TIP OF THE WEEK

This “Tip of the Week” is being prepared to inform Class Members that in recognition of the longer than anticipated processing timeframe for Settlement Claims, an extension has been granted for the time period for class members to cure defects related to Claims Distribution Fund claims (Category 1, 2 and Medical Necessity Claims). The time period has been extended from thirty days to sixty days (postmarked date) from the date of the defect letter.

PREVIOUS TIPS OF THE WEEK

Previous Tip #1:

NOTE ON FACILITATION LIST REQUESTS

Please be advised that if Class Members do not request a Facilitation List before February 4, 2005, depending upon the size of the List, it is possible that Class Members will not receive Facilitation Lists in time to use to file Category Two Claims by the February 18, 2005 deadline. Although the Settlement Administrator is making every attempt to send Facilitation Lists to Class Members within 3-5 days of receipt of a request, it can take longer than 3-5 days to process and send the List.

AS SUCH, CLASS MEMBERS ARE ADVISED THAT THEY SHOULD REQUEST FACILITATION LISTS NO LATER THAN FEBRUARY 4, 2005, AND ARE FURTHER ADVISED THAT FACILITATION LISTS REQUESTED AFTER FEBRUARY 4, 2005 ARE LIKELY NOT TO BE RECEIVED IN TIME TO BE UTILIZED IN FILING CATEGORY TWO CLAIMS.

If you have additional questions please call the Settlement Administrator at (877) 683-9363, or you can call Class Counsel Melissa Calabrese, Esq. toll free (866) 809-8003 or you can email Ms. Calabrese at mcalabrese@whatleydrake.com.

 

Previous Tip #2:

Opportunity to Withdraw Category A Claims

If you have submitted a Category A Proof of Claim Form but have changed your mind and instead wish to file Category One, Two or Medical Necessity Denial Proofs of Claim for compensation from the Claims Distribution Fund, you have the opportunity to withdraw your original Category A claim so that you may file claims against the Claims Distribution Fund. To do so, you must submit a completed Category A Withdrawal Form to the Settlement Administrator at:

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

Your Category A Withdrawal Form must be postmarked by February 1, 2005 to be valid. Any Category One, Two, or Medical Necessity Denial Proofs of Claim you subsequently submit must satisfy the existing requirements for filing such Proofs of Claim, including that they be postmarked by February 18, 2005. Note that by filing a Category A Withdrawal Form, you will no longer be entitled to receive compensation from the Category A Claim Fund, unless you subsequently file a valid Category A Claim Form postmarked by February 18, 2005.

Previous Tip #3:

The deadline for submitting claims in all Claim Categories is quickly approaching. Requests for payment postmarked after February 18, 2005 will be denied. Please make sure your claim is postmarked on or before February 18, 2005. Claims must be sent to the Settlement Administrator at the following address:

CIGNA Physician Settlement
Settlement Administrator
PO Box 3170
Portland, OR 97208-3170

Previous Tip #4:

When using a CIGNA HealthCare Remittance Form (also referred to as an Explanation of Payment or EOP) to support a Category One, Two, or Medical Necessity Proof of Claim and the EOP does not show the CPT/HCPCS Level II Codes that you originally submitted to CIGNA, you may use the corresponding HCFA 1500 or accounting records for that service to show the codes originally submitted.

Previous Tip #5:

Please list only those codes for which you seek compensation.

When filling out cover sheets for Category One, Two, and Medical Necessity Proofs of Claim, list only those CPT/HCPCS Level II Codes for which you are seeking settlement compensation. Do not list any CPT/HCPCS Level II Code if you are not claiming for that code, even if it appears on your supporting documentation.

Previous Tip #6:

Please check your Category One, Two or Medical Necessity compensation Proof of Claim before you submit it:

  1. Make sure that each request for payment relates to a Fee for Service claim that you originally submitted to CIGNA HealthCare, not another company.
  2. Fill out the Proof of Claim form completely.
  3. Complete a cover sheet and attach the cover sheet to the supporting documents for each individual request for payment you submit with your Proof of Claim.
  4. Confirm that the Fee for Service Claim for which you are requesting payment has a date of service on or between August 4, 1990 and April 22, 2004.
  5. If you are filing a Category One Proof of Claim, make sure that the Fee for Service claim for which you are requesting payment falls within the dates of service shown on the Category One Code List.
  6. If you are filing a Category Two or Medical Necessity Denial Proof of Claim, remember to include the required clinical documentation (see Questions 37, 38, 48, and 49 under the Frequently Asked Questions portion of this website for details on clinical information requirements).
  7. Sign the Proof of Claim form.

Previous Tip #7:

The Category One Cover Sheet, which appears as the last page of the Proof of Claim Form for Category One Compensation, has been revised to add the following explanatory language above the code boxes:

Specific CPT code pairs (dropped/paid codes) as listed on Exhibit 1 - Category One Code List.

This language clarifies that you should fill in the code boxes below this text with the dropped and paid CPT code combinations appearing on the Category One Code List. The Settlement Administrator will continue to accept Category One Proofs of Claim submitted using the old Category One Cover Sheet. The new cover sheet simply includes this explanation about how to complete the cover sheet.

Previous Tip #8:

FAQ #21 and #22 have been revised to clarify instructions for Category A Claim Forms filed by Physician Groups or Physician Organizations. A Physician Group or Physician Organization can file a single Category A Claim Form requesting Category A compensation for each of the physicians in the group/organization without obtaining individual signatures from each physician. If the group/organization wishes to obtain a single check for the entire group/organization, it must complete a single Category A Claim Form, sign it on behalf of the physicians, and include with the form a list of the physicians on whose behalf it is filing the form. The list must include the group or organization's name and TIN, the physicians' full names, and, if available, each physicians' individual TINs or Social Security Numbers. The Settlement Administrator will send one check to the group/organization worth the total amount of each physician's share of the Category A fund.

If a group/organization wishes to file for Category A compensation on behalf its physicians but have each physician receive an individual check from the Category A fund, the group/organization must submit separate Category A Claim Forms for each physician using the physician's individual TIN or Social Security Number, not the group/organization TIN, on each physician's Category A Claim Form. The group/organization can still sign on behalf of each physician. The Settlement Administrator will send a check to each physician in the group/organization for his or her share of the Category A fund.

The new text of FAQ #21 and #22 now read as follows:

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

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

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

The group will receive a single check for its Category A payment which will include one share of the Category A Settlement Fund for each Physician Class Member included in the filing. The check will be sent to the group or organization for the group TIN.

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

Yes. If a Physician Group or Physician Organization wishes to file for Category A compensation on behalf of its members and wants each member within the group or organization to receive a separate payment, the group must submit separate Category A Claim Forms on behalf of each Physician. The group or organization can sign on behalf of each Physician employed by or otherwise working with it at the time the Category A Claim Form is submitted, without obtaining individual signatures from the individual Physicians. The group or organization must list the Physician's individual TIN or Social Security Number -- not the group or organization TIN -- on each Physician's Category A Claim Form when completing Category A Claim Forms on each Physician's behalf. A group or organization cannot file claims for Category A compensation on behalf of former members.

Previous Tip #9:

Category Two Compensation may be sought for all denials of or reductions in payment with respect to claims submitted to CIGNA HealthCare resulting from the application of Claim Coding and Bundling Edits other than those for which Category One Compensation applies. If Category One Compensation applies, it is the exclusive remedy. See FAQ # 34 (34. Under what circumstances is Category Two Compensation available?) and FAQ # 12 (12. What are Claim Coding and Bundling Edits?)

An application for Category Two Compensation must include supporting documentation demonstrating that the denial or reduction in payment resulted from Claim Coding and Bundling Edits. See FAQ # 37 for an explanation of what records you may use as supporting documentation for a Category 2 claim.

Previous Tip #10:

There is no fee to submit a claim under the settlement. However, third party vendors who provide services to assist class members in submitting claims may charge a fee for their services. The vendor will tell you whether it charges a fee to assist in submitting a claim.

Previous Tip #11:

The Category One Code List shows the CPT code combinations and the dates of service for which Category One compensation is available. You are eligible for the Category One compensation amount shown in the "Fee" column if you submit the required documentation showing that:

  • you submitted the CPT code listed in the "Dropped Code" column; AND
  • you submitted the CPT code listed in the "Paid Code" column; AND
  • you submitted these codes together to CIGNA HealthCare; AND
  • the date of service was within the time periods shown in the "Date of Service" column.
  • Also, for asterisked codes on the Category One CPT Code List, you must show that you were denied payment for the CPT code listed in the "Denied Code" column.

A new question, FAQ #28a, has been added to the Q&A section of this website to describe the specific contents the Category One Code List. A copy of FAQ #28a follows:

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

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

Previous Tip #12:

In order to assist you in identifying claims which are eligible for Category Two Compensation, CIGNA HealthCare has used its best efforts to create an electronic Facilitation List. See Q&A 1FAQ # 35. The facilitation list is only a guide. All items on the list are not necessarily eligible for compensation under the settlement, and items not on the list may be eligible for Category Two compensation. Class Members are not limited to this list in submitting Category Two claims to the Settlement Administrator.

Previous Tip #13:

When submitting a Category 2 or Medical Necessity Proof of Claim, make sure you submit clinical documentation where required.

Clinical documentation must be submitted along with the Proof of Claim for certain Category 2 claims and all Medical Necessity claims. For a detailed explanation of when clinical documentation is required, see questions 36, 37, and 38 for Category 2 claims and questions 48 and 49 for Medical Necessity claims. For a detailed list of what documentation is required for specific code ranges, see the Clinical Documentation section of this website.

The Notice of Commencement of Claims Period and Settlement Agreement, found in the Documents section of this website, also details the Clinical Documentation requirements.

Previous Tip #14:

Questions 21 and 22 have been added to the FAQs to clarify the requirements for physician groups submitting Category A claims. Question 21 addresses Physician Groups or Physician Organizations that file a single Category A Claim Form and request that all members' Category A shares be included in one check. Question 22 addresses Physician Groups or Physician Organizations that file separate Category A Claim Forms on behalf of each of its members, and request that each physician receive a separate check.

Below is the text of questions 21 and 22:

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

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

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

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

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

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

Previous Tip #15:

When certifying a Category A Proof of Claim, make sure you select the correct check box relating to your status in SECTION III: CERTIFICATION.

Check "I am a Physician in active practice" if you are or work in the office of a currently practicing physician.

Do NOT check "I am the legal representative of a Physician who was in active practice on or after August 4, 1990" UNLESS you have been appointed as legal representative for the estate of a deceased physician, the estate of a bankrupt physician, etc.

Previous Tip #16:

FAQ #3 has been revised to include the definition of a Physician, Physician Group and Physician Organization, as well as the definition of the Class. In addition, FAQ#3 instructs that "If you do not meet one of these definitions, you are not a class member and are not eligible to submit claims under this Settlement."

The new text of FAQ#3 now reads as follows:

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

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

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