Cigna 2010 Annual Report Download - page 28

CIGNA CORPORATION  2010 Form 10K
8
PARTI
ITEM 1 Business
that can be initiated by telephone or in writing and involves two
levels of internal review. For those matters not resolved by internal
reviews, CIGNA HealthCare customers are off ered the option of a
voluntary external review of claims.  e CIGNA HealthCare formal
appeals process addresses member inquiries and appeals concerning
initial coverage determinations based on medical necessity and other
benefi ts/coverage determinations. CIGNA HealthCare’s formal
appeals process meets National Committee for Quality Assurance
(“NCQA”), Employee Retirement Income Security Act of 1974
(“ERISA”), Utilization Review Accreditation Commission (“URAC”)
and/or applicable state regulatory requirements.
Quality Medical Care
CIGNA HealthCare’s commitment to promoting quality medical
care to its customers is refl ected in a variety of activities including:
credentialing medical health care professionals and facilities that
participate in CIGNA HealthCare’s managed care and PPO networks
as well as developing the CIGNA CareSM specialist physician
designation described below.
Participating Provider Network
CIGNA HealthCare has an extensive national network of participating
health care professionals which, as of December 31, 2010, consisted
of approximately 5,500 hospitals and approximately 640,800 health
care professionals as well as other facilities, pharmacies and vendors
of health care services and supplies.
In most instances, CIGNA HealthCare contracts directly with
the participating hospital, health care professional or other facility
to provide covered services to customers at agreed-upon rates of
reimbursement. In some instances, however, CIGNA HealthCare
companies contract with third parties for access to their provider
networks and care management services. In addition, CIGNA
HealthCare has entered into strategic alliances with several regional
managed care organizations (Tufts Health Plan, HealthPartners, Inc.,
Health Alliance Plan, and MVP Health Plan) to gain access to their
provider networks and discounts.
CIGNA Medical Group
CIGNA Medical Group (CMG) is the multi-specialty medical group
practice division of CIGNA HealthCare of Arizona, Inc. which delivers
primary care and certain specialty care services through 32 medical
facilities and approximately 225 employed clinicians in the Phoenix,
Arizona metropolitan area. Eighteen of CMG’s multi-specialty health
care centers and their affi liated primary care physicians have received
the top level (level 3) of Patient Centered Medical Homes (PCMH)
accreditation from NCQA. CMG currently holds the highest level of
this accreditation for the greatest number of practices and physicians
in the state of Arizona.
CIGNA Care
SM
CIGNA Care is a benefi t design option available for CIGNA
HealthCare administered plans in 64 service areas across the
country. CIGNA Care designated physicians are a subset of
participating physicians in certain specialties who are designated as
CIGNA Care physicians based on specifi c clinical quality and cost-
effi ciency selection criteria. Customers pay reduced co-payments or
co-insurance when they receive care from a specialist designated as a
CIGNA Care provider. CIGNA participating specialists are evaluated
annually for the CIGNA Care designation.
Provider Credentialing
CIGNA HealthCare credentials physicians, hospitals and other health
care professionals in its participating provider networks using quality
criteria which meet or exceed the standards of external accreditation
or state regulatory agencies, or both. Typically, most health care
professionals are re-credentialed every three years.
External Validation
CIGNA continues to demonstrate its commitment to quality and
has expanded its scope of external validation of its quality programs
through nationally recognized accreditation organizations. Each
of CIGNA’s 23 HMO and POS plans that have undergone an
accreditation review has earned Excellent or Commendable status
from the NCQA, a private, nonprofi t organization dedicated to
improving health care quality. In addition, CIGNA’s provider
transparency, wellness, utilization management, case management
and demand management programs have been awarded the highest
outcomes possible. From NCQA, CIGNA earned Physician &
Hospital Quality Certifi cation and Wellness and Health Promotion
Accreditation. From URAC, an independent, nonprofi t health care
accrediting organization dedicated to promoting health care quality
through accreditation, certifi cation and commendation, CIGNA has
full accreditation for Health Utilization Management.
HEDIS® Measures
In addition, CIGNA HealthCare participates in NCQA’s Health Plan
Employer Data and Information Set (“HEDIS®”) Quality Compass
Report. HEDIS® Eff ectiveness of Care measures are a standard set
of metrics to evaluate the eff ectiveness of managed care clinical
programs. CIGNA HealthCare’s national results compare favorably
to industry averages.
Accountable Care Organizations
CIGNA has collaborated with a number of Accountable Care
organizations in 2010, and expects to continue to expand these
arrangements.  e overall objective of these organizations is to
improve the quality of care and service experience for individuals
while lowering costs and improving the overall value for our
customers.  e goal in collaborating with an Accountable Care
organization is to identify health care delivery organizations (medical
groups and hospital organizations) that can coordinate end-to-end
care for a defi ned population of patients.
Markets and Distribution
CIGNA HealthCare off ers products in the following markets:
•national accounts, which are multi-site employers generally with
more than 5,000 employees;
•middle market, which is generally defi ned as multi-site employers
with more than 250 but fewer than 5,000 employees, and single-
site employers with more than 250 employees;