CIGNA Behavioral Health Practitioner Connection – CARE ADVOCACY PROGRAM (CAP): OUTPATIENT REVIEW PROCESS

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CBH Practitioner Conection
Volume XXIII, 3rd Quarter

The right help at the right time!

CARE ADVOCACY PROGRAM (CAP): OUTPATIENT REVIEW PROCESS

The Care Advocacy Program (CAP) was designed to help participants have greater access to care, while at the same time reducing administrative tasks for practitioners. Under CAP, practitioners are no longer required to obtain pre-authorization or submit treatment summaries when providing routine care. As a result, the way that outpatient services were managed and reviewed also had to evolve.

The CAP outpatient process was designed for routine outpatient claim evaluation, to identify certain clinical or utilization conditions that would indicate a clinical review is needed. When a claim is submitted for payment on routine outpatient services, the claim is evaluated for benefit. If the claims system identifies one of these conditions during benefit evaluation, the claim is flagged, prompting a call to a practitioner to request that an outpatient review be scheduled.

The practitioner will be instructed to contact the scheduling department at 800.241.4057 ext. 2452. When scheduling the review, it is helpful for the practitioner to have his/her calendar available, as well as relevant HIPAA verification information (including Tax ID #). The scheduling department has access to the Care Managers’ schedules and can set up an appointment for the clinical review at a time that is convenient for both practitioner and care manager. The practitioner must respond to the request for review within 7 days of the original call. Failure to schedule the review within 7 days may impact future claim payment.

On the day of the review, the practitioner should have his or her Tax ID # available, as well as identifying information about the participant (i.e., date of birth, subscriber’s social security or alternative participant identification [AMI] number). The practitioner and care manager will participate in a clinical discussion around diagnostic impressions, the treatment being provided, progress made, current symptoms, treatment and discharge goals, as well as coordination with other treating providers. The review process should take approximately 30 minutes to complete. Once the review is completed, if further sessions are approved, a counter is set in the system to track the number of visits authorized. When these visits have been used, the claims review process is reset. If further sessions are not approved, the request follows the standard peer review process.

There are certain circumstances practitioners should keep in mind when scheduling or completing an outpatient review with a care manager. Some states have very tight regulatory timeframes within which CBH needs to make clinical decisions. If CBH requests a review within a very small window of time, it is most likely due to a state regulation. Practitioners should also note that all products are not created equal; different products may require different outpatient service management. Additionally, CBH’s contractual relationships with its customers may include unique outpatient care management requirements. If unsure about benefits or expectations for a specific case, practitioners should contact a Customer Service Representative by using the toll-free number on the back of the participant’s card. And finally, it is common for Care Managers’ schedules to be full for up to 4 or 5 business days. The scheduling team will work with practitioners in finding the most immediate mutually available time for review.

It is our goal that the enhancements made to the outpatient review process can add value, promote more clinically appropriate outcomes, and improve the partnership between CBH clinical staff and participating practitioners. If there are any questions regarding the outpatient review process, practitioners may contact a Provider Education Specialist or send an email to ProviderEducation@CIGNABehavioral.com.