Cigna Reference Guide for physicians, hospitals, ancillaries, and other health care professionals

Introduction

CIGNA LIFESOURCE

TRANSPLANT NETWORK

PROVIDER REFERENCE GUIDE

Cigna LifeSOURCE is committed to providing access to

quality transplant care, improved health, and lower costs.

January 2024

PCOMM-2024-1940

Table of contents

Introduction ............................................................................................................ 4

Inside the guide .................................................................................................. 4

Our commitment and mission ................................................................................ 4

Notes ................................................................................................................ 5

The transplant process ............................................................................................ 6

Zone 1: Evaluation .............................................................................................. 6

Zone 2: Pre-transplant ......................................................................................... 6

Solid organs.............................................................................................. 6

Bone marrow, stem cell, and cord blood transplants ....................................... 6

Zone 3: Transplant event ......................................................................................7

Zone 4: Post-transplant follow up .......................................................................... 7

Quality information .................................................................................................. 8

Quality performance ............................................................................................ 8

Guidelines for network inclusion ............................................................................ 8

Ventricular assist device ........................................................................... 11

Chimeric Antigen Receptor T-Cell (CAR-T) Therapy Network ...........................11

Communicating staff and program changes ........................................................... 11

Appeal information ............................................................................................. 12

Case management ..................................................................................................13

Purpose ............................................................................................................

Goals and objectives .......................................................................................... 13

Managed services .............................................................................................. 13

Contact information ........................................................................................... 14

Coverage positions, clinical resource tools, and criteria ........................................... 14

Customer handbook ........................................................................................... 15

Referrals and appeals ............................................................................................. 16

Clinical coverage decisions and appeals ................................................................. 16

Prior authorization .................................................................................. 16

Authorization process ............................................................................... 16

Coverage determinations ......................................................................... 16

Appeals of coverage determinations .......................................................... 16

Clinical trial determinations ...................................................................... 16

Transplant case management referral process ....................................................... 17

Medical documentation checklists .......................................................................... 18

Medical documentation checklist for adult transplants ............................................. 19

Medical documentation checklist for pediatric transplants ....................................... 23

Medicare eligibility ................................................................................................. 26

Claim submissions ................................................................................................. 27

Cigna Healthcare customers ............................................................................... 27

Cigna Healthcare, Cigna Global Health Benefits

, and Shared Administration

Repricing (Taft-Hartley) plans ................................................................... 27

SAMBA account ...................................................................................... 27

Cigna Healthcare Medicare Advantage Arizona customers ............................. 28

Network Access Clients (NACs) ........................................................................... 28

Bundled billing ................................................................................................. 29

Sample claims cover sheet ................................................................................. 29

Required claim documentation ............................................................................ 30

Dispute resolution ................................................................................................. 31

Payment appeal process .................................................................................... 31

Travel benefit ........................................................................................................ 32

Air ambulance transport ........................................................................................ 33

Network Access Clients .......................................................................................... 34

Referral process ............................................................................................... 34

Claim process .................................................................................................. 34

Sample referral letter ........................................................................................ 36

Pharmacy, infusion services, and behavioral health services .................................. 37

Express Scripts ................................................................................................. 37

How to submit an order ........................................................................... 37

Accredo ........................................................................................................... 37

Coram

CVS Specialty

infusion services (Coram) ............................................... 37

Evernorth Behavioral Health ............................................................................... 38

Important contact information ................................................................................ 39

Legal statement ...................................................................................................... 40

Introduction

Welcome to Cigna LifeSOURCE Transplant Network

! For starters, we'd like you to

know that we're committed to giving all of our customers access to quality services

and benefits. That means working with you across all the aspects of today's health

care world. To help us stay on the same page, we have created this Reference

Guide for you. It highlights the programs and policies intended to keep our

relationship smooth and productive – for the sake of the people we serve together.

The Reference Guide contains Administrative Guidelines and Program Requirements

for the programs, policies, rules, and procedures pertaining to Cigna Healthcare

insured or administered benefit plans. We will give you advance notice of material

changes to our Administrative Guidelines and Program Requirements. Your Cigna

LifeSOURCE Participation Provider Agreement and this Reference Guide describe

many of the terms under which you agree to provide services to Cigna Healthcare

Plan Participants. Those terms include the reimbursement rates applicable to

Covered Services provided to Participants. However, the actual benefits payable by

a Payer for Covered Services provided to a Participant in all cases is determined by

the terms of the Payer’s Benefit Plan.

Inside the guide

Cigna LifeSOURCE Transplant Network is a specialized component of Cigna

Healthcare that offers access to high-performing transplant providers with an

enhanced benefit for customers with Cigna Healthcare-administered coverage. The

network is dedicated to managing and providing access to complex medical

services, including transplantation, cellular therapies, and the associated medical

and surgical services with the goal to reduce costs, reduce or eliminate unnecessary

procedures, maintain or improve the quality of the transplant procedure, and

improve the overall transplant experience for our customers and their families. The

Cigna LifeSOURCE Transplant Network Provider Reference Guide includes

information regarding case management, clinical documentation, network program

inclusion requirements, processes, administrative guidelines, contacts, claims,

terminology, and more.

This comprehensive guide provides the policies and procedures Cigna LifeSOURCE

employs to help you manage Cigna Healthcare customers who need a transplant.

We hope this guide helps you as we work together to ensure Cigna Healthcare

customers receive quality and affordable transplant care.

Our commitment and mission

The Cigna LifeSOURCE Transplant Network focuses on high-quality health care

providers to service our transplant customers and their families, which includes:

• A national quality program

• A comprehensive dedicated transplant case management team

• Coverage positions

• Specially trained claims personnel

• Dedicated contracting, medical directors, and clinical staff

• Travel benefits, when applicable

Introduction

Health care and transplant professionals head up the Cigna LifeSOURCE team. This

team of dedicated individuals work to uphold and improve all aspects of the Cigna

LifeSOURCE Transplant Network.

Notes

Please note that state law may supersede information provided in this manual.

Please check your facility’s contract for state-specific information. To check state-

specific information, please visit the Cigna for Health Care Professionals website

(CignaforHCP.com

). Registration is required (at no cost).

The transplant process

Cigna LifeSOURCE includes specialized, dedicated transplant case managers who

supervise services for transplant recipients through each phase of

the transplant process. Cigna LifeSOURCE identifies the phases of transplantation

as “zones.”

Zone 1: Evaluation

Please call Transplant Case Management at 800.668.9682 to get prior

authorization before you begin evaluation.

This is the candidacy period. The customer is evaluated by the transplant team to

determine if they are an acceptable candidate for a transplant.

This zone includes all diagnostic tests performed on the customer and a live donor,

if applicable. A Zone 1 authorization should be requested if human leukocyte

antigen (HLA) typing for potential liver donors will be performed as these services

are part of the evaluation period. Please notify the Transplant Care Manager if a

living donor will be receiving testing. Zone 1 should also be requested if an

unrelated search is conducted, as these services are also transplant services and

only intended to be covered if a customer is actively pursuing a transplant.

The transplant center is expected to provide all diagnostic tests. These

tests cannot be outsourced.

While some tests, such as colorectal testing and gynecological and dental exams,

may seem less critical to transplant, they are required to ascertain the health status

of Cigna LifeSOURCE customers facing transplant. If you are in doubt about

required testing, please consult the customer’s case manager.

Unless otherwise stated in your facility’s contract, the zone begins when the

customer starts the evaluation and must be authorized by Cigna Healthcare for the

evaluation. It ends on the date the patient is accepted into the hospital’s transplant

program, or deemed not acceptable as a transplant candidate.

Zone 2: Pre-transplant

Zone 2 is the pre-transplant period that occurs after Zone 1 and continues until the

day prior to the transplant procedure, or the beginning of the transplant event.

Non-transplant-related care (for the underlying disease condition) is typically

excluded from this zone. Please contact Transplant Case Management prior to

listing the patient for a transplant to ensure that correct authorizations are in place.

Solid organs

For solid organs, this zone includes transplant-related care only for routine

surveillance of the recipient as needed to maintain their candidacy status. This

includes any testing required to determine organ function, clinic visits, etc. Zone 2

does not include ongoing maintenance care such as renal dialysis.

Bone marrow, stem cell, and cord blood transplants

In typical contract language for autologous bone marrow and stem cell transplants

(BMT\SCT), the beginning of this zone is represented by the acceptance of the

The transplant process

participant into the hospital’s transplant program unless your facility’s contract

specifies otherwise.

For allogeneic BMT/SCT, the candidacy zone typically starts after the recipient has

been accepted into the program and ends the day prior to the transplant event.

Note: Approval is only given for one year at a time. When a patient approaches

one year in Zone 2, the case manager will contact your transplant program to find

out the status of the patient and to assess whether to extend Zone 2 approval.

Zone 3: Transplant event

For solid organ transplants, Zone 3 typically begins on the day of or the day prior to

the transplant procedure and ends when the recipient is discharged from the

hospital.

For autologous and allogeneic-related BMT/SCT, the transplant event zone typically

begins with mobilization.

For allogeneic unrelated BMT/SCT and cord blood transplants, Zone 3 typically

begins with the onset of preparative regimen. Please refer to your facility’s

contract.

Zone 3 includes living donor services for up to 30 days after the date of donation.

Please refer to your facility’s contract.

All transplant-related services for the recipient provided during this time are

included in the Zone 3 rate unless there is a specific exclusion referenced in the

contract. Please refer to your specific contract for terms related to the management

and treatment of the underlying disease.

The Zone 3 start date and end date is specific to each transplant facility’s contract.

Please consult your contract to determine the exact end date.

Note: The infusion of stem cells, including donor cells performed as a “boost” to

enhance cell recovery, is not considered a transplant and will be included in the

Zone 3 rate if performed during this period.

Zone 4: Post-transplant follow up

The time period typically included in this zone is one year.

Your facility’s contract should be reviewed for the specific amount of time and the

services included in this zone.

Zone 4 includes all transplant-related follow-up care for the recipient.

Quality information

Quality performance

The foundation of the Cigna LifeSOURCE Transplant Network is our quality

performance program managed through the Network Performance Review

Committee (NPRC).

The quality process is essential in ensuring program performance and in providing

our customers and their families with access to excellence in transplant care. Each

transplant program under network consideration begins the quality process by

completing a Request for Information (RFI). The Cigna LifeSOURCE network uses

the United Network for Organ Sharing (UNOS) standardized RFI form for all solid

organ transplant procedures, and the American Society for Transplantation and

Cellular Therapy (ASTCT) standardized RFI form for all BMT\SCT procedures to

support consistency in the process.

The RFI provides program-specific data that is evaluated against the Cigna

LifeSOURCE performance guidelines for each transplant type. The published

guidelines are located at cignalifesource.com

. Critical components evaluated in the

RFI include, but are not limited to:

• Annual volumes of transplant procedures

• Patient survival

• Graft survival

• Transplant wait time

• Mortality on wait list

• Facility support

• Team stability

• Team training and experience

• Quality improvement program

• Protocols (patient selection, pre- and post-transplant management)

• Patient safety

• Communication systems

Guidelines for network inclusion

In addition to the RFI content, Cigna LifeSOURCE annually evaluates each

transplant program to determine continued compliance with established guidelines.

Facilities considered for the Cigna LifeSOURCE Transplant Network must be a Cigna

Healthcare -participating provider and maintain hospital accreditation (e.g., Joint

Commission of Hospital Accreditation or the National Integrated Accreditation for

Healthcare Organizations [NIAHO] by Det Norske Veritas [DNV] Healthcare).

The following accreditations must be met for each program prior to network

consideration:

• Centers for Medicare & Medicaid Service (CMS) solid organ program

certification: Hospital Conditions of Participation: Requirements for Approval and

Re-Approval of Transplant Centers to Perform Organ Transplants

• The Foundation for the Accreditation of Cellular Therapy (FACT) for all bone

marrow transplant programs, the National Marrow Donor Program (NMDP) as a

transplant center, and the Centers for International Blood and Marrow Research

Quality information

(CIBMTR).

• Listing at the Designated network level will also be dependent on a market

check to confirm the rates for each program are competitively priced relative to

equivalent programs in the region and/or market.

Solid organ program annual volume guidelines

The Cigna LifeSOURCE Transplant Network is a two-tiered network comprised of:

• Top tier network level transplant programs, Cigna LifeSOURCE Designated

network

• Second-tier level transplant programs, Cigna LifeSOURCE Supplemental

network

Designated level programs must have three years of risk-adjusted performance

data published in the Scientific Registry of Transplant Recipients (SRTR) and

continue to meet the annual program volumes in the table below.

Supplemental level programs must have one year of risk-adjusted performance

data published by the SRTR.

Solid organ annual Designated-level minimum volume guidelines

Transplant

program

Adult minimum volume Pediatric minimum volume

Heart 12 Average of five in the previous two years

Lung 12 Minimum of one in the previous two

years

Liver 12* Five

Kidney 30** Five

Intestinal Three

Minimum of three in the previous two

years

PTA/PAK/SPK**

Six – kidney program must

be approved

N/A

* Adult liver – 12 total combined deceased and living donors. Living liver programs must

demonstrate active, ongoing live donor transplants annually.

** Adult kidney – 30 total combined deceased and living donors. Kidney-only transplant

centers are considered on a case-by-case basis only.

*** Pancreas transplant alone (PTA), pancreas after kidney (PAK), simultaneous pancreas

kidney (SPK)

BMT/SCT program annual Designated level volume guidelines

• Adult programs must perform 50 total with at least 20 being allogeneic

• Pediatric programs must perform 15 total, combined autologous and

allogeneic

Quality information

Programs must meet the minimum volume requirements for two consecutive years

for Designated level consideration.

Performance guidelines for solid-organ programs

The following steps review the quality and performance of each transplant program

listed in the Cigna LifeSOURCE Transplant Network:

1. The most recent outcome and volume data from the SRTR and Organ

Procurement Transplant Network (OPTN) websites are used to determine if

the solid organ programs meet the Cigna LifeSOURCE transplant program

quality and performance guidelines.

The Cigna LifeSOURCE NPRC reviews program outcomes based on a

calculated Relative Performance Index (RPI). The RPI is consists of the

following statistical components: the waitlist transplant rate (getting a

deceased donor transplant faster), the pre-transplant mortality rate (adult

survival on waitlist), and the one-year graft survival and three-year graft

survival rates

• Pre-Transplant Mortality rate is defined as the number of patient deaths

that occurred while waiting for a transplant in a current year relative to

the national experience.

• Wait-list Transplant rate is defined as the number of patients on the

waitlist transplanted within a year relative to the national experience.

• Graft Failure Survival rate is a measure of actual transplant program

results compared with expected program results that are based on

modeling transplant outcomes from all programs in the United States.

These metrics create the program RPI. Programs in quintiles 2-5 of the RPI

will remain in the Designated network level.

2. Solid organ programs that fall into the lowest quintile of the RPI may move

to the Supplemental network level.

Performance guidelines for BMT/SCT programs

All adult and pediatric bone marrow/stem cell transplant programs must perform

both autologous and allogeneic programs for network consideration.

Designated

• Adult and pediatric programs must achieve FACT certification, hold NMDP

certification as a transplant center, and participate with the Center for

International Blood and Marrow Research (CIBMTR).

• Programs must be listed as “performing as predicted” (0) or

“overperforming” (+1) on the current CIBMTR Center Specific Survival

report. Designated network-level programs subsequently listed as

“underperforming” (–1) for ONE year will move to the Supplemental level.

• Demonstrate actual overpredicted survival ratios (actual/predicted) equal or

better than 0.90.

Quality information

Supplemental

• BMT/SCT adult and pediatric programs must achieve FACT and NMDP

transplant center certification, participate with the CIBMTR, and demonstrate

active program volumes each year.

• If programs move to the Supplemental level, they must achieve TWO

consecutive years of performing as predicted (0) or overperforming (1) to be

reinstated to the Designated level.

Additional network program requirements

• All new facility transplant programs approved for the Designated level must

agree to a site visit if a visit is requested.

• All network transplant programs must participate in the annual survey.

Programs that do not respond may be subject to administrative action under

the terms of their agreement with Cigna Healthcare. This may include

shifting the programs from the Designated to the Supplemental level.

• Solid organ transplant programs with live donor programs must continue to

demonstrate ongoing live donor transplants on a yearly basis to be included

as a live donor program.

• Designated and Supplemental-level programs must permit Cigna Healthcare

customers to multi-list.

• Programs that are at risk of losing accreditations or certifications will be

removed from the network program listings.

Ventricular assist device

Heart transplant programs must participate in the Cigna LifeSOURCE Transplant

Network for the ventricular assist device (VAD) program to be included. The VAD

program must obtain and maintain CMS certification for destination therapy and

hold accreditation by the Joint Commission or DNV Healthcare.

Chimeric Antigen Receptor T-Cell (CAR-T) Therapy Network

CAR-T programs considered for the network must be in conjunction with bone

marrow/stem cell transplant (BMT/SCT) programs in the Cigna LifeSOURCE

Transplant Network. CAR-T programs must obtain and maintain FACT accreditation

for both hematopoietic stem cell therapy and immune effector cell therapy.

For additional information on the network guidelines or RPI methodology, please

view the Network Inclusion Guidelines

(https://cignalifesource.com/assets/docs/cignalifesource/LifeSOURCEGuidelinesNet

workInclusion.pdf).

Communicating staff and program changes

A Cigna Healthcare quality director will ask annually if you have had any changes in

your transplant staff or operation of your transplant program. It is important that

you let us know when any changes happen. This is a requirement of most Cigna

LifeSOURCE contracts. Please email

LifeSOURCEProgramRequests@Cignahealthcare.com

with any personnel or program

status changes.

Quality information

Appeal information

If you are dissatisfied with our assessment of quality data (i.e., the RPI), please

submit an appeal in writing for reconsideration.

Cigna LifeSOURCE Transplant Network remains committed to continuing discussions

with the national transplant organizations and providers in the development of

network inclusion guideline updates. In addition, the network providers are

independent providers and are not employees or agents of Cigna Healthcare.

Case management

Purpose

The Transplant Case Management Unit includes utilization review and case

management services. It is designed to objectively monitor, evaluate, and

positively influence the provision and cost of medical care for customers referred for

transplant case management services in accordance with the terms of their benefit

plan.

Please call the Transplant Case Manager assigned to your patient prior to

providing any services.

Goals and objectives

The Transplant Case Management Unit’s goal is to effectively use available health

care resources to ensure and provide quality and appropriate care.

This is accomplished by:

• Consistently reviewing the medical necessity of procedures and treatments to

determine the appropriate level of care and setting in which the care will be

provided. This includes transplant-related and other non-transplant medical

services required by a transplant patient while their case is “open.”

• Providing and promoting access to appropriate and cost-efficient health care

services through appropriate referral to a Cigna LifeSOURCE facility,

providing customer education, and facilitating communication and developing

partnerships among customers, health care providers, and Cigna Healthcare

in an effort to enhance cooperation and appropriate use of health care

services.

• Managing all transplant participants, especially those who are considered at

risk of requiring extensive or ongoing health care services, or of developing

significant health care complications, and facilitating coordination and

continuity of care to assist providers in achieving optimal medical outcomes.

• Delivering our services in a customer service-focused platform. This includes

allowing reasonable access and timely communication of decisions made

during the transplant case management process.

• Providing services in compliance with requirements of regulatory and

accrediting bodies.

• Maintaining strict adherence to participant confidentiality.

• Partnering with the National Quality Review Council to identify and improve

transplant services, and provide effective monitoring and evaluation of

participant care and services.

• Promptly identifying and analyzing opportunities to improve service level,

and implementing action and follow up.

• Communicating quality of care concerns, as appropriate, to Cigna Healthcare

or Cigna LifeSOURCE medical director(s)

Managed services

The Transplant Case Management Unit manages services including, but not limited

to, the following:

• Solid organs

• Ventricular Assist Devices (VAD) and Total Artificial Hearts (TAH)

Case management

• Stem cell/bone marrow transplants

• Chimeric Antigen Receptor T-cell (CAR-T) Therapy

Please note that the Transplant Case Management Unit will not manage

participants who have Medicare as their primary insurance due to end-

stage renal disease or kidney transplant.

Contact information

General LifeSOURCE Case Management Transplant Unit contact information:

Telephone

Hours of operation:

8:00 a.m. to 6:00

p.m. ET

Monday through

Friday

800.668.9682

Prompts will direct the caller to the appropriate

confidential mailbox during non-operational hours.

Calls regarding urgent requests will be returned

within two hours. Other calls will be returned within

24 to 48 hours.

Note: All urgent requests require confirmation that

the physician responsible has specifically stated that

a determination is medically urgent.

Fax 877.598.2484

The Transplant Case Manager is your direct link to all prior authorizations for

transplant and non-transplant related services. Once your patient enters Transplant

Case Management, all services are handled by the assigned case manager for total

patient care.

Examples of when the case manager should be contacted include, but are not

limited to:

• Prior to the patient’s transplant consultation

• To obtain Zone 1 evaluation testing approval

• Prior to any movement between zones

• Prior to listing for the transplant

• Prior to any inpatient admission, whether transplant is related or not

• Prior to all specific tests, such as MRI, CT, and PET scans

• Prior to scheduling any home health care, durable medical equipment (DME),

and infusions (including intravenous immunoglobulin [IVIg])

• To obtain prior authorization per benefit plan specific requirements

Frequent contact with the assigned case manager is vital to ensuring that all care is

approved and authorized. If there is any question as to whether a service requires

prior authorization, the assigned case manager will be able to accurately advise

you. This partnership helps to provide the best care and coverage for our

customers.

Coverage positions, clinical resource tools, and criteria

When appropriate, the following guidelines are used for prior authorization,

concurrent and retrospective review of coverage for transplant-related services,

non-transplant services and procedures, inpatient admissions, and home care

services.

Case management

• Coverage positions are developed and maintained under the Cigna

Healthcare Clinical Review Unit (CRU) (medical management unit) under the

direction of Cigna LifeSOURCE Medical Director(s). These are developed,

maintained, and reviewed for all transplant procedures, including living

donors.

Cigna LifeSOURCE recognizes that transplant procedures are varied and

change as medicine advances. For up-to-date Cigna LifeSOURCE coverage

criteria for various transplant procedures, please register and log in to the

Cigna for Health Care Professionals website (CignaforHCP.co

m). Click on

Review coverage policies, go to View Documents under Medical

Administrative A-Z Index, and click on the procedure to find the appropriate

transplant criteria. Or, go to Medical and Administrative Categories >

Transplants.

• Milliman Care Guidelines for elective and emergent, inpatient, outpatient,

and home care services.

• Optimal Treatment Guidelines (OTG) for appropriateness of surgical

procedures and alternative diagnostic and treatment approaches.

• Tools to Administer Benefits (TABS) and Administrative Policies and

Procedures (APP).

Customer handbook

Cigna Healthcare customers who are identified as potential transplant patients will

receive a handbook, “By Your Side,” which includes extensive information on how

they can best use their benefits.

Patients can also request a handbook from their Transplant Case Manager.

Note: Cigna Healthcare Medicare Advantage customers (excluding Cigna Healthcare

Arizona Medicare Advantage) do not receive a customer handbook.

Referrals and appeals

Clinical coverage decisions and appeals

Prior authorization

While Cigna Healthcare has eliminated some prior authorization requirements, it

continues to deliver value for you and your patients in situations such as transplant.

Prior authorization is required for each zone and all zone movement.

• Consultations for transplant should be pre-approved even if not asking for

evaluation approval

• Should be used to facilitate agreement to zone dates

• Serves as point of entry to validate eligibility and coverage

• Precertification required for all IVIg, cardiac assist devices, clinical trials, and

donor searches (related and unrelated)

Please note that prior authorization is required for additional surgical

procedures performed on the same day as the transplant procedure, or in

the same admission as the transplant.

Authorization process

1. Call 800.668.9682 and follow the prompts to reach a transplant referral

analyst, or fax to 877.598.2824

2. An analyst assigns the case to a Transplant Case Manager and benefit

specialist

3. The Transplant Case Manager will contact you and inform you of the

customer’s basic transplant coverage

4. If transplant is recommended following evaluation, contact the Transplant

Case Manager with evaluation results including:

• Results of evaluation testing

• Letter recommending transplant event approval

Coverage determinations

Only a Cigna Healthcare Medical Director can deny authorization for clinically based

services. A customer, their authorized representative, or a health care provider has

the right to appeal a denial of coverage for services.

Appeals of coverage determinations

This process generally includes provisions for expedited appeals (where

appropriate), at least one level of internal appeal and, in many instances, an

external review conducted by an independent review organization. The appeals

process may be adjusted to comply with state and federal guidelines.

Clinical trial determinations

Participation in a clinical trial depends on the customer’s specific benefit plan

language and on legislative mandates. Please discuss with the Transplant Case

Manager as soon as you think a customer might be a candidate for a clinical trial

prior to signing them up for the trial.

Referrals and appeals

Transplant case management referral process

You must contact the Transplant Case Manager before providing any

services.

Use the editable Referral Form at CignaLifeSOURCE.com under Health Care

Providers.

Download the form, add the information requested, and fax to 877.598.2484, or

Call the Transplant Case Management Unit at 800.668.9682 (see below).

If you choose to call, please provide the Transplant Referral Analyst with the following:

•

Patient’s first name and last name, with spelling

•

Patient’s Cigna Healthcare ID number

•

Caller’s name and return telephone number

•

Transplant type requested and date of planned evaluation or procedure (if known)

Case is assigned to a Transplant Case Manager who will:

Work with a benefits specialist to verify the eligibility of the customer

Review coverage information

Contact the health care provider and facility

Contact the customer

Medical documentation checklists

Case managers in the Transplant Case Management Unit use transplant-specific

checklists to ensure all needed tests have been completed and submitted. To

perform the most complete review possible, Transplant Case Managers will typically

request the information in the checklists on the following pages. Please use these

checklists to assist us with managing your patient’s coverage. If a box has an X, we

ask that you provide the information for the corresponding transplant treatment.

Please include all documents that contain or refer to the information the physician

or hospital reviewed or relied upon in reaching the decision to transplant a patient.

Note that an authorization for coverage decision will NOT be made until these

records are received and reviewed.

Medical documentation necessary for referral for evaluation – obtain

from primary care provider (PCP) or specialty care provider ( SCP)

The following information should be requested of all participants:

1. Letter of medical necessity describing transplant procedure, or

2. Clinical data to support the request

Medical documentation checklists

Medical documentation checklist for adult transplants

Adult Transplant

Allogenic

stem

cell/bone

marrow

Autologous

stem

cell/bone

marrow

Chimeric

Antigen

Receptor T

-cell

(CAR

-T) Therapy

Heart or

heart/lung

Kidney

Liver, intestine,

or multi-visceral

Lung

Pancreas or

kidney/pancre

Cardiopulmonary

Chest X-ray or CT

X X X X X X X X

MRI or CT of thorax

Electrocardiogram (EKG)

X X X X X X X X

Echocardiography or cardiac catheterization

Echocardiography or other cardiac functional test

MUGA/CATH that evaluates EF and valvular status

X X X

Cardiac clearance if abnormal from physical exam or

history of heart failure or heart disease

X X

Pulmonary function testing: spirometry, volumes,

DLCO, and room air arterial blood gas (ABG)

Pulmonary ventilation/perfusion (VQ) scan or CT

angiogram: for heart/lung transplants if history of

deep vein thrombosis (DVT) or pulmonary

embolism, or evidence of pulmonary hypertension

on echocardiography or cardiac catheterization

Medical documentation checklists

Allogenic

stem

cell/bone

marrow

Autologous

stem

cell/bone

marrow

Chimeric

Antigen

Receptor

T-cell

(CAR

-T) Therapy

Heart or

heart/lung

Kidney

Liver, intestine,

or multi-visceral

Lung

Pancreas or

kidney/pancre

Labs

Complete blood count (CBC), chemistry panel, liver

profile, and renal profile

X X X X X X X X

Estimated glomerular filtration rate (GFR) or

creatinine clearance if not on dialysis

Estimated glomerular filtration rate (GFR) or

creatinine clearance if level is greater than 2.0

Hgb A1c

ABO blood type

X X X X X X X X

Human leukocyte antigen (HLA) typing

HIV status

X X X X X X X X

Hepatitis serologies

X X X X X X X X

C-peptide level

Medical documentation checklists

Allogenic

stem

cell/bone

marrow

Autologous

stem

cell/bone

marrow

Chimeric

Antigen

Receptor

T-cell

(CAR

-T) Therapy

Heart or

heart/lung

Kidney

Liver, intestine,

or multi-visceral

Lung

Pancreas or

kidney/pancre

Abdominal CT, MRI, or ultrasound

Cancer surveillance

Age 45 and older – age and condition appropriate

colon cancer screening (can include colonoscopy or

sigmoidoscopy or fecal occult blood test x3,

computed tomographic [CTC]/virtual colonoscopy,

stool-based deoxyribonucleic acid (DNA)

(Cologuard

)

Females age 21 and older – gynecological exam with

Pap smear within the past three years unless

absolute neutrophil count (ANC) < 1,000

Females age 50 and older – mammography within

the past three years

Other

requirements

Recent history and complete physical examination

(including rectal/pelvic, breast, and oral/dental,

unless contraindicated)

Psychosocial evaluation performed at the transplant

center

X X X X X X X X

Medical documentation checklists

Allogenic

stem

cell/bone

marrow

Autologous

stem

cell/bone

marrow

Chimeric

Antigen

Receptor

T-cell

(CAR

-T) Therapy

Heart or

heart/lung

Kidney

Liver, intestine,

or multi-visceral

Lung

Pancreas or

kidney/pancre

Documentation of candidacy approval by facility

selection committee

X X X X X

Model for End-stage Liver Disease (MELD) score

Dental clearance, if abnormal physical exam

PPD testing for tuberculosis with history of

exposure, past history or family history of

tuberculosis, or abnormal chest X-ray

Protocol or written transplant treatment plan

Additional testing or clearance required by the

transplant team to address any comorbidities not

included above

New York Heart Association Functional Class

Medical documentation checklists

Medical documentation checklist for pediatric transplants

Pediatric

Transplant

Allogenic stem

cell/bone

marrow

Autologous stem

cell/bone

marrow

Chimeric

Antigen

Receptor T

-cell

(CAR

T) Therapy

Heart or

heart/lung

Kidney

Liver,

intestine,

multi-visceral

Lung

Pancreas or

kidney/pancreas

Cardiopulmonary

Chest x-ray or CT X X X X X X X X

Electrocardiogram (EKG) X X X X X X X X

Echocardiography or cardiac catheterization

Echocardiography or other cardiac functional test

MUGA/ CATH that evaluates EF and valvular status

X X

Labs

Complete blood count (CBC), chemistry panel,

liver profile, and renal profile

X X X X X X X X

Hgb A1c

Estimated glomerular filtration rate (GFR) or

creatinine clearance if not on dialysis

Medical documentation checklists

Allogenic stem

cell/bone

marrow

Autologous stem

cell/bone

marrow

Chimeric

Antigen

Receptor T

-cell

(CAR

T) Therapy

Heart or

heart/lung

Kidney

Liver,

intestine,

multi-visceral

Lung

Pancreas or

kidney/pancreas

Estimated glomerular filtration rate (GFR) or

creatinine clearance if level is greater than 2.0

ABO blood type X X X X X X X X

Human leukocyte antigen HLA typing X

HIV status X X X X X X X X

Hepatitis serologies X X X X X X X X

Other

requirements

Recent history and complete physical examination

(including oral/dental component and

breast/rectal/pelvis examination as age and

condition appropriate)

Abdominal CT, MRI, or ultrasound

Psychosocial evaluation of caregivers performed at

the transplant center

X X X X X X X X

Documentation of candidacy approval by facility

selection committee

X X X X X

Medical documentation checklists

Allogenic stem

cell/bone

marrow

Autologous stem

cell/bone

marrow

Chimeric

Antigen

Receptor T

-cell

(CAR

T) Therapy

Heart or

heart/lung

Kidney

Liver,

intestine,

multi-visceral

Lung

Pancreas or

kidney/pancreas

Pediatric End-stage Liver Disease (PELD) score

Protocol or written transplant treatment plan X X X

PPD testing for tuberculosis with history of

exposure, past history, family history of

tuberculosis, or abnormal chest X-ray

Dental clearance, if abnormal physical exam X X X X X X X X

Additional testing or clearance required by the

transplant team to address any comorbidities not

included above

New York Heart Association Functional Class

Note: If a living donor is being considered for a patient, information required for review per UNOS and OPTN policies:

Verbal or written confirmation of: Psychosocial evaluation, completion of independent living donor advocate (ILDA),

donor medical evaluation (physical evaluation and lab work), and donor informed consent.

These checklists are a guide and are not absolute. Please contact your patient’s Transplant Case Manager if you have

questions or concerns. For more information please refer to our medical documentation

checklist.

Medicare eligibility

For end-stage renal disease (ESRD) and kidney transplants

• Does the patient have end-stage renal disease and is on dialysis?

• Will the patient be receiving a kidney transplant without having started

dialysis prior to the transplant?

If you answered yes to either of the above questions, the patient may be eligible for

Medicare Part A and Part B, regardless of age.

Follow up with the Transplant Case Manager to review the patient’s benefit plan for

coverage limitations that may apply when they are eligible for Medicare. The benefit

plan may assume enrollment in BOTH MEDICARE PART A&B and pay as

SECONDARY even if the patient is not enrolled in Medicare.

Follow up with the Transplant Case Manager to discuss the patient’s particular

benefit plan.

Claim submission

Submit claims to the following address:

Cigna LifeSOURCE SAMBA

PO Box 188007

Chattanooga, TN 37422

Claim submissions

We have several lines of business that account for the transplant referrals that

Cigna LifeSOURCE submits to your transplant programs. To ensure accurate and

timely claim processing and repricing, please follow these instructions.

• Submit claims to the correct address noted below.

• For questions about where to send a transplant claim for all business lines

noted below, please call 800.287.0539.

• Please do not submit claims electronically.

• Do not submit claims to the address on the customer’s ID card.

To check on the status of transplant claims, please call the applicable customer

service number below or send an email, if applicable, and provide the following

information:

1. Patient’s name

2. Patient’s ID number

3. Dates of service for claims in question

4. Billed charges amount

Cigna Healthcare customers

Cigna Healthcare, Cigna Global Health Benefits

, and Shared

Administration Repricing (Taft-Hartley) plans. Please refer to the

Network Access Client (NAC) section below regarding claim submission

for Strategic Alliance customers.

U.S. mail

Submit claims to:

Cigna LifeSOURCE Transplant Claims

PO Box 182203

Chattanooga, TN 37422

FedEx only

Submit claims to:

Cigna LifeSOURCE Transplant Claims

5810 Brainerd Road

Chattanooga, TN 37411

Customer service:

• Cigna Healthcare, Cigna Global Health Benefits, and Shared Administration

Repricing: 800.287.0539

SAMBA account

Claim submission

Cigna Healthcare Medicare Advantage Arizona customers

Submit claims to the following address:

Cigna Healthcare of Arizona, Inc.

PO Box 38639

Phoenix, AZ 85069

Customer service: 800.627.7534

Network Access Clients (NAC)

Including Cigna Payer Solutions and Strategic Alliance relationships (HealthPartners,

Priority Health or MVP HealthCare issued ID card)

Referral letters are typically sent to the transplant program financial coordinator

and the managed care office, identifying these individuals and instructing that

claims should be submitted to the following address.

Please do not submit claims to the Chattanooga address for these

individuals.

Submit claims to the appropriate address below.

Effective December 1, 2021

U.S. mail

Cigna LifeSOURCE NAC Transplant Claims

PO Box 6471

Indianapolis, IN 46206

FedEx only

Attn: Trevor Evans

Cigna LifeSOURCE NAC Transplant Claims

11595 N. Meridian Street, Suite 600

Carmel, IN 46032

Alternatively, you may email claims to NACClaims@evernorth.com.

If you have questions, please email LifeSourceNACInquiries@evernorth.co

m and

provide the information below:

1. Patient’s name

2. Patient’s date of birth

3. Patient’s ID number

4. Dates of service for claims in question

5. Billed charges amount

6. Provider’s name

Customer service: 800.287.0539

Claim submission

Email claims submissions

All LifeSOURCE claims (except Medicare) can now be emailed to

LifeSOURCETransplantClaims@Cignahealthcare.com

Send secure emails through your Cigna-established TLS connection. If you do not

have a TLS connection established, please send an email to

LifeSOURCETranspl[email protected]

to request one.

The following coversheet is required for every email submitted with claims.

Please follow this process for each email:

• One email per member. Each email should contain 2 or 3 separate

attachments/files.

• One attachment/file for claims. Start the file name with prefix “cl_” (you can

attach more than 1 claim per file, but there has to be at least 1 claim file

attached and it needs to be named with prefix “cl_”.)

• One attachment/file for the required coversheet. Start the file name with

prefix “cs_” (please make sure all the required information marked with an

asterisk is filled out on the coversheet).

• One attachment/file for itemization. Start the file name with prefix “it_”

(itemizations are required for zone 3).

Bundled billing

If the hospital and physicians are reimbursed under a single Zone 3 case rate, the

hospital must bill all hospital and physician claims for services rendered during the

transplant admission, or transplant period, as one packet with a cover sheet.

Interim bills for Zone 3 will be accepted as long as a cover sheet is included with

each submission. The Zone 3 case rate payment will be made on the first packet

submission. Contract terms and provisions will continue to apply to processing of

any subsequent Zone 3 claims. For BMT/SCTs, a global packet after each cell

infusion may be submitted, but the global packet must include all applicable claims

for that transplant period.

If the hospital and physician group have separate Zone 3 case rates, the hospital

and physician group must bundle bill their respective claims as outlined above.

Note: Shared Administration Repricing (SAR) and Network Access Clients (NACs)

will not process a global case rate zone payment unless all hospital and physician

claims are included in the packet, even if there are no inlier or outlier provisions

that would apply.

Claim submissions

Required claim documentation

• Zone Authorizations (Prior Authorizations) for each zone should be

included on the UB-04 claim form (box 63) and submitted on separate claim

forms for each zone.

• Multiple zones should not be billed on the same UB-04 claim form, unless

specifically identified otherwise in your contract. Typically, the charges for

each zone should be on a separate UB-04 claim form.

• Non-transplant-related care charges should be submitted on a separate

UB-04 claim form from the transplant-related care charges.

• Split years claims must either be submitted with separate UB-04 claim

forms for each year, or with an itemization that includes revenue codes and

dates of service for each charge.

• Itemized bills may be required to process your claim. It should always

include the revenue code and date of service for each charge.

• Donor claims should be billed under the recipient’s name and benefit plan

ID number and clearly marked as a donor claim. The donor’s name can be

included as a remark and the donor’s authorization number should be

included on the claim.

Once a patient enters Transplant Case Management, all claims for that patient are

handled by our dedicated transplant claims teams – including non-transplant-

related services. This dedicated claims service continues for one-year post-

transplant to ensure that all related claims are reimbursed accurately.

Dispute resolution

Payment appeal process

Payment disputes should be submitted to the Cigna National Appeals Organization.

All appeals must be initiated in writing within 180 calendar days of the date of the

initial payment or denial decision. If the appeal relates to a payment that Cigna

Healthcare adjusted, the appeal must be initiated within 180 calendar days from

the date of the last payment adjustment.

The appeal process aims to resolve contractual disputes about post-service

payment denials (or partial denials) and other payment disputes. If the issue is not

resolved to the provider’s satisfaction, a dispute resolution may be requested,

including arbitration, as the final resolution step.

For additional information on how to submit an appeal, review and follow the claim

adjustment and appeals guidelines on the Cigna for Health Care Professionals

website (CignaforHCP.com). For Claim Appeals Policies and Procedures: Cigna

HealthCare Appeal Policy and Procedures.

Please contact the patient’s Transplant Case Manager or the customer service

number on the back of the patient’s ID card for further assistance.

Arbitration of disputes

If the dispute is not resolved through the appeal processes described above, either

party can initiate arbitration by providing written notice to the other. Please see

facility’s contract for specifics. The appeal processes must be followed in its entirety

before initiating arbitration.

Note: The terms and conditions of the arbitration provision in the provider contract

apply.

If the parties are unable to agree upon an arbitrator within 30 days after one of the

parties has notified the other of the desire to submit a dispute for arbitration, then

the parties will prepare a Request for a Dispute Resolution List and submit it to the

American Health Lawyers Association Alternative Dispute Resolution Service (AHLA

ADR Service), along with the appropriate administration fee.

If a hospital fails to request an appeal or arbitration for a payment dispute within

the applicable time frames, the last determination from Cigna Healthcare regarding

the dispute shall be binding on the hospital. Customers cannot be billed for

payments that are denied if the hospital failed to submit the request for review or

arbitration within the required time frames.

For more information on how to appeal a denial, please contact the patient’s

Transplant Case Manager.

Travel benefit

Cigna Healthcare offers a transplant travel benefit to eligible participants up to

$10,000 when they choose a Cigna LifeSOURCE Designated Program.

This benefit covers eligible transportation and lodging for the transplant recipient

and one caregiver (up to two caregivers for a dependent minor) when traveling to

and from their home and the Cigna LifeSOURCE transplant facility. The recipient

must participate in the Transplant Case Management Program to be eligible for this

benefit.

The travel program is available only when Cigna Healthcare has authorized

coverage for a transplant at a Cigna LifeSOURCE Transplant Network facility that is

Designated for the specific transplant being requested, and when the facility is

located more than 60 miles (one-way) from the recipient’s home. The customer

must receive approval from their case manager to use this benefit. This benefit may

not be the same for all customers.

Air ambulance transport

Cigna Healthcare has contracted with several air ambulance companies

at competitive rates.

Please work with the Cigna LifeSOURCE Case Manager to contact a

contracted air ambulance provider when appropriate and medically

necessary. If an urgent situation arises after business hours, please

contact the Health Information Line at 800.856.9286 to arrange for

these services.

Air ambulance transport

Air ambulance transport is covered when medically necessary only if:

• The individual’s medical condition is such that transportation by basic or

advanced life support is required and ground ambulance is not clinically

appropriate due to the medical condition, or

• ground ambulance transportation is not available or feasible.

Important points to note:

1. Coverage for air ambulance transport is limited to the closest appropriate

Cigna LifeSOURCE Transplant Network Center.

2. All air ambulance transport, if covered, for a transplant event or related

service is a core medical benefit and is not eligible for reimbursement under

the Transplant Travel Benefit. The standard air ambulance benefit applies.

3. Air ambulance transport provided solely for the convenience of the individual

is not a covered benefit. Air ambulance is considered a convenience for an

individual who chooses to remain outside a reasonable driving distance from

the transplant facility while on the waiting list. An individual is expected to

remain within a reasonable driving distance from the transplant facility to

allow safe transport to the transplant facility within the time frame specified

by the facility when an organ becomes available for transplantation.

Network Access Clients

Cigna LifeSOURCE NAC Transplant Claims

PO Box 6471

Indianapolis, IN 46206

Network Access Clients

Network Access Clients (NACs) contract with us specifically to access the Cigna

LifeSOURCE Transplant Network for their payers needing transplantation benefit

management and support. These clients do not have benefit plans for which Cigna

is the claims administrator, including Cigna Payer Solutions. Cigna currently has

this arrangement with approximately 400 different payors.

Referral process

The customer initiates the referral process by filling out an online referral form and

forwarding it to Cigna LifeSOURCE. One of our Transplant Care Coordinators (TCC)

will review the referral form to ensure that the benefits are adequate and that the

form is complete. The TCC will then forward a referral letter via fax, unless an email

is requested, to the appropriate contacts at your organization – typically the

financial coordinator at the transplant program and the managed care office. A

sample referral letter is included on page 37.

The TCC will follow up on a regular basis with the transplant program and the

payer’s case manager to check on the status of the case – whether the patient

continues to be a candidate for transplant – to confirm zone dates and the date that

the case is closed. This helps to keep all parties informed and ensures that

everyone is in agreement on the status of the customer, whether pre-transplant

admissions are transplant related or not, and to ensure accuracy in repricing of

claims.

Claim process

A dedicated post office box has been set up for the NAC claims. Each referral letter

will note this address to ensure that you submit NAC claims to the correct address:

Please note that this is a separate mailing address for NAC claims for each referral.

If NAC claims are mailed to the Cigna LifeSOURCE address for Cigna customers,

they will most likely be denied and returned to your billing department.

A dedicated Cigna LifeSOURCE claims representative reprices claims and the

average turnaround time is five business days. The payer is instructed to pay within

30 days of the date the claim is received and repriced, and a specific due date is

provided on the claims cover sheet. The claims and claims cover sheet are sent to

the appropriate payer for processing. If there are any questions or concerns about

an amount that the payer has paid on a particular claim (or batch of claims) or if

there is nonpayment of a claim, please contact the NAC claims team. (Refer to the

contact information and sample claims cover sheet on pages 29 and 30.)

Cigna LifeSOURCE will reprice claims for all four zones. At the time we find out that

a case is ready to be closed under the terms of our agreement, we will fax a letter,

Network Access Clients

unless an email is requested, stating that Cigna LifeSOURCE is preparing to close

the case, provide the case closure date, and request final submission of claims.

For questions concerning referrals, please contact Sarah Shafer at 860.902.9604,

or Sarah.Shafer@evernorth.com

Network Access Clients

Today’s date January 31, 2022

Transplant Facility University Hospital

Transplant Type

Liver

Sample referral letter

Cigna LifeSOURCE Transplant Network Referral Notification

This notification is NOT an authorization for services.

Please contact the case manager below for authorizations.

ALL questions regarding benefits and eligibility MUST be

directed to the payor listed below.

Please use the number provided on the

member's insurance ID card when submitting

claims.

Please do NOT use the member's social

security number as the member's ID number.

Claims should be submitted to:

Cigna LifeSOURCE NAC Claims

PO Box 6471

Indianapolis, IN 46206

Claims sent via FedEx ONLY should be submitted to:

Cigna LifeSOURCE NAC Claims

11595 N. Meridian Street, Suite 600

Carmel, IN 46032

Claims can also be submitted via email to NACClaims@evernorth.com

Please do not submit the claims to the Cigna LifeSOURCE address in Chattanooga as they will be denied due to member not being a Cigna Healthcare

member.

Claims will be repriced and forwarded to Payor within 5 business days of receipt by Cigna Healthcare.

Please allow 45 days for processing of the claim before contacting the Payor at the phone number provided above.

If you have not received resolution after contacting the payor, please email the claims repricing team at

LifeSourceNACInquiries@evernorth.com Please provid

e the name of the person you contacted, the date and time you contacted them, and the

information you were provided.

The above-named Payor has signed a direct Service Agreement with Cigna Healthcare for access to the Cigna LifeSOURCE Participation Agreement between

Cigna Health Corporation, Inc. and the above named Facility for the above-named Patient. The Service Agreement provides the following terms:

•

Payor is responsible for verifying Patient’s benefits and eligibility for transplant services. Payor is not responsible for covering transplant services that it has

not authorized. Any dispute about coverage is solely between the patient and the Payor.

•

The Payor will pay for the transplant services and supplies that are covered under the Patient’s benefit contract and provided by the Hospital and Group

pursuant to Hospital and Group’s Participation Agreement with Cigna LifeSOURCE. The Service Agreement creates direct obligations of Payor to Hospital

and Group, and if Payor fails to perform its obligation to Hospital or Group, Hospital and Group will have a direct cause of action against Payor.

•

The Payor agrees to have the claim processed promptly so that payment is received by the applicable provider within 30 calendar days of receipt of claims

by the designated payor designee, and in accordance to required criteria of a "clean" claim (a "clean" claim is completed in compliance with UB92 and HCFA

1500 requirements or its successors and includes a claims coversheet from Cigna LifeSOURCE Transplant Network.) Prompt payment state laws will

apply.

•

The Payor will reimburse Hospital per the terms of the Cigna LifeSOURCE Transplant Network agreement between Hospital and Cigna Healthcare for all

hospital and professional transplant related services for zones 1 – 4. All exclusions and terms of the Cigna LifeSOURCE agreement apply.

Transplant Care Coordinator Name:

Mary Smith, RN

Telephone Number:

999-999-9999

Fax Number:

777-777-7777

Email Address:

Mary.Smith@company.com

Claims are to be submitted directly to Cigna

LifeSOURCE Transplant Network.

Claims submitted directly to the payor will be

denied.

All claims beginning with the referral effective

date are to be submitted directly to Cigna

LifeSOURCE Transplant Network.

Claims repricing will begin on the first date of

the evaluation.

Member Name John Smith

Policy Number 12345678

Date of Birth

1/1/1960

Referral Date

1/31/2022

Evaluation Start Date 2/2/2022

Member Accessing Non-Transplant Related Rates

Yes

Medicare Advantage Member? Yes

Payor ABC Health Plan

Employer Group XYZ Corporation

Case Manager Name Sue Smith

Case Manager’s Phone Number 222-333-4444

Utilization Review Nurse's Name John Jones

Utilization Review Nurse's Phone Number 222-333-5555

Payor's Customer Service Phone Number

222-333-6666

Pharmacy, infusion services, and behavioral health services

• Call 800.351.3606, option 101 to speak with a specialist

• Send a fax to 800.351.3616

Pharmacy, infusion services, and behavioral health

services

Express Scripts

Express Scripts Pharmacy

, a Cigna Healthcare company, is our home delivery

pharmacy. We deliver specialized care that puts patients first, through a smarter

approach to pharmacy services. Express Scripts makes prescription medications

safer and more affordable for customers.

Express Scripts provides the following for initial discharge orders post-transplant:

• Prescription-only medications associated with transplants

• Some transplant-related over the counter (OTC) medication

• Diabetic supplies, blood pressure, and cholesterol medications

• Express Scripts can bill Cigna Healthcare directly for the medications. They

can also bill Medicare as either a primary or secondary payer for covered

immunosuppressive medications for eligible customers

• 90-day supplies available

• Free, overnight shipping directly to hospital or patient

How to submit an order

Accredo

Accredo, a Cigna Healthcare company, is the national preferred source for specialty

medications, and is in the pharmacy network for many of your patients with Cigna

Healthcare-administered plans. By using an in-network pharmacy, your patients

with Cigna Healthcare coverage will be able to take full advantage of their specialty

drug coverage options.

Through Accredo, you and your patients have access to a team of pharmacists and

nurses with extensive training and experience. You will be able to obtain specialty

products, including many limited distribution drugs (LDDs) or those with exclusive

distribution, and your eligible patients will be able to obtain financial assistance

coordination.

Information on Accredo as well as medication-specific order forms can be found on

Accredo.com > Prescribers >

Referral Form

Contact Accredo for specialty medication prescriptions and renewals at

800.294.6012.

Coram

CVS Specialty

infusion services (Coram)

Coram, a CVS Health company, is a leading provider of specialty infusion and

enteral nutrition services nationally, and acute infusion services in many markets.

Their experienced clinicians coordinate care and education for patients and help

ensure a smooth transition home. They are dedicated to increasing access to

quality care for patients, while delivering excellent outcomes and lowering health

Pharmacy, infusion services, and behavioral health services

care costs. With more than 35 years of experience, they are the only national home

infusion provider accredited by The Joint Commission.

As a preferred infusion provider for Cigna LifeSOURCE Transplant Network, Coram

delivers high-quality, personalized care to your transplant patients in their home or

alternate-care setting. They provide comprehensive pre- and post-transplant

therapies, including:

• Anti-infectives (antibiotics, antivirals, antifungals)

• Enteral nutrition (tube feeding)

• Immunoglobulins (intravenous and subcutaneous)

• Immunosuppressive

• Parenteral nutrition

• Inotropes (cardiology)

Call 800.423.1411 or the appropriate number listed below to make a referral.

Coram accepts referrals seven days a week.

• Infusion services for specialty medications, including immunoglobulins

Telephone: 866.899.1661

Fax: 866.843.3221

• Enteral nutrition services

Telephone: 877.936.6874

Fax: 800.693.7322 or 866.202.7319

• Acute infusion services, including infused antibiotics, parenteral nutrition, and

inotropes

Telephone: 800.423.1411

Fax: 949.639.5606

Evernorth Behavioral Health

Cigna LifeSOURCE customers may have access to behavioral health coverage. The

psychological impact of serious illness often requires treatment. Many of your

patients have access to benefits including crisis counseling by phone, one-on-one

counseling, inpatient psychiatric counseling, and more.

Remember, for the entire time your patient is in Transplant Case Management

through Cigna LifeSOURCE, they must still work with their Transplant Case Manager

for behavioral health coverage. The case manager will work with Evernorth

Behavioral Health.

Your patient must confirm their behavioral health coverage through their Transplant

Case Manager. For more information about behavioral health benefits and eligibility,

please visit the Evernorth provider website (Provider.Evernorth.com

) or call

Behavioral Provider Services at 800.926.2273.

Important contact information

Below you will find Cigna LifeSOURCE Unit important contacts. Cigna LifeSOURCE

Unit hours of operation are from 8:00 a.m. to 5:00 p.m. EST.

Important contacts

Contact Position Telephone Email

Dr. Stephen

Crawford

Medical

Director

770.261.3485 Stephen.Crawford@CignaHealthcare.co

Dr. Janet

Campion

Medical

Director

Janet.Campion@CignaHealthcare.com

Dr. Maryann

Payne

Medical

Director

Maryann.Payne@CignaHealthcare.com

Dr. Jeff

Schriber

Medical

Director

480.244.2142

Jeff.Schriber@CignaHealthcare.co

Adriana

Mariani

National

Quality

Director

860.902.2973

[email protected]m

Arianna

Graves

LifeSOURCE

Provider

Relations

770.261.7899

Arianna.Graves@CignaHealthcare.com

Sarah Shafer

Network

Access

Clients

Transplant

Care

Coordinator

Supervisor

860.902.9604

Sarah.Shafer@evernorth.com

Other important contacts

Contact Telephone

Cigna LifeSOURCE Transplant Case

Management and Referral Line

800.668.9682

Cigna LifeSOURCE Customer Service* 800.287.0539

*Please see claims submission page for additional customer service contact

information.

Legal statement

All Cigna Healthcare products and services are provided exclusively by or through

operating subsidiaries of The Cigna Group, including Cigna Health and Life

Insurance Company (CHLIC), Connecticut General Life Insurance Company,

Evernorth Behavioral Health, Inc., Evernorth Care Solutions, Inc., Express Scripts,

Inc., or their affiliates.