Cigna 2009 Annual Report Download - page 28

8
Service and Quality
CIGNA HealthCare operates 11 service centers that together processed approximately 122 million medical claims in 2009.
Satisfying customers and members is a primary business objective and critical to the Company’s success. To further this objective, in
2009, the Company made its call centers available 24 hours a day, seven days a week. As of December 31, 2009, CIGNA operates six
member service centers that members can call toll-free about their healthcare benefits, wellness programs and claims. CIGNA
HealthCare customer service representatives are empowered to immediately resolve a wide range of issues to help members obtain the
most from their benefit plans. In addition, a customer service representative can resolve a 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 of 1974 (“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: credentialing medical providers and facilities that participate in CIGNA HealthCare’s managed care and PPO networks;
developing the CIGNA CareSM specialist physician designation described below; and participating 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, 2009, consisted of approximately 5,400 hospitals and approximately 612,000 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 continues to consolidate the network it acquired from Great-West Healthcare with
its existing participating provider network.
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 CareSM. 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.
Provider Credentialing. CIGNA HealthCare credentials physicians, hospitals and other health care providers 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 providers are re-credentialed every three years.
Health Plan Credentialing. 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, nonprofit
organization dedicated to improving health care quality. CIGNA's PPO and Open Access Plus plans in all 50 states have full
accreditation status from NCQA. In addition to achieving outstanding accreditation outcomes for its HMO, POS, PPO and OAP
products, 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 Certification and
Wellness and Health Promotion Accreditation. From URAC, an independent, nonprofit health care accrediting organization dedicated
to promoting health care quality through accreditation, certification and commendation, CIGNA has full accreditation for Health
Utilization Management, Case Management and Health Call Centers.