CUADRO MEDICO CIGNA PDF

In California, Cigna offers a number of products, services, tools and capabilities to a wide variety of clients and to individuals. If you are offered a Cigna plan through your employer and would like a better understanding of the benefit plan s offered to you, look for general descriptions in our Products and Services section. Cigna offers a broad network of health care professionals and facilities throughout California. Our interactive Provider Directory can show you the participating physicians, hospitals and pharmacies located in the area you specify. Customer's can also login to myCigna.

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In California, Cigna offers a number of products, services, tools and capabilities to a wide variety of clients and to individuals. If you are offered a Cigna plan through your employer and would like a better understanding of the benefit plan s offered to you, look for general descriptions in our Products and Services section.

Cigna offers a broad network of health care professionals and facilities throughout California. Our interactive Provider Directory can show you the participating physicians, hospitals and pharmacies located in the area you specify. Customer's can also login to myCigna.

Some hospitals and other providers do not provide one or more of the following services that may be covered under your plan contract and that you or your family member might need: family planning; contraceptive services, including emergency contraception; sterilization, including tubal ligation at the time of labor and delivery; infertility treatments; or abortion.

You should obtain more information before you enroll. Call your prospective doctor, medical group, independent practice association, or clinic, or call Cigna at the number on your ID card to ensure that you can obtain the health care services you need.

If you are currently enrolled in a Cigna plan, and would like to learn more about what mental health services are available under your plan, which doctors are in the network and how to obtain services, please call the number on your Cigna ID card. Drug List: For information about which drugs are considered "Formulary" or "Preferred" and generally cost you less out-of-pocket, click on the following link: Prescription Drug List. Cigna provides language assistance services free of charge to customers who live in California and customers who live outside of California and who are covered under a policy issues in California.

The below documents are in multiple languages. Notice of Language Assistance. California Customer Interpreter Card. Cigna Language Assistance Survey. HMO or Network Plan enrollee living in California and meet certain criteria, you may be able to continue to receive services from a health care professional who is not in the Cigna network. If you are currently enrolled and your health care professional or facility leaves the Cigna network, or a new enrollee transitioning to a Cigna plan, and are covered under a policy insured by Cigna Health and Life Insurance Company you may be able to continue to receive services from a health care professional or facility that is not in the Cigna network.

Please refer to your plan booklet for more information. You have 60 days from the date of the notice to apply. Covered California You can buy health insurance through Covered California.

The State of California set up Covered California to help people and families, like you, find affordable health insurance. You can use Covered California if you do not have insurance through your employer, Medi-Cal or Medicare. You must apply during an open or special enrollment period. If you have a life change such as marriage, divorce, a new child or loss of a job, you can apply during a special enrollment period.

Medi-Cal is California's health care program for people with low incomes. Starting in , you can get Medi-Cal if:. Your eligibility is based on your income. It is not based on how much money you have saved or if you own your own home. You do not have to be on public assistance to qualify for Medi-Cal. You can apply for Medi-Cal anytime. To qualify for Medi-Cal if you are over 65, disabled or a refugee, other rules and requirements apply.

You can also call or visit your county social services office. Covered Expenses are expenses for services or supplies which are not excluded from your benefit plan, are recommended by a Physician, and are Medically Necessary for the care and treatment of an Injury or a Sickness. Prior Authorization means the approval that must be received prior to services being rendered, in order for certain services and benefits to be covered expenses under your policy.

The Prior Authorization review may include benefit verification and a clinical review to determine whether the service or supply is medically necessary. If Cigna administers your behavioral health benefits, our staff can answer your benefit questions and assist you in getting behavioral health care and can assist you or your provider with the claim submission process or help answer questions about how claims have been processed.

Just contact us by dialing the number on your ID card. For routine outpatient office visits for behavioral care with an in-network psychiatrist or therapist, you do not need to contact us before your treatment appointment. To find an in-network psychiatrist or therapist, use our online directory or call us at the number listed on your member benefit card.

Be sure you understand the difference between in-network and out-of-network coverage. Seeing an in-network psychiatrist or therapist means you'll pay less and do not have to file a claim for reimbursement of covered expenses.

For any other type of behavioral care, you must contact us to pre-authorize benefit coverage to receive the maximum amount payment for your claims. Call the toll-free phone number on your health plan identification card to reach our staff. An Advocate or Care Manager will be happy to help. Have your insurance ID card number available when you call. Our phones are staffed 24 hours a day, seven days a week.

When you contact us, you'll be connected with the staff who can best meet your needs. Our Customer Service and Advocate staff can answer benefit or network questions and our licensed Care Managers can help to select the type and level of care you need.

If you don't understand what is and isn't covered under your plan, please contact us. We can help explain your coverage, deductibles and copays, and tell you how to access the kind of care you need. Also, carefully read your benefit plan materials from your employer or health plan for details on your coverage.

We want you to be satisfied with the care that you receive. That's why we've established an internal grievance process for addressing your concerns and resolving your problems. Grievances include both complaints and appeals.

Complaints can include concerns about people, quality of service, quality of care, benefit exclusions or eligibility. Appeals are requests to reverse a prior denial or a modified decision about your care. A participating health care professional or any other person you identify may join with or assist you or act as your agent in submitting a grievance to Cigna or the DMHC. If you are concerned about the quality of service or care you have received a benefit exclusion or an eligibility issue you should contact us to file a verbal or written complaint.

If we are unable to resolve your complaint on the day your call was received, or if we receive your complaint in the mail, we will investigate your complaint and will notify you of the outcome within 30 calendar days, unless your complaint is regarding the treatment you received.

These complaints will be investigated by a clinician. If appropriate the complaint may go before a committee of physician reviewers.

The outcome of these types of investigations must be kept confidential according to California law. If you are not satisfied with the outcome of a decision that was made about your care and are requesting that Cigna reverse a previous decision, you should contact us to file a verbal or written appeal within one year of receiving the denial notice.

Be sure to share any new information that may help justify a reversal of the original decision. We will tell you who to contact at Cigna should you have questions or if you would like to submit additional information about your appeal. We will make sure that your appeal is handled by someone who has authority to take action.

We will investigate your appeal and notify you of our decision within 30 calendar days. You may request that the appeal process be expedited if the timeframes under this process would seriously jeopardize your life or health or your ability to regain maximum functionality, or if you are experiencing severe pain. A competent Cigna medical professional, in consultation with your treating physician, will decide if an expedited appeal is necessary.

When an appeal is expedited, Cigna will respond orally and in writing with a decision within 72 hours. If you have request for language assistance please call member services using the number on your ID card.

The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at 1. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, or one that has not been satisfactorily resolved by your health plan, or one that has not been resolved after 30 days, call the Department for assistance.

If you are eligible for IMR, the IMR process will provide an impartial review of: medical decisions made by a health plan related to the medical necessity of a proposed service or treatment; coverage decisions for treatments that are experimental or investigational in nature; and payment disputes for emergency or urgent medical services.

The department also has a toll-free telephone number and a TDD line for the hearing and speech impaired. You have the right to contact the California Department of Insurance for assistance at any time. The Commissioner may be contacted at the following address and fax number:. If you have received an appeal decision from Cigna that you are not satisfied with, you may also request voluntary mediation with us before exercising the right to submit a grievance to the DMHC if you are enrolled in a Cigna HealthCare of California plan or to the California Department of Insurance if you are enrolled in a Cigna Health and Life Insurance Company plan.

In order for mediation to take place, you and Cigna each have to voluntarily agree to the mediation.

Cigna will consider each request for mediation on a case-by-case basis. Each side will equally share the expenses of the mediation. To initiate mediation, please submit a written request for mediation to: Cigna HealthCare of California, Inc. To the extent permitted by law, Cigna contractually requires the use of binding arbitration when disputes are left unsettled by other means. If your plan is governed by ERISA, you have the right to bring civil action under Section a if you are not satisfied with the outcome of the appeal procedure.

In most instances, you may not initiate a legal action until you have completed the Cigna internal appeal process. You can notify us of complaints or appeals concerning Cigna Behavioral Health in one of the following ways:. For more specific information about these grievance procedures, please refer to your Group Service Agreement or contact our Customer Services Department.

If the Cigna Behavioral Health customer is a minor or is incompetent or unable to exercise rational judgment or give consent, the parent, guardian, conservator, relative or other legal representative acting on behalf of the member, as appropriate, may submit a grievance to Cigna Behavioral Health or the California Department of Managed Health Care DMHC or "the Department" as the agent of the member.

In addition, a participating provider or any other person you identify may assist you or act as your agent in submitting a grievance to Cigna Behavioral Health or the DMHC. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the Department for assistance. If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services.

The Department also has a toll-free telephone number: 1. Please refer to your plan documents for information that is applicable to your specific plan. If you are considering becoming a plan member or customer and have questions about your plan coverage, please contact your employer. All plans may have exclusions, limitations, reduction of benefits and terms under which the policy may be continued in force or discontinued.

Rates may vary by plan and are subject to change. For a complete list of both covered and not covered services under your plan or policy, including benefits required by your state, see your evidence of coverage, plan booklet, insurance certificate or your employer's summary plan description.

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Cigna in California

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