological treatment - Interventions that focus on
the functions of the nervous system.
Neuropsychological testing - The administering of a
comprehensive battery of tests to evaluate neurocognitive,
behavioral, and emotional strengths and weaknesses and their
relationship to normal and abnormal central nervous system
functioning.
Neuropsychological treatment - Interventions designed to
improve or minimize deficits in behavioral and cognitive
processes.
Other similar coverage - The medical/surgical benefits
provided under a health benefit plan. This term recognizes a
distinction between medical/surgical benefits, which
encompass benefits for physical illnesses or injuries, as
opposed to benefits for mental/behavioral health under a
health benefit plan.
Outpatient day treatment services - Structured services
provided to address deficits in physiological, behavioral,
and/or cognitive functions. Such services may be delivered in
settings that include transitional residential, community
integration, or non-residential treatment settings.
Post-acute care treatment services - Services provided after
acute care confinement and/or treatment that are based on an
assessment of the individual's physical, behavioral, or
cognitive functional deficits, which include a treatment goal of
achieving functional changes by reinforcing, strengthening, or
re-establishing previously learned patterns of behavior and/or
establishing new patterns of cognitive activity or
compensatory mechanisms.
Post-acute transition services - Services that facilitate the
continuum of care beyond the initial neurological insult
through rehabilitation and community reintegration.
Psychophysiological testing - An evaluation of the
interrelationships between the nervous system and other
bodily organs and behavior.
Psychophysiological treatment - Interventions designed to
alleviate or decrease abnormal physiological responses of the
nervous system due to behavioral or emotional factors.
Remediation - The process(es) of restoring or improving a
specific function.
Services - The work of testing, treatment, and providing
therapies to an individual with an acquired brain injury.
Therapy - The scheduled remedial treatment provided
through direct interaction with the individual to improve a
pathological condition resulting from an acquired brain injury.
myCigna.com 69
Examinations for Detection of Cervical Cancer
Benefits are provided for each covered female age 18 and over
for an annual medically recognized diagnostic examination for
the early detection of cervical cancer. Benefits include at a
minimum: a conventional Pap smear screening; or a screening
using liquid-based cytology methods, as approved by the
United States Food and Drug Administration, alone or in
combination with a test approved by the United States Food
and Drug Administration for the detection of the human
papillomavirus.
If any person covered by this plan has questions concerning
the above, please call Cigna at 1-800-244-6224, or write us at
the address on the back of your ID card.
HC-IMP16 04-10
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Important Information About Your
Medical Plan
Direct Access for OB/GYN Services
Female insureds covered by this plan are allowed direct access
to a licensed/certified Participating Provider for covered
OB/GYN services. There is no requirement to obtain an
authorization of care from your Primary Care Physician for
visits to the Participating Provider of your choice for
pregnancy, well-woman gynecological exams, primary and
preventive gynecological care, and acute gynecological
conditions.
HC-IMP3 04-10
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The Schedule
The following sentence is added to the “Hospital Emergency
Room” section under the “Emergency and Urgent Care
Services” section of The Schedule shown in your medical
certificate:
Emergency and Urgent Care Services
Hospital Emergency Room
(including a properly licensed freestanding emergency
medical care facility)
The Schedule is amended to indicate the following:
Cardiovascular Disease Screening
Charges for Cardiovascular Disease Screenings are payable at
100%, with one screening every 5 years, not to exceed $200.
The Medical Schedule is amended to indicate that no separate
maximum/deductible shall apply to Diabetic Equipment.
If you are enrolled in a plan which excludes Pharmacy
provisions, the Medical Schedule is amended to indicate that a
$10 copay shall apply for In-Network Diabetic Medications.
The Nutritional Evaluation annual maximum shown in the
Medical Schedule is amended to indicate the following:
“3 visits per person however, the 3 visit limit will not apply to
treatment of diabetes.”
SCHEDTX-ET
Covered Expenses
charges made for annual mammogram for women 35 years
of age and older.
charges made for reconstructive surgery of craniofacial
abnormalities for a child who is younger than 18 years of
age to improve the function of, or to attempt to create a
normal appearance for an abnormal structure caused by
congenital defects, developmental deformities, trauma,
tumors, infection or disease.
charges made for an acquired brain injury including:
cognitive rehabilitation therapy; cognitive communication
therapy; neurocognitive therapy and rehabilitation;
neurobehavioral, neurophysiological, neuropsychological
and psychophysiological testing and treatment;
neurofeedback therapy and remediation; post-acute
transition services and community reintegration services,
including outpatient day treatment services or other post-
acute care treatment services; and reasonable expenses
related to periodic reevaluation of the care of an individual
covered under the plan who has incurred an acquired brain
injury, has been unresponsive to treatment, and becomes
myCigna.com 70
responsive to treatment at a later date, at which time the
cognitive rehabilitation services would be a covered benefit.
charges made for an annual medically recognized diagnostic
examination for the early detection of cervical cancer for
each covered female age 18 and over. Such coverage shall
include at a minimum: a conventional Pap smear screening;
or a screening using liquid-based cytology methods, as
approved by the United States Food and Drug
Administration, alone or in combination with a test
approved by the United States Food and Drug
Administration for the detection of the human
papillomavirus.
charges for a screening test for hearing loss from birth
through the date the child is 30 days old, and necessary
diagnostic follow-up care related to the screening test
from birth through the date the child is 24 months old.
Unless you are enrolled in a Health Savings Account or a
High Deductible Health Plan, a deductible will not apply.
charges for or in connection with a medically recognized
screening exam for the detection of colorectal cancer for
each insured who is at least 50 years of age and at normal
risk for developing colon cancer. Coverage will include: an
annual fecal occult blood test; and either a flexible
sigmoidoscopy performed every five years; or a
colonoscopy performed every 10 years.
charges for a drug that has been prescribed for the treatment
of a covered chronic, disabling or life-threatening Sickness,
provided that drug is Food and Drug (FDA) approved for at
least one indication and is recognized for treatment in one
of the standard reference compendia (The United States
Pharmacopoeia Drug Information, The American Medical
Association Drug Evaluations, or the American Hospital
Formulary Service Drug Information) or supported by
articles in accepted, peer-reviewed medical literature.
Coverage will also be provided for any medical services
necessary to administer the drug.
charges made for all generally recognized services
prescribed in relation to Autism Spectrum Disorder for
Dependent children through age 9. Such coverage must be
prescribed by a Physician in a treatment plan and shall
include evaluation and assessment services; applied
behavior analysis; behavior training and behavior
management; speech therapy; occupational therapy;
physical therapy; or medications or nutritional supplements
used to address symptoms of autism spectrum disorder.
Autism Spectrum Disorder means a neurobiological
disorder that includes autism, Asperger's syndrome, or
Pervasive Developmental Disorder--Not Otherwise
Specified. Neurobiological disorder means an illness of the
nervous system caused by genetic, metabolic, or other
biological factors.
charges for a service provided through Telemedicine for
diagnosis, consultation, treatment, transfer of medical data,
and medical education.
These benefits may not be subject to a greater deductible,
copayment, or coinsurance than for the same service under
this plan provided through a face-to-face consultation.
The term Telemedicine means the practice of health care
delivery, diagnosis, consultation, treatment, transfer of
medical data, and medical education through the use of
interactive audio, video, or other electronic media. It does
not include the use of telephone or fax.
charges for Hospital Confinement of a mother and her
newborn child for 48 hours following an uncomplicated
vaginal delivery, or for 96 hours following an
uncomplicated cesarean delivery. After consulting with her
attending Physician the mother may request an earlier
discharge if it is determined that less time is needed for
recovery. If medical necessity requires the mother and/or
newborn to remain confined for longer than 48 hours, the
additional confinement will be covered. If the mother is
discharged prior to the 48 or 96 hours described above, a
postpartum home care visit will be covered. Postpartum
home care services include parent education; assistance and
training in breast feeding and bottle feeding; and the
performance of any necessary and appropriate clinical tests.
charges for diagnostic and surgical treatment for conditions
effecting temporomandibular joint and craniomandibular
disorders which are a result of: an accident; trauma; a
congenital defect; a developmental defect; or a pathology.
charges made for or in connection with annual diagnostic
examinations for the detection of prostate cancer, regardless
of medical necessity; and a prostate-specific antigen (PSA)
test for a man who is at least 50 years of age and
asymptomatic or at least 40 years of age with a family
history of prostate cancer, or another prostate risk factor.
charges for a minimum of 48 hours of inpatient care
following a mastectomy and a minimum 24 hours following
a lymph node dissection for the treatment of breast cancer.
A shorter period of inpatient care may be deemed
acceptable if the insured consults with the Physician and
both agree it is appropriate.
charges for immunizations for children from birth through
age 5. These immunizations will include: diphtheria;
Haemophilus influenzae type b; hepatitis B; measles;
mumps; pertussis; polio; rubella; tetanus; varicella (chicken
pox); rotavirus; and any other children's immunizations
required by the State Board of Health. A deductible,
copayment, or coinsurance is not required for
immunizations.
myCigna.com 71
Biologically Based Mental Illness
Charges for treatment of Biologically-Based Mental Illness at
the same rate as for other illnesses. A Biologically-Based
Mental Illness is defined as: schizophrenia, paranoid and other
psychotic disorders, bipolar disorders (hypomanic, manic,
depressive, and mixed), major depressive disorder,
schizoaffective disorders (bipolar or depressive), obsessive-
compulsive disorders, and depression in childhood or
adolescence.
Diabetes
The following benefits will apply to insulin and non-insulin
dependent diabetics as well as covered individuals who have
elevated blood sugar levels due to pregnancy or other medical
conditions:
Diabetes Equipment and Supplies:
Blood glucose monitors, including those designed to be
used by the legally blind;
Test strips specified for use with a corresponding glucose
monitor;
Lancets and lancet devices;
Visual reading strips and urine testing strips and tablets
which test for glucose, ketones and protein;
Insulin and insulin analog preparations;
Injection aids, including devices used to assist with insulin
injection and needleless systems;
Insulin syringes;
Biohazard disposal containers;
Insulin pumps, both external and implantable, and
associated appurtenances which include insulin infusion
devices, batteries, skin preparation items, adhesive supplies,
infusion sets, insulin cartridges, durable and disposable
devices to assist in the injection of insulin, and other
required disposable supplies;
Repairs and necessary maintenance of insulin pumps (not
otherwise provided under warranty) and rental fees for
pumps during the repair and maintenance. This shall not
exceed the purchase price of a similar replacement pump;
Prescription and non-prescription medications for
controlling blood sugar level;
Podiatric appliances, including up to two pair of therapeutic
footwear per year, for the prevention of complications
associated with diabetes;
Glucagon emergency kits.
If determined as medically necessary by a treating physician,
new or improved treatment and monitoring equipment or
supplies (approved by the FDA) shall be covered.
The training program for diabetes self-management shall be
recognized by the American Diabetes Association and shall be
performed by a certified diabetes educator (CDE), a
multidisciplinary team coordinated by a CDE (e.g., a dietician,
nurse educator, pharmacist, social worker), or a licensed
healthcare professional (e.g., physician, physician assistant,
registered nurse, registered dietician, pharmacist) determined
by his or her licensing board to have recent experience in
diabetes clinical and educational issues. All individuals
providing training must be certified, licensed or registered to
provide appropriate health care services in Texas.
Self-management training shall include the development of an
individual plan, created in collaboration with the member, that
addresses:
Nutrition and weight evaluation;
Medications;
An exercise regimen;
Glucose and lipid control;
High risk behaviors;
Frequency of hypoglycemia and hyperglycemia;
Compliance with applicable aspects of self-care;
Follow-up on referrals;
Psychological adjustment;
General knowledge of diabetes;
Self-management skills;
Referral for a funduscopic eye exam.
myCigna.com 72
This training shall be provided/covered upon the initial
diagnosis of diabetes or, the written order of the
practitioner/physician when a change in symptoms or
conditions warrant a change in the self-management regime
or, the written order of a practitioner/physician that periodic or
episodic continuing education is needed.
Clinical Trials
Charges made for routine patient care costs in connection
with a phase I, II, III or IV clinical trial if the clinical trial
is conducted in relation to the prevention, detection or
treatment of a life threatening disease or condition. The
clinical trial must be approved by: the Centers for Disease
Control and Prevention of the U.S. Department of Health
and Human Services; the National Institutes of Health; the
U.S. Food and Drug Administration; the U.S. Department
of Defense; the U.S. Department of Veterans Affairs; or an
institutional review board of an institution in this state that
has an agreement with the Office for Human Research
Protections of the U.S. Department of Health and Human
Services.
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Inpatient Mental Health Services
Services that are provided by a Hospital while you or your
Dependent is Confined in a Hospital for the treatment and
evaluation of Mental Health. Inpatient Mental Health Services
include Partial Hospitalization and Mental Health Residential
Treatment Services.
Partial Hospitalization sessions are services that are provided
for not less than 4 hours and not more than 12 hours in any 24-
hour period.
Mental Health Residential Treatment Services are services
provided by a Hospital for the evaluation and treatment of the
psychological and social functional disturbances that are a
result of subacute Mental Health conditions.
Mental Health Residential Treatment Center means an
institution which specializes in the treatment of psychological
and social disturbances that are the result of Mental Health
conditions; provides a subacute, structured, psychotherapeutic
treatment program, under the supervision of Physicians;
provides 24-hour care, in which a person lives in an open
setting; and is licensed in accordance with the laws of the
appropriate legally authorized agency as a residential
treatment center.
A person is considered confined in a Mental Health
Residential Treatment Center when she/he is a registered bed
patient in a Mental Health Residential Treatment Center upon
the recommendation of a Physician.
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Breast Reconstruction and Breast Prostheses
charges made for reconstructive surgery following a
mastectomy; benefits include: surgical services for
reconstruction of the breast on which surgery was
performed; surgical services for reconstruction of the
nondiseased breast to produce symmetrical appearance;
postoperative breast prostheses; and mastectomy bras and
external prosthetics, limited to the lowest cost alternative
available that meets external prosthetic placement needs.
During all stages of mastectomy, treatment of physical
complications, including lymphedema therapy, are covered.
Such coverage shall be provided in a manner determined to
be appropriate in consultation with the Physician and the
insured.
Reconstructive Surgery
charges made for reconstructive surgery or therapy to repair
or correct a severe physical deformity or disfigurement
which is accompanied by functional deficit; (other than
abnormalities of the jaw or conditions related to TMJ
disorder) provided that: the surgery or therapy restores or
improves function; reconstruction is required as a result of
Medically Necessary, noncosmetic surgery; or the surgery
or therapy is performed prior to age 19 and is required as a
result of the congenital absence or agenesis (lack of
formation or development) of a body part.
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Termination of Insurance
Special Continuation of Medical Insurance
If Medical Insurance for you or your Dependent would
otherwise cease for any reason except due to involuntary
termination for cause or due to discontinuance in entirety of
the policy or an insured class, coverage may be continued if:
the person was covered by this policy and/or a prior policy
for the three months immediately prior to the date coverage
would otherwise cease, and
the person elects continuation coverage and pays the first
monthly premium within 60 days of the later of either the
myCigna.com 73
date coverage would otherwise cease or the date required
notice is provided.
Coverage will continue until the earliest of the following:
6 months after continuation coverage is elected for plans
with COBRA and 9 months after continuation coverage is
elected for those without;
the end of the period for which premium is paid;
the date the policy is discontinued and not replaced;
the date the person becomes eligible for Medicare; and
the date the person becomes insured under another similar
policy or becomes eligible for coverage under a group plan
or a state or federal plan.
Texas – Special Continuation of Dependent Medical
Insurance
If your Dependent's Medical Insurance would otherwise cease
because of your death or retirement, or because of divorce or
annulment, his insurance will be continued upon payment of
required premium, if: he has been insured under the policy, or
a previous policy sponsored by your Employer, for at least one
year prior to the date the insurance would cease; or he is a
Dependent child less than one year old. The insurance will be
continued until the earliest of:
three years from the date the insurance would otherwise
have ceased;
the last day for which the required premium has been paid;
with respect to any one Dependent, the earlier of the dates
that Dependent: becomes eligible for similar group
coverage; or no longer qualifies as a Dependent for any
reason other than your death or retirement or divorce or
annulment; or
the date the policy cancels.
If, on the day before the Effective Date of the policy, medical
insurance was being continued for a Dependent under a group
medical policy: sponsored by your Employer; and replaced by
the policy, his insurance will be continued for the remaining
portion of his period of continuation under the policy, as set
forth above.
Your Dependent must provide your Employer with written
notice of retirement, death, divorce or annulment within 15
days of such event. Your Employer will, upon receiving notice
of the death, retirement, divorce or annulment, notify your
Dependent of his right to elect continuation as set forth above.
Your Dependent may elect in writing such continuation within
60 days after the date the insurance would otherwise cease, by
paying the required premium to your Employer.
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Medical Benefits Extension Upon Policy
Cancellation
If the Medical Benefits under this plan cease for you or your
Dependent due to cancellation of the policy, and you or your
Dependent is Totally Disabled on that date due to an Injury or
Sickness, Medical Benefits will be paid for Covered Expenses
incurred in connection with that Injury or Sickness. However,
no benefits will be paid after the earliest of:
the date you exceed the Maximum Benefit, if any, shown in
the Schedule;
the date you are covered for medical benefits under another
group policy;
the date you are no longer Totally Disabled;
90 days from the date your Medical Benefits cease; or
90 days from the date the policy is canceled.
Totally Disabled
You will be considered Totally Disabled if, because of an
Injury or a Sickness:
you are unable to perform the basic duties of your
occupation; and
you are not performing any other work or engaging in any
other occupation for wage or profit.
Your Dependent will be considered Totally Disabled if,
because of an Injury or a Sickness:
he is unable to engage in the normal activities of a person of
the same age, sex and ability; or
in the case of a Dependent who normally works for wage or
profit, he is not performing such work.
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When You Have A Complaint Or An
Adverse Determination Appeal
For the purposes of this section, any reference to "you," "your"
or "Member" also refers to a representative or provider
designated by you to act on your behalf, unless otherwise
noted.
We want you to be completely satisfied with the care you
receive. That is why we have established a process for
addressing your concerns and solving your problems.
When You Have a Complaint
We are here to listen and help. If you have a complaint
regarding a person, a service, the quality of care, a rescission
myCigna.com 74
of coverage, or contractual benefits not related to Medical
Necessity, you can call our toll-free number and explain your
concern to one of our Customer Service representatives. A
complaint does not include: a misunderstanding or problem of
misinformation that can be promptly resolved by Cigna by
clearing up the misunderstanding or supplying the correct
information to your satisfaction; or you or your provider's
dissatisfaction or disagreement with an adverse determination.
You can also express that complaint in writing. Please call us
at the Customer Service Toll-Free Number that appears on
your Benefit Identification card, explanation of benefits or
claim form, or write to us at the following address:
Cigna
National Appeals Organization (NAO)
PO Box 188011
Chattanooga, TN 37422
We will do our best to resolve the matter on your initial
contact. If we need more time to review or investigate your
complaint, we will send you a letter acknowledging the date
on which we received your complaint no later than the fifth
working day after we receive your complaint. We will respond
in writing with a decision 30 calendar days after we receive a
complaint for a postservice coverage determination. If more
time or information is needed to make the determination, we
will notify you in writing to request an extension of up to 15
calendar days and to specify any additional information
needed to complete the review.
You may request that the appeal process be expedited if, (a)
the time frames under this process would seriously jeopardize
your life, health or ability to regain maximum function or in
the opinion of your Physician would cause you severe pain
which cannot be managed without the requested services; or
(b) your appeal involves nonauthorization of an admission or
continuing inpatient Hospital stay.
If you request that your appeal be expedited based on (a)
above, you may also ask for an expedited external
Independent Review at the same time, if the time to complete
an expedited level-one appeal would be detrimental to your
medical condition.
Cigna's Physician reviewer, or your treating Physician, will
decide if an expedited appeal is necessary. When a complaint
is expedited, we will respond orally with a decision within the
earlier of: 72 hours; or one working day, followed up in
writing within 3 calendar days.
If you are not satisfied with the results of a coverage decision,
you can start the complaint appeals procedure.
Complaint Appeals Procedure
To initiate an appeal of a complaint resolution decision, you
must submit a request for an appeal in writing to the following
address:
Cigna
National Appeals Organization (NAO)
PO Box 188011
Chattanooga, TN 37422
You should state the reason why you feel your appeal should
be approved and include any information supporting your
appeal. If you are unable or choose not to write, you may ask
to register your appeal by telephone. Call us at the toll-free
number on your Benefit Identification card, explanation of
benefits or claim form.
Your complaint appeal request will be conducted by the
Complaint Appeals Committee, which consists of at least three
people. Anyone involved in the prior decision, or subordinates
of those people, may not vote on the Committee. You may
present your situation to the Committee in person or by
conference call.
We will acknowledge in writing that we have received your
request within five working days after the date we receive
your request for a Committee review and schedule a
Committee review. The Committee review will be completed
within 30 calendar days. If more time or information is needed
to make the determination, we will notify you in writing to
request an extension of up to 15 calendar days and to specify
any additional information needed by the Committee to
complete the review. In the event any new or additional
information (evidence) is considered, relied upon or generated
by Cigna in connection with the complaint appeal, Cigna will
provide this information to you as soon as possible and
sufficiently in advance of the decision, so that you will have
an opportunity to respond. Also, if any new or additional
rationale is considered by Cigna, Cigna will provide the
rationale to you as soon as possible and sufficiently in advance
of the decision so that you will have an opportunity to
respond.
You will be notified in writing of the Committee's decision
within five working days after the Committee meeting, and
within the Committee review time frames above if the
Committee does not approve the requested coverage.
You may request that the appeal process be expedited if, the
time frames under this process would seriously jeopardize
your life, health or ability to regain maximum function or in
the opinion of your Physician would cause you severe pain
which cannot be managed without the requested services; or
your appeal involves non-authorization of an admission or
continuing inpatient Hospital stay. Cigna's Physician reviewer
or your treating Physician will decide if an expedited appeal is
necessary. When an appeal is expedited, we will respond
myCigna.com 75
orally with a decision within the earlier of: 72 hours; or one
working day, followed up in writing within three calendar
days.
When You have an Adverse Determination Appeal
An Adverse Determination is a decision made by Cigna that
the health care service(s) furnished or proposed to be
furnished to you is (are) not Medically Necessary or clinically
appropriate. An Adverse Determination also includes a denial
by Cigna of a request to cover a specific prescription drug
prescribed by your Physician. If you are not satisfied with the
Adverse Determination, you may appeal the Adverse
Determination orally or in writing. You should state the reason
why you feel your appeal should be approved and include any
information supporting your appeal. We will acknowledge the
appeal in writing within five working days after we receive the
Adverse Determination Appeal request.
Your appeal of an Adverse Determination will be reviewed
and the decision made by a health care professional not
involved in the initial decision. In the event any new or
additional information (evidence) is considered, relied upon or
generated by Cigna in connection with the appeal, Cigna will
provide this information to you as soon as possible and
sufficiently in advance of the decision, so that you will have
an opportunity to respond. Also, if any new or additional
rationale is considered by Cigna, Cigna will provide the
rationale to you as soon as possible and sufficiently in advance
of the decision so that you will have an opportunity to
respond.
We will respond in writing with a decision within 30 calendar
days after receiving the Adverse Determination appeal
request.
You may request that the appeal process be expedited if, (a)
the time frames under this process would seriously jeopardize
your life, health or ability to regain maximum function or in
the opinion of your Physician would cause you severe pain
which cannot be managed without the requested services; or
(b) your appeal involves nonauthorization of an admission or
continuing inpatient Hospital stay. If you request that your
appeal be expedited based on (a) above, you may also ask for
an expedited external Independent Review at the same time, if
the time to complete an expedited level-one appeal would be
detrimental to your medical condition.
Cigna's Physician reviewer or your treating Physician will
decide if an expedited appeal is necessary. When an appeal is
expedited, we will respond orally with a decision within the
earlier of: 72 hours; or one working day, followed up in
writing within three calendar days.
In addition, your treating Physician may request in writing a
specialty review within 10 working days of our written
decision. The specialty review will be conducted by a
Physician in the same or similar specialty as the care under
consideration. The specialty review will be completed and a
response sent within 15 working days of the request. Specialty
review is voluntary. If the specialty reviewer upholds the
initial adverse determination and you remain dissatisfied, you
are still eligible to request a review by an Independent Review
Organization.
Independent Review Procedure
If you are not fully satisfied with the decision of Cigna's
Adverse Determination appeal process or if you feel your
condition is life-threatening, you may request that your appeal
be referred to an Independent Review Organization. In
addition, your treating Physician may request in writing that
Cigna conduct a specialty review. The specialty review
request must be made within 10 days of receipt of the Adverse
Determination appeal decision letter.
Cigna must complete the specialist review and send a written
response within 15 days of its receipt of the request for
specialty review. If the specialist upholds the initial Adverse
Determination, you are still eligible to request a review by an
Independent Review Organization. The Independent Review
Organization is composed of persons who are not employed
by Cigna or any of its affiliates. A decision to use the
voluntary level of appeal will not affect the claimant's rights to
any other benefits under the plan.
There is no charge for you to initiate this independent review
process and the decision to use the process is voluntary. Cigna
will abide by the decision of the Independent Review
Organization.
In order to request a referral to an Independent Review
Organization, certain conditions apply. The reason for the
denial must be based on a Medical Necessity or clinical
appropriateness determination by Cigna. Administrative,
eligibility or benefit coverage limits or exclusions are not
eligible for appeal under this process. You will receive
detailed information on how to request an Independent
Review and the required forms you will need to complete with
every Adverse Determination notice.
The Independent Review Program is a voluntary program
arranged by Cigna.
Appeal to the State of Texas
You have the right to contact the Texas Department of
Insurance for assistance at any time for either a complaint or
an Adverse Determination appeal. The Texas Department of
Insurance may be contacted at the following address and
telephone number:
Texas Department of Insurance
333 Guadalupe Street
P.O. Box 149104
Austin, TX 78714-9104
1-800-252-3439
myCigna.com 76
Notice of Benefit Determination on Appeal
Every notice of an appeal decision will be provided in writing
or electronically and, if an adverse determination, will include:
information sufficient to identify the claim; the specific reason
or reasons for the denial decision; reference to the specific
plan provisions on which the decision is based; a statement
that the claimant is entitled to receive, upon request and free
of charge, reasonable access to and copies of all documents,
records, and other Relevant Information as defined; a
statement describing any voluntary appeal procedures offered
by the plan and the claimant's right to bring an action under
ERISA section 502(a); upon request and free of charge, a copy
of any internal rule, guideline, protocol or other similar
criterion that was relied upon in making the adverse
determination regarding your appeal, and an explanation of the
scientific or clinical judgment for a determination that is based
on a Medical Necessity, experimental treatment or other
similar exclusion or limit; and information about any office
of health insurance consumer assistance or ombudsman
available to assist you in the appeal process. A final notice
of adverse determination will include a discussion of the
decision.
You also have the right to bring a civil action under Section
502(a) of ERISA if you are not satisfied with the decision on
review. You or your plan may have other voluntary alternative
dispute resolution options such as Mediation. One way to find
out what may be available is to contact your local U.S.
Department of Labor office and your State insurance
regulatory agency. You may also contact the Plan
Administrator.
Relevant Information
Relevant Information is any document, record, or other
information which was relied upon in making the benefit
determination; was submitted, considered, or generated in the
course of making the benefit determination, without regard to
whether such document, record, or other information was
relied upon in making the benefit determination; demonstrates
compliance with the administrative processes and safeguards
required by federal law in making the benefit determination;
or constitutes a statement of policy or guidance with respect to
the plan concerning the denied treatment option or benefit or
the claimant's diagnosis, without regard to whether such
advice or statement was relied upon in making the benefit
determination.
Legal Action Under Federal Law
If your plan is governed by ERISA, you have the right to bring
a civil action under Section 502(a) of ERISA if you are not
satisfied with the outcome of the Appeals Procedure. In most
instances, you may not initiate a legal action against Cigna
until you have completed the Complaint or Adverse
Determination Appeal process. If your Complaint is expedited,
there is no need to complete the Complaint Appeal process
prior to bringing legal action.
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Definitions
Dependent
Dependents include:
any child of yours who is:
less than 26 years old.
26 or more years old, unmarried, and primarily supported
by you and incapable of self-sustaining employment by
reason of mental or physical disability which arose while
the child was covered as a Dependent under this Plan, or
while covered as a dependent under a prior plan with no
break in coverage.
Proof of the child's condition and dependence must be
submitted to Cigna within 31 days after the date the child
ceases to qualify above. From time to time, but not more
frequently than once a year, Cigna may require proof of
the continuation of such condition and dependence.
The term child means a child born to you; a child legally
adopted by you; the child for whom you are the legal
guardian; the child who is the subject of a lawsuit for adoption
by you; the child who is supported pursuant to a court order
imposed on you (including a qualified medical child support
order), or your grandchild who is your Dependent for federal
income tax purposes at the time of application. It also includes
a stepchild.
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myCigna.com 77
CIGNA HEALTH AND LIFE INSURANCE
COMPANY, a Cigna company (hereinafter called
Cigna)
CERTIFICATE RIDER – Utah Residents
Rider Eligibility: Each Employee who is located in Utah
You will become insured on the date you become eligible,
including if you are not in Active Service on that date due to
your health status.
This rider forms a part of the certificate issued to you by
Cigna.
The provisions set forth in this rider comply with the legal
requirements of Utah group insurance plans covering insureds
located in Utah. These provisions supersede any provisions in
your certificate to the contrary unless the provisions in your
certificate result in greater benefits.
HC-ETUTRDR
When You Have A Complaint Or An
Appeal
For the purposes of this section, any reference to "you," "your"
or "Member" also refers to a representative or provider
designated by you to act on your behalf, unless otherwise
noted.
We want you to be completely satisfied with the care you
receive. That is why we have established a process for
addressing your concerns and solving your problems.
Start With Customer Service
We are here to listen and to help. If you have a concern
regarding a person, a service, the quality of care, or
contractual benefits, or a rescission of coverage, you can call
our toll-free number and explain your concern to one of our
Customer Service representatives. Please call us at the
Customer Service Toll-Free Number that appears on your
Benefit Identification card, explanation of benefits or claim
form.
We will do our best to resolve the matter on your initial
contact. If we need more time to review or investigate your
concern, we will get back to you as soon as possible, but in
any case within 30 days.
If you are not satisfied with the results of a coverage decision,
you can start the appeals procedure.
Appeals Procedure
Cigna has a two step appeals procedure for coverage
decisions. To initiate an appeal, you must submit a request for
an appeal in writing, within 365 days of receipt of a denial
notice, to the following address:
Cigna HealthCare Inc.
National Appeals Organization (NAO)
PO Box 188011
Chattanooga, TN 37422
You should state the reason why you feel your appeal should
be approved and include any information supporting your
appeal. If you are unable or choose not to write, you may ask
to register your appeal by telephone. Call us at the toll-free
number or address on your Benefit Identification card,
explanation of benefits or claim form.
Level-One Appeal
Your appeal will be reviewed and the decision made by
someone not involved in the initial decision. Appeals
involving Medical Necessity or clinical appropriateness will
be considered by a health care professional.
For level-one appeals, we will respond in writing with a
decision within 15 calendar days after we receive an appeal
for a required preservice or concurrent care coverage
determination (decision). We will respond within 30 calendar
days after we receive an appeal for a postservice coverage
determination. If more time or information is needed to make
the determination, we will notify you in writing to request an
extension of up to 15 calendar days and to specify any
additional information needed to complete the review.
You may request that the appeal process be expedited if, (a)
the time frames under this process would seriously jeopardize
your life, health or ability to regain maximum function or in
the opinion of your Physician would cause you severe pain
which cannot be managed without the requested services; or
(b) your appeal involves nonauthorization of an admission or
continuing inpatient Hospital stay.
If you request that your appeal be expedited based on (a)
above, you may also ask for an expedited external
Independent Review at the same time, if the time to complete
an expedited level-one appeal would be detrimental to your
medical condition.
Cigna's Physician reviewer, in consultation with the treating
Physician, will decide if an expedited appeal is necessary.
When an appeal is expedited, we will respond orally with a
decision within 72 hours, followed up in writing.
myCigna.com 78
Level Two Appeal
If you are dissatisfied with our level one appeal decision, you
may request a second review. To start a level two appeal,
follow the same process required for a level one appeal.
If the appeal involves a coverage decision based on issues of
medical necessity, clinical appropriateness or experimental
treatment, a medical review will be conducted by a Physician
reviewer in the same or similar specialty as the care under
consideration, as determined by Cigna’s Physician reviewer.
For all other coverage plan-related appeals, a second-level
review will be conducted by someone who was not involved
in any previous decision related to your appeal, and not a
subordinate of previous decision makers. Provide all relevant
documentation with your second-level appeal request.
For required preservice and concurrent care coverage
determinations, Cigna’s review will be completed within 15
calendar days. For postservice claims, Cigna’s review will be
completed within 30 calendar days. If more time or
information is needed to make the determination, we will
notify you in writing to request an extension of up to 15
calendar days and to specify any additional information
needed to complete the review.
In the event any new or additional information (evidence) is
considered, relied upon or generated by Cigna in connection
with the level-two appeal, Cigna will provide this information
to you as soon as possible and sufficiently in advance of the
decision, so that you will have an opportunity to respond.
Also, if any new or additional rationale is considered by
Cigna, Cigna will provide the rationale to you as soon as
possible and sufficiently in advance of the decision so that you
will have an opportunity to respond.
You will be notified in writing of the decision within five
working days after the decision is made, and within the review
time frames above if Cigna does not approve the requested
coverage.
You may request that the appeal process be expedited if the
time frames under this process would seriously jeopardize
your life, health or ability to regain maximum function or in
the opinion of your Physician would cause you severe pain
which cannot be managed without the requested services; or
your appeal involves nonauthorization of an admission or
continuing inpatient Hospital stay. Cigna's Physician reviewer,
in consultation with the treating Physician will decide if an
expedited appeal is necessary. When an appeal is expedited,
we will respond orally with a decision within 72 hours,
followed up in writing.
Independent Review Procedure
If you are not fully satisfied with the decision of Cigna's level
two appeal review regarding your Medical Necessity or
clinical appropriateness issue, you may request that your
appeal be referred to an Independent Review Organization.
The Independent Review Organization is composed of persons
who are not employed by Cigna HealthCare or any of its
affiliates. A decision to use the voluntary level of appeal will
not affect the claimant's rights to any other benefits under the
plan.
There is no charge for you to initiate this independent review
process. Cigna will abide by the decision of the Independent
Review Organization.
In order to request a referral to an Independent Review
Organization, certain conditions apply. The reason for the
denial must be based on a Medical Necessity or clinical
appropriateness determination by Cigna. Administrative,
eligibility or benefit coverage limits or exclusions are not
eligible for appeal under this process.
To request a review, you must notify the Appeals Coordinator
within 180 days of your receipt of Cigna's level two appeal
review denial. Cigna will then forward the file to the
Independent Review Organization.
The Independent Review Organization will render an opinion
within 30 days. When requested and when a delay would be
detrimental to your condition, as determined by Cigna's
Physician reviewer, the review shall be completed within three
days.
The Independent Review Program is a voluntary program
arranged by Cigna.
Appeal to the State of Utah
You have the right to contact the Utah State Department of
Insurance for assistance at any time. The Utah State
Department of Insurance may be contacted at the following
address and telephone number:
Utah State Department of Insurance
State Office Building, Room 3110
Salt Lake City, UT 84114-6901
800-439-3805
Notice of Benefit Determination on Appeal
Every notice of a determination on appeal will be provided in
writing or electronically and, if an adverse determination, will
include: information sufficient to identify the claim; the
specific reason or reasons for the adverse determination;
reference to the specific plan provisions on which the
determination is based; a statement that the claimant is entitled
to receive, upon request and free of charge, reasonable access
to and copies of all documents, records, and other Relevant
Information as defined; a statement describing any voluntary
appeal procedures offered by the plan and the claimant's right
to bring an action under ERISA section 502(a); upon request
and free of charge, a copy of any internal rule, guideline,
protocol or other similar criterion that was relied upon in
making the adverse determination regarding your appeal, and
an explanation of the scientific or clinical judgment for a
myCigna.com 79
determination that is based on a Medical Necessity,
experimental treatment or other similar exclusion or limit; and
information about any office of health insurance consumer
assistance or ombudsman available to assist you in the appeal
process. A final notice of adverse determination will include a
discussion of the decision.
You also have the right to bring a civil action under Section
502(a) of ERISA if you are not satisfied with the decision on
review. You or your plan may have other voluntary alternative
dispute resolution options such as Mediation. One way to find
out what may be available is to contact your local U.S.
Department of Labor office and your State insurance
regulatory agency. You may also contact the Plan
Administrator.
Relevant Information
Relevant Information is any document, record, or other
information which was relied upon in making the benefit
determination; was submitted, considered, or generated in the
course of making the benefit determination, without regard to
whether such document, record, or other information was
relied upon in making the benefit determination; demonstrates
compliance with the administrative processes and safeguards
required by federal law in making the benefit determination;
or constitutes a statement of policy or guidance with respect to
the plan concerning the denied treatment option or benefit or
the claimant's diagnosis, without regard to whether such
advice or statement was relied upon in making the benefit
determination.
Legal Action
If your plan is governed by ERISA, you have the right to bring
a civil action under Section 502(a) of ERISA if you are not
satisfied with the outcome of the Appeals Procedure. In most
instances, you may not initiate a legal action against Cigna
until you have completed the Level One and Level Two
Appeal processes. If your Appeal is expedited, there is no
need to complete the Level Two process prior to bringing
legal action.
HC-APL135 01-11
V1-ET
Definitions
Dependent
A child also includes a legally adopted child, including that
child from the date of placement for adoption. Coverage for an
adopted child will begin from:
the moment of birth, if adoption occurs within 30 days of
the child's birth; or
the date of placement, if placement for adoption occurs 30
days or more after the child's birth.
This coverage requirement ends if the child is removed from
placement prior to the child being legally adopted.
"Placement for Adoption" means the assumption and retention
by a person of a legal obligation for total or partial support of
a child in anticipation of the adoption of the child.
HC-DFS699 01-15
V1-ET1
CIGNA HEALTH AND LIFE INSURANCE
COMPANY, a Cigna company (hereinafter called
Cigna)
CERTIFICATE RIDER – Vermont Residents
Rider Eligibility: Each Employee who is located in
Vermont
You will become insured on the date you become
eligible, including if you are not in Active Service on
that date due to your health status.
This rider forms a part of the certificate issued to you by
Cigna.
The provisions set forth in this rider comply with the
legal requirements of Vermont group insurance plans
covering insureds located in Vermont. These provisions
supersede any provisions in your certificate to the
contrary unless the provisions in your certificate result in
greater benefits.
HC-ETVTRDR
Important Notices
Vermont Mandatory Civil Unions Endorsement for
Health Insurance
Purpose:
Vermont law requires that health insurers offer coverage
to parties to a civil union that is equivalent to coverage
provided to married persons. This endorsement is part of
myCigna.com 80
and amends this policy, contract or certificate to comply
with Vermont law.
Definitions, Terms, Conditions and Provisions
The definitions, terms, conditions and any other
provisions of the policy, contract, certificate and/or
riders and endorsements to which this mandatory
endorsement is attached are hereby amended and
superseded as follows:
Terms that mean or refer to a marital relationship, or
that may be construed to mean or refer to a marital
relationship, such as “marriage,” “spouse,” “husband,”
“wife,” “dependent,” “next of kin,” “relative,”
“beneficiary,” “survivor,” “immediate family” and any
other such terms include the relationship created by a
civil union established according to Vermont law.
Terms that mean or refer to the inception or
dissolution of a marriage, such as “date of marriage,”
“divorce decree,” “termination of marriage” and any
other such terms include the inception or dissolution of
a civil union established according to Vermont law.
Terms that mean or refer to family relationships
arising from a marriage, such as “family,” “immediate
family,” “dependent,” “children,” “next of kin,”
“relative,” “beneficiary,” “survivor” and any other
such terms include family relationships created by a
civil union established according to Vermont law.
“Dependent” means a spouse, party to a civil union
established according to Vermont law, and a child or
children (natural, stepchild, legally adopted or a minor
or disabled child who is dependent upon the insured
for support and maintenance) who is born to or
brought to a marriage or to a civil union established
according to Vermont law.
“Child” or “covered child” means a child (natural,
stepchild, legally adopted or a minor or disabled child
who is dependent upon the insured for support and
maintenance) who is born to or brought to a marriage
or to a civil union established according to Vermont
law.
Caution: Federal Rights May or May Not Be
Available
Vermont law grants parties to a civil union the same
benefits, protections and responsibilities that flow from
marriage under state law. However, some or all of the
benefits, protections and responsibilities related to health
insurance that are available to married persons under
federal law may not be available to parties to a civil
union. For example, federal law, the Employee
Retirement Income Security Act of 1974 known as
"ERISA," controls the employer/employee relationship
with regard to determining eligibility for enrollment in
private employer health benefit plans. Because of
ERISA, Act 91 does not state requirements pertaining to
a private employer's enrollment of a party to a civil
union in an ERISA employee welfare benefit plan.
However, governmental employers (not federal
government) are required to provide health benefits to
the dependents of a party to a civil union if the public
employer provides health benefits to the dependents of
married persons. Federal law also controls group health
insurance continuation rights under "COBRA" for
employers with 20 or more employees as well as the
Internal Revenue Code treatment of health insurance
premiums. As a result, parties to a civil union and their
families may or may not have access to certain benefits
under this policy, contract, certificate, rider or
endorsement that derive from federal law. You are
advised to seek expert advice to determine your rights
under this contract.
HC-IMP26 04-10
V4-ET
The Schedule
Any deductible or coinsurance applicable to annual
routine or diagnostic mammograms does not apply.
SCHED-VTET
Covered Expenses
charges made for or in connection with mammograms
for breast cancer screenings, not to exceed an annual
mammogram for women age 40 or over, or
mammograms for women less than age 40 upon
recommendation of a health care provider.
Cancer Clinical Trials
Routine patient care services directly associated with a
patient’s participation in a phase I, II, III or IV approved
cancer clinical trial.
An “approved cancer clinical trial” is an organized,
systematic, scientific study of therapies, tests, or other
myCigna.com 81
clinical interventions for purposes of treatment,
palliation, or prevention of cancer in human beings.
The approved trial must:
seek to answer a credible and specific medical or
scientific question for the purpose of advancing cancer
care;
enroll only those patients for whom there is no clearly
superior, noninvestigational treatment alternative;
have available clinical or preclinical data that provides
a reasonable expectation that the treatment obtained in
the approved trial will be at least as effective as the
noninvestigational alternative;
be conducted under the auspices of one of the
following Vermont cancer care providers: Vermont
Cancer Center at Fletcher Allen Health Care, the
Norris Cotton Cancer Center at Dartmouth-Hitchcock
Medical Center, or approved clinical trials being
administered by a Vermont hospital and its affiliated,
qualified Vermont cancer care providers;
be conducted by a facility and personnel capable of
conducting such a trial by virtue of experience,
training and volume of patients treated to maintain
such expertise;
be conducted under the auspices of a peer-reviewed
protocol that has been approved by one of the
following entities: one of the National Institutes of
Health (NIH); an NIH-affiliated cooperative group that
is a formal network of facilities that collaborate on
research projects and have an established NIH-
approved peer-review program operating within the
group; the FDA in the form of an investigational new
drug application or exemption; or the federal
department of Veterans Affairs or Defense.
“Routine patient care services” are any Covered
Expenses under this plan, including any Medically
Necessary health care service that is incurred as a result
of the treatment being provided to the patient for the
purposes of the approved cancer clinical trial. Routine
patient care services do not include the following:
the cost of investigational new drugs that have not
been approved for market for any indication by the
FDA, or the costs of any drug being studied under an
FDA-approved investigational new drug exemption
for the purpose of expanding the drug’s labeled
indications.
the costs of nonhealth care services that may be
required as a result of the treatment being provided for
the purposes of the approved cancer clinical trial.
the costs of the services that are clearly inconsistent
with widely accepted and established regional or
national standards of care for a particular diagnosis
and performed specifically to meet the requirements of
the approved cancer clinical trial.
the costs of any tests or services performed
specifically to meet the needs of the approved cancer
clinical trial protocol.
the costs of running the approved cancer clinical trial
and collecting and analyzing data.
the costs associated with managing the research
associated with the approved clinical trial.
the costs for noninvestigational treatments or services
that would not otherwise be covered under the
patient’s health benefit plan.
any product or service paid for by the trial sponsor.
HC-COV70 04-10
V1-ET3
When You Have A Complaint Or An
Appeal (Grievance)
For the purposes of this section, any reference to "you,"
"your" or "Member" also refers to a representative or
provider designated by you to act on your behalf, unless
otherwise noted.
We want you to be completely satisfied with the care
you receive. That is why we have established a process
for addressing your concerns and solving your problems.
Customer Service
We are here to listen and help. If you have a concern
regarding a person, a service, the quality of care, or
contractual benefits, you are welcome to call our toll-
free number and explain your concern to one of our
Customer Service representatives. You can also express
that concern in writing. Please call or write to us at the
following:
Customer Services Toll-Free Number or address that
appears on your Benefit Identification card,
explanation of benefits or claim form.
myCigna.com 82
We will do our best to resolve the matter on your
initial contact. If we need more time to review or
investigate your concern, we will get back to you as
soon as possible, but in any case within 30 days.
You must pay for services given by a Participating
Provider or non-Participating Provider if your claim is
denied.
If you are not satisfied with the results of a coverage
decision, you can start the appeals procedure.
Prescription Drug Benefit Management Disclosure
Cigna will allow an exception to a benefit management
requirement described in this certificate that applies to
coverage for Prescription Drugs and Related Supplies,
and will provide coverage on the same basis as Cigna
would have for the benefit management requirement, if
your Physician certifies, based on relevant clinical
information about you and sound medical or scientific
evidence or the known characteristics of the drug, that
the benefit management requirement:
has been ineffective, or is reasonably expected to be
ineffective or significantly less effective in treating
your condition, such that an exception is Medically
Necessary; or
has caused you, or is reasonably expected to cause
you, adverse or harmful reactions.
To request an exception, your Physician should contact:
Cigna Pharmacy Management
Attn: Pharmacy Services Center
P.O. Box 29030
Phoenix, AZ 85038-9030
Tel. (800) 244-6224
Cigna will accept the Physician’s advance certification
telephonically, when the Physician designates the
situation to be an emergency. Cigna has the right to
require the certification to be later confirmed in writing.
A denial of a request for an exception to a benefit
management requirement is a determination subject to
independent external review under Vermont law. In this
situation, the terms of the “External Review Procedure
For Non-Mental Health/Substance Abuse Issues”
provision, and the “Notice of Benefit Determination on
Appeal” provision, both contained in this section of your
certificate, apply.
If you or your Dependent have a grievance relating to
Cigna's pharmaceutical benefit management program,
you should refer to the following “Appeals Procedure”
provisions. These provisions also apply to initiating this
type of grievance.
Appeals Procedure
Cigna has a two-step appeals procedure for coverage
decisions.
While a level one appeal is a required part of the
process, a level two appeal is completely voluntary. For
example, if a level one appeal is not resolved to your
satisfaction, you may choose to make an external appeal
to an Independent Panel of Mental Health Care
Providers or to an Independent Review Organization, as
described later in this provision, rather than pursuing
Cigna’s voluntary level two appeal process.
The voluntary level two appeal review will be done
without deference to the initial adverse benefit
determination or to the adverse determination of a level
one appeal.
The appeal review takes into account all comments,
documents, records, and other information relating to the
appeal that you submit, regardless of whether that
information was submitted or considered: in the initial
benefit determination (for a level one or a voluntary
level two appeal); or during the level one appeal (for a
voluntary level two appeal). Additional assistance is also
available from the Vermont Department of Financial
Regulation (DFR), as described later in this provision.
To initiate an appeal, you must submit a request for an
appeal in writing within 365 days of receipt of a denial
notice. You should state the reason why you feel your
appeal should be approved and include any information
supporting your appeal, including any written comments,
documents, records and other information relating to
your appeal. If you are unable or choose not to write,
you may ask to register your appeal by telephone.
Reasonable accommodations will be made to help a
person with a disability participate in the appeal process.
Additionally, if English is not your primary language,
we will provide you with information about how to file
an appeal and how to participate in the appeal process, in
your primary language, upon your request. Call or write
to us at the toll-free number or address on your Benefit
Identification card, explanation of benefits or claim
form. We will document the appeal for you and provide
copies of that documentation to you, or to your
representative.
myCigna.com 83
For any appeal related to an adverse benefit
determination, should a reversal of that decision be
made during any step of the appeal process, Cigna
will promptly authorize or otherwise arrange for
coverage of a covered service that was denied or
restricted. Neither you nor your treating provider
will be liable for any services provided before
notification to you of the adverse benefit
determination and the final outcome of any appeal or
independent external review. However, if your
treating provider or his or her designee refuse or
repeatedly fail to communicate with us, when the
opportunity to communicate with us has been offered
in a time and manner convenient to them, your
treating provider will be liable for any services
provided to you. You will not be liable in either case.
You must pay for services given by a Participating
Provider or a non-Participating Provider in the event
of a final denial of your claim.
Level One Appeal
Your appeal will be reviewed and the decision made by
someone not involved in the initial decision. This person
will also not be the subordinate of any individual who
was involved with the initial decision or other issue that
is the subject of the appeal. Appeals involving an
adverse benefit determination that is based in whole or
in part on a medical judgment will be considered by a
health care professional who is a clinical peer of your
treating provider.
You may request that we identify to you any clinical
expert whose advice we obtained in connection with
your adverse benefit determination, regardless of
whether or not that expert’s advice was relied on when
the determination was made. Any clinical expert we ask
to consult with us regarding your level one appeal will
not be the same clinical expert (if any) we consulted
with regarding the adverse benefit determination that is
the subject of your appeal, or the subordinate of that
clinical expert (if any).
A Cigna medical director or his or her designee will
offer to directly communicate with your treating
provider, or your treating provider’s designee, before the
appeal is decided.
You will have reasonable access to, and may obtain
copies of, all documents, records and other information
relevant to your appeal upon request and free of charge,
within two business days. In the case of a concurrent or
urgent preservice review, you will have access to or may
obtain the materials immediately upon request.
Level One Urgent, Preservice Appeal
For an urgent preservice level one appeal, we will orally
notify you and your treating provider (if known) of our
determination as soon as is possible based on your
medical condition, but in no case later than 72 hours
after we receive the appeal. We will send written
confirmation of the determination to you and your
treating provider (if known), within 24 hours of our oral
notification to you.
Mental health/substance abuse and pharmacy benefit
requests are generally considered urgent under Vermont
regulatory requirements.
Level One Non-Urgent, Preservice Appeal
For a non-urgent preservice level one appeal, we will
send written confirmation to you and your treating
provider (if known) of our determination as soon as is
possible based on your medical condition, but in no case
later than 30 calendar days after we receive the appeal.
Level One Concurrent Review Appeal
For a level one appeal related to a request to continue or
extend a course of treatment (i.e. a concurrent review),
we will orally notify you and your treating provider (if
known) of our determination as soon as is possible based
on your medical condition, but in no case later than 24
hours after we receive the appeal. We will send written
confirmation of the determination to you and your
treating provider (if known), within 24 hours of our oral
notification to you.
Level One Post-Service Appeal
For a level one post-service appeal, we will send written
confirmation to you and your treating provider (if
known) of our determination within a reasonable time
period, but in no case later than 60 calendar days after
we receive the appeal.
Level One Appeal Not Related to an Adverse Benefit
Determination
For a level one appeal not related to an adverse benefit
determination, we will send written confirmation to you
within 60 calendar days after we receive the appeal.
Voluntary Level Two Appeal
If you are dissatisfied with our level one appeal decision,
you may request a voluntary second review. To start a
voluntary level two appeal, follow the same process
myCigna.com 84
required for a level one appeal. If you decide to pursue a
voluntary second level appeal review, that decision has
no effect on your right to any other benefits under this
plan.
The voluntary level two appeal review will be done
without deference to the initial adverse benefit
determination or to the adverse determination of a level
one appeal.
Neither you nor your provider acting on your behalf are
responsible for any fees or costs associated with a
voluntary level two appeal, should you choose to pursue
one.
You will have reasonable access to, and may obtain
copies of, all documents, records and other information
relevant to your appeal upon request and free of charge,
within two business days. In the case of a concurrent or
urgent preservice review, you will have access to or may
obtain the materials immediately upon request.
Most requests for a second review will be conducted by
the Appeals Committee, which consists of at least three
people. Anyone who is a member of the Committee may
not: have been involved in the initial adverse benefit
determination or other issue that is the subject of the
appeal; have been involved in the adverse determination
of the level one appeal; or be the subordinate of any
person involved with the initial determination or other
issue that is the subject of the appeal. For appeals
involving Medical Necessity or clinical appropriateness,
the Committee will consult with at least one Physician
reviewer in the same or similar specialty as the care
under consideration, as determined by Cigna's Physician
reviewer.
You may request that we identify to you any clinical
expert whose advice we obtained in connection with
your adverse benefit determination, regardless of
whether or not that expert’s advice was relied on when
the determination was made. Any clinical expert we ask
to consult with us regarding your voluntary level two
appeal will not be the same clinical expert (if any) we
consulted with regarding the adverse benefit
determination that is the subject of your appeal, or the
subordinate of that clinical expert (if any).
For a voluntary level two appeal we will acknowledge in
writing that we have received your request and schedule
a Committee review. You will be consulted regarding
setting the meeting date for a voluntary second level
appeal review. You may present your situation to the
Committee in person or by conference call; however,
participating in person or via telephone is not a
requirement for the voluntary second level appeal
meeting to proceed.
Voluntary Level Two Urgent, Preservice Appeal
For an urgent preservice voluntary level two appeal, we
will orally notify you and your treating provider (if
known) of our determination as soon as is possible based
on your medical condition, but in no case later than 72
hours after we receive the appeal. We will send written
confirmation of the determination to you and your
treating provider (if known), within 24 hours of our oral
notification to you.
Mental health/substance abuse and pharmacy benefit
requests are generally considered urgent under Vermont
regulatory requirements.
Voluntary Level Two Non-Urgent, Preservice Appeal
For a non-urgent preservice voluntary level two appeal,
we will send written confirmation to you and your
treating provider (if known) of our determination as soon
as is possible based on your medical condition, but in no
case later than 30 calendar days after we receive the
appeal.
Voluntary Level Two Concurrent Review Appeal
For a voluntary level two appeal related to a request to
continue or extend a course of treatment (i.e. a
concurrent review), we will orally notify you and your
treating provider (if known) of our determination as soon
as is possible based on your medical condition, but in no
case later than 24 hours after we receive the appeal. We
will send written confirmation of the determination to
you and your treating provider (if known), within 24
hours of our oral notification to you.
Voluntary Level Two Post-Service Appeal
For a voluntary level two post-service appeal, we will
send written confirmation to you and your treating
provider (if known) of our determination within a
reasonable time period, but in no case later than 60
calendar days after we receive the appeal.
Voluntary Level Two Appeal Not Related to an
Adverse Benefit Determination
For a voluntary level two appeal not related to an
adverse benefit determination, we will send written
notification to you within 60 calendar days after we
receive the appeal.
myCigna.com 85
External Review Procedure For Mental
Health/Substance Abuse Issues
If you are dissatisfied with either a Level One Appeal
decision or a voluntary Level Two Appeal decision, you
may request an External Review of your issue by an
Independent Panel of Mental Health Care Providers (IP).
To start the External Review by an IP, you, your mental
health care provider or your representative on your
behalf, must file a written request with Cigna and the IP.
You must include your consent for Cigna to release
confidential patient files to the IP. The IP address is:
Independent Panel of Mental Health Care Providers
Vermont Department of Financial Regulation (DFR)
89 Main Street
Montpelier, VT 05620-3601
800-631-7788(toll-free) or 802-282-2900
When Cigna receives your request for an External
Review, Cigna will send the file supporting the initial
decision and the appeal decision(s) to the IP within: 24
hours of receiving the request in emergency situations;
and within five working days of receiving the request in
all other situations.
The IP may address inquiries to any of the parties (you,
your mental health care provider or your authorized
representative, or Cigna) and may set a reasonable time
period for a response. If Cigna does not provide all
necessary information in the required time periods, the
delay will result in a presumption in your favor and will
not delay the IP’s review of the issue. The IP also has
the authority to request any or all of the parties to meet
with the IP. The IP will make its review decision within
24 hours of receiving all necessary information in
emergency situations; and within 15 working days in all
other situations. The IP will send its decision by mail or
facsimile to Cigna and to the person who filed the
request for External Review. Emergency decisions will
be communicated by telephone, facsimile or delivered
by express mail as appropriate. Cigna is required to
abide by the IP’s decision. If you have a complaint about
a matter that is not related to Medical Necessity or
clinical appropriateness, you may file a consumer
complaint with the Insurance Consumer Services
Division at the following address:
Insurance Consumer Services Division
Vermont Department of Financial Regulation (DFR)
89 Main Street, Drawer 20
Montpelier, VT 05620-3101
802.828.3302
External Review Procedure For Non-Mental
Health/Substance Abuse Issues
If you are dissatisfied with a level one appeal or a
voluntary level two appeal decision, you may request an
External Review of your issue by an Independent
Review Organization (IRO).
You (or your authorized representative or your provider
on your behalf) may file a written request for External
Review within 90 days from the date you receive
Cigna’s final, written appeal decision. External Appeals
for non-Mental Health/Substance Abuse issues may be
requested for the following reasons:
The health care service is a covered benefit that Cigna
has determined to be not Medically Necessary.
A limitation is placed on the selection of a health care
provider that you claimed to be inconsistent with
limits imposed by this plan and any applicable laws
and regulations.
The health care treatment has been determined to be
experimental or investigational or an off-label use of a
drug.
myCigna.com 86
The health care service involves a medically-based
decision that a condition is preexisting.
The written request for External Review must be filed
with the DFR at the following address:
External Appeals Program
Vermont Department of Financial Regulation (DFR)
89 Main Street, Montpelier, VT 05620-3601
Telephone: 800-631-7788 (toll-free) or 802-828-2900
The insured must file on a form provided by the DFR
and include the $25 fee or a request for a waiver or
reduction of the fee, for the general release of medical
records relevant to the appeal, identification of insurer
and a copy of the denial level from the relevant level of
appeal. An oral request will also be accepted if made
within the 90-day period provided that the request is
confirmed in writing on the state request form within 10
calendar days. The External Appeal program is a
voluntary program.
Once notified by the DFR that the External Appeal has
been accepted for review by an IRO, Cigna must submit
all information relevant to the appeal, including: the
review criteria used in making the decision; copies of
any applicable policies or procedures; and copies of all
medical records considered in making the decision in the
appeal process. Cigna may request an extension of up to
10 days to submit information and documentation,
granted by the DFR for good cause.
Cigna must pay the costs of the External Appeal to the
DFR within 30 days of notification of the reasonable and
necessary costs of the review by the IRO.
The DFR will provide the request form for an External
Appeal. An oral request will also be accepted if made
within the 90-day period provided that the request is
confirmed in writing on the state request form within 10
calendar days. Within five working days of receiving the
External Appeal request the DFR will process the form
and materials, and accept the appeal for review by an
IRO after determining: that you are or were insured; the
service is a covered service under the plan; the External
Appeal involves an appealable decision; you have
exhausted the internal process; and all information has
been provided.
The DFR will notify you when the External Appeal
submission is complete, and whether the External
Appeal has been accepted for review by an IRO. Cigna
must submit any required documentation within 10
calendar days from the date Cigna receives the request
notice. Cigna may request a 10-calendar day extension
for good cause. You may have an extension for any
reason.
The DFR shall provide copies of documentation (and
follow-up information) to you and to Cigna; each will
have three working days to file responsive
documentation with the DFR.
The DFR will assign the External Appeal on a rotating
basis to an IRO for clinical review.
The DFR will review the determination of the IRO and
then issue the determination to you and to Cigna, which
will be binding on Cigna but not on you.
The IRO will conduct a full review, and may request any
additional information from you, Cigna, or the DFR. The
IRO will complete the review, and forward its written
determination to the DFR within five calendar days from
receipt if the External Appeal involves emergency or
urgently needed care; and 30 calendar days from receipt
for all other External Appeal requests. The IRO’s written
determination will include the clinical rationale for the
determination. The IRO may request an extension from
the Commissioner.
Additional Assistance
You have the right to contact the Health Insurance
Consumer Services unit within the DFR for assistance at
any time. This unit can help you if you need general
information about health insurance, have concerns about
our activities, or are not satisfied with how we resolved
your complaint. The DFR may be contacted at the
following address and telephone number:
Health Insurance Consumer Services Division
Vermont Department of Financial Regulation (DFR)
89 Main Street, Montpelier, VT 05620-3101
800-631-7788 (toll-free) or 802-828-2900
The Office of Health Care Ombudsman’s telephone
hotline service can also provide help to Vermonters who
have problems or questions about health care and health
insurance. Contact them at:
Office of Health Care Ombudsman
264 North Winooski Avenue
Burlington, VT 05402
Telephone: 888-917-7787 or 802-863-2316
TTY: 888-884-1955 or 802-863-2473
myCigna.com 87
Applies to All Issues
Notice of Benefit Determination on Appeal
Every notice of a determination on appeal will be
provided in writing or electronically and, if an adverse
determination, will include: the specific reason or
reasons for the adverse determination; reference to the
specific plan provisions on which the determination is
based; a statement that the claimant is entitled to receive,
upon request and free of charge, reasonable access to
and copies of all documents, records, and other Relevant
Information as defined; a statement describing any
voluntary appeal procedures offered by the plan and the
claimant's right to bring an action under ERISA section
502(a); and upon request and free of charge, a copy of
any internal rule, guideline, protocol or other similar
criterion that was relied upon in making the adverse
determination regarding your appeal, and an explanation
of the scientific or clinical judgment for a determination
that is based on a Medical Necessity, experimental
treatment or other similar exclusion or limit.
You also have the right to bring a civil action under
Section 502(a) of ERISA if you are not satisfied with the
decision on review. You or your plan may have other
voluntary alternative dispute resolution options such as
Mediation. One way to find out what may be available is
to contact your local U.S. Department of Labor office
and your state insurance regulatory agency. You may
also contact the Plan Administrator.
Relevant Information
Relevant Information is any document, record, or other
information which was relied upon in making the benefit
determination; was submitted, considered, or generated
in the course of making the benefit determination,
without regard to whether such document, record, or
other information was relied upon in making the benefit
determination; or constitutes a statement of policy or
guidance with respect to the plan concerning the denied
treatment option or benefit or the claimant's diagnosis,
without regard to whether such advice or statement was
relied upon in making the benefit determination.
Legal Action
If your plan is governed by ERISA, you have the right to
bring a civil action under Section 502(a) of ERISA if
you are not satisfied with the outcome of the Appeals
Procedure. In most instances, you may not initiate a
legal action against Cigna until you have completed the
Level One and Level Two Appeal processes. If your
Appeal is expedited, there is no need to complete the
Level Two process prior to bringing legal action.
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Definitions
Medically Necessary/Medical Necessity
Medically Necessary care means health care services,
including diagnostic testing, preventive services and
aftercare, that are appropriate in terms of type, amount,
frequency, level, setting, and duration to the person’s
diagnosis or condition. Medically Necessary care must
be informed by generally accepted medical or scientific
evidence and consistent with generally accepted practice
parameters as recognized by health care professions in
the same specialties as typically provide the procedure or
treatment, or diagnose or manage the medical condition;
must be informed by the unique needs of each individual
patient and each presenting situation; and:
help restore or maintain the person’s health; or
prevent deterioration of, or palliate, the person’s
condition; or
prevent the reasonably likely onset of a health problem
or detect an incipient problem.
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CIGNA HEALTH AND LIFE INSURANCE
COMPANY, a Cigna company (hereinafter called
Cigna)
CERTIFICATE RIDER – Wyoming Residents
Rider Eligibility: Each Employee who is located in Wyoming
You will become insured on the date you become eligible,
including if you are not in Active Service on that date due to
your health status.
This rider forms a part of the certificate issued to you by
Cigna.
myCigna.com 88
The provisions set forth in this rider comply with the legal
requirements of Wyoming group insurance plans covering
insureds located in Wyoming. These provisions supersede any
provisions in your certificate to the contrary unless the
provisions in your certificate result in greater benefits.
HC-ETWYRDR
Covered Expenses
charges for cancer screening tests, including: a pelvic
examination, Pap smear and clinical breast cancer
examination, including a mammogram; a prostate
examination and laboratory tests; and a colorectal cancer
examination and laboratory tests for any nonsymptomatic
person.
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