Cigna 2008 Annual Report Download - page 26

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containment; health advocacy; 24-hour help line; case management; disease management; pharmacy benefit management; behavioral
health care management services (through its provider networks); or any combination of the services. The employer/plan sponsor is
responsible for self-funding all claims, but may purchase stop-loss insurance from CIGNA HealthCare or other insurers for claims in
excess of a predetermined amount, for either individuals (“specific”), the entire group (“aggregate”), or both.
In 2008, CIGNA purchased Great-West Healthcare, the healthcare division of Great-West Life & Annuity Insurance Company
(“Great-West”). Great-West Healthcare has historically offered similar products and services through similar funding arrangements,
although Great-West Healthcare focused on smaller customers, and as a result, a substantially higher portion of the claims in their
book of business are covered by some type of stop-loss arrangement.
Financial information, including premiums and fees is presented in the Health Care section of the MD&A beginning on page 54
and Note 21 to CIGNA’s Consolidated Financial Statements beginning on page 130.
Service and Quality
CIGNA HealthCare operates eleven service centers that together processed approximately 122 million medical claims in 2008.
Satisfying customers and members is a primary business objective and critical to the Company’s success. To address a variety of
member issues, CIGNA HealthCare offers members access to its grievance and appeals processes. CIGNA operates six member
service centers that members can call toll-free to address requests for information and complaints and grievances. CIGNA HealthCare
customer service representatives are empowered to immediately resolve a wide range of issues to help members obtain the most from
their benefit plan. In many cases, a customer service representative can resolve the member’s issue. If an issue cannot be resolved
informally, CIGNA HealthCare has a formal appeals process 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 members are offered the option of a voluntary
external review of claims. The CIGNA HealthCare formal appeals process addresses member inquiries and appeals concerning initial
coverage determinations based on medical necessity and other benefits/coverage determinations. CIGNA HealthCare’s formal
appeals process meets National Committee for Quality Assurance (“NCQA”), Employee Retirement Income Security Act (“ERISA”),
Utilization Review Accreditation Commission (“URAC”) and/or applicable state regulatory requirements.
CIGNA HealthCare’s commitment to promoting quality care and service to its members is reflected in a variety of activities
including: the credentialing of medical providers and facilities that participate in CIGNA HealthCare’s Managed Care and PPO
networks; the development of the CIGNA Care® specialist physician designation described below, and participation in initiatives that
provide information to members to enable educated health care decision-making.
Participating Provider Network. CIGNA HealthCare has an extensive national network of participating health care providers,
which as of December 31, 2008 consisted of approximately 5,200 hospitals and approximately 573,000 providers as well as other
facilities, pharmacies and vendors of health care services and supplies (these hospital and provider counts exclude the impact of the
Great-West Healthcare acquisition). As part of the purchase of Great-West Healthcare, CIGNA acquired the participating provider
network of Great-West Healthcare. In many cases, the providers in the Great-West Healthcare network were already in the CIGNA
HealthCare participating provider network, however, the acquisition has expanded and strengthened CIGNA HealthCare’s network in
some regions of the country. CIGNA HealthCare is in the process of consolidating the network it acquired from Great-West with its
existing participating provider network. As of December 31, 2007, CIGNA HealthCare’s national network of participating health care
providers consisted of approximately 5,100 hospitals and approximately 542,000 providers.
In most instances, CIGNA HealthCare contracts directly with the participating provider to provide covered services to members at
agreed-upon rates of reimbursement. In some instances, however, CIGNA HealthCare companies contract with third parties for
access to their provider networks. 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 Care®. CIGNA Care is a benefit design option available for CIGNA HealthCare administered plans in 57 service areas
across the country. CIGNA Care is a subset of participating physicians in certain specialties who are designated as CIGNA Care
physicians based on specific clinical quality and cost-efficiency selection criteria. Members 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.