Individual Medical Practitioners Terms and Conditions

The CIGNA fee schedule is set out as follows:

Code / Description / Surgeon's fee / Anaesthetist’s fee / Hospital category

Each procedure has been given a procedure code. When completing a claim or submitting an invoice for a CIGNA patient, please include the procedure code as well as a description of the treatment. This will avoid any ambiguity about which procedures were performed and enable CIGNA to ensure accurate and prompt processing of the information.

If there is not a code in the Schedule for a procedure, it may still be eligible for CIGNA funding. Please contact us at authorisation@cigna.com and 01475 492145.

Each procedure code has a maximum figure up to which a surgeon or anaesthetist can charge their fees.

In particularly complicated cases or unusual circumstances, CIGNA is prepared to consider an enhanced fee. In these instances please contact us at authorisation@cigna.com and 01475 492145 to discuss the individual case.

For complexity category purposes, procedures are classified into the following 25 categories:

Minor 1, Minor 2, Minor 3, Minor 4, Minor 5

Inter 1, Inter 2, Inter 3, Inter 4, Inter 5

Major 1, Major 2, Major 3, Major 4, Major 5

Major+ 1, Major+ 2, Major+ 3, Major+ 4, Major+ 5

CMO 1, CMO 2, CMO 3, CMO 4, CMO 5

A consultation is defined as: A meeting between a patient and their consultant to evaluate the nature and progress of a condition (disease, illness or injury) and to establish a diagnosis, prognosis and treatment plan. It is intended to reimburse you for the management of that patient’s treatment in between consultations and includes any writing of prescriptions, reports and advice to other medical professionals in relation to that patient’s care. A consultation should be carried out on a face-to-face basis where possible. However, CIGNA will cover telephone or video call consultations where clinically appropriate and in place of a face to face consultation.

Consultation fees are inclusive of any room charges. This means that CIGNA does not cover any additional fees for the use or hire of consultation rooms.

Fees for Consultations

CIGNA’s guideline fees for consultations are up to the following amounts:

*Consultant Paediatricians, Oncologists, Neurologists and Cardiologists if the initial consultation is over 40 minutes

It is important to note that, in order to support both its Members and Providers during the pandemic, Cigna has decided to reimburse remote consultations at the same level as face to face; subject to clinical appropriateness. However, this may be reviewed in the future and you should regularly check this website for updates.

Consultations and procedures

CIGNA will cover eligible procedures carried out on the same day as an initial consultation. However, CIGNA will not cover follow-up consultations carried out on the same day as planned procedures. The procedure fee includes all component parts of that procedure including pre-operative assessment, the procedure itself and all routine aftercare, such as in-patient follow-up consultations and out-patient consultations on the same day.

If a patient needs to be admitted the day before surgery, please contact us at authorisation@cigna.com and 01475 492145 to provide details of early admission, please note that most policies do not cover admissions prior to the day of any planned surgery. 

In-patient care and consultations

Following surgery, the cost of routine in-patient and day care is already included in the surgical and anaesthesia fees.

CIGNA will cover an initial in-patient consultation where a patient is transferred from an emergency admission to a private consultant’s care or when another consultant, of a different speciality, needs to review a patient, provided that the members’ policy covers the care needed. CIGNA will not cover an admission directly into intensive care.

If the patient is an NHS hospital in-patient and would like to transfer their stay to a private facility, CIGNA require the consultant who is accepting them to provide information so we can check whether the care is covered before they transfer to a private facility. In these instances, please contact us at authorisation@cigna.com and 01475 492145

Without being provided with the relevant information about the patient’s condition and proposed treatment, we’ll be unable to confirm whether the care is covered. If the patient is transferred without confirmation from us, we may not be able to cover the care and the patient may be liable for the cost. 

When a patient needs to stay in hospital longer than the average length of stay for that particular procedure, we can consider requests to extend cover for that stay; only when a valid clinical explanation for delaying their discharge is provided. In these instances, please contact us at authorisation@cigna.com and 01475 492145 to authorise extended length of stays.

Anaesthetist consultations

There are occasions when CIGNA may consider covering a consultation with an anaesthetist prior to admission for surgery. For example, when the patient presents with co-morbidities which affect at least one of the following;

• the choice of general or regional anaesthesia;
• the anaesthetic techniques for the procedure (i.e. induced hypotension);
• the decision to proceed with surgery.

In these instances, anaesthetists should contact CIGNA at authorisation@cigna.com and 01475 492145 to pre-authorise the consultation. Consultations that have not been pre authorised may not be covered. .

CIGNA will not cover charges for being on-call or when you invoice on behalf of another clinician that has visited the patient.

Claims for in-patient care that is NOT routine post-operative care, and has been pre-authorised with Cigna, should be made using code 20320 up to a maximum fee of £60 per day.

Surgery

The surgery fees shown for a procedure encompasses all pre- and post-operative care associated with in-patient or day-case surgery and includes the management of all common complications related to each condition.

These include, but are not restricted to:

• Bleeding
• Suction
• Uncomplicated sepsis
• IV fluids
• Catheterisation
• Removal of sutures
• Local anaesthesia (please see below)

Anaesthesia

Anaesthesia fees include;
(a) Routine pre-operative assessment and informed consent, including financial consent and information about fees and charges
(b) Induction, maintenance of anaesthesia and all support activities, including monitoring, before, during and after surgery
(c) Pain control throughout the hospital stay
(d) Post-operative care including 72 hours intensive therapy

The same anaesthetic category applies; irrespective of the technique (general anaesthesia, sedation, regional anaesthesia) or combination of techniques, including monitoring, used by an anaesthetist.

Regional anaesthesia/IV sedation administered by the operator

CIGNA will pay a separate fee for IV sedation and IV regional anaesthesia (subject to multiple procedures rules) to recognise that they are more complex than topical and infiltrative anaesthesia, and often require additional support to set up and administer. 

The following codes should be used for the administration of IV sedation and IV regional anaesthesia;

X3510 - IV sedation administered by operator
25040 - IV regional anaesthesia (i.e. Bier’s Block) administered by operator

Local Anaesthetic

AC100, and X3800 cannot be claimed for as the reimbursement of administration of local anaesthetic is included in the main procedure

Epidural analgesia

When an epidural is administered in addition to general anaesthesia or within 24 hours either side of the operation, CIGNA's multiple procedure policy applies

Missing codes

If the code for the procedure performed is not listed on the CIGNA fee schedule, then please contact us at authorisation@cigna.com and 01475 492145.

For surgery and anaesthesia
When clearly separate procedures have been performed on the same member, on the same day, in the same setting, CIGNA fees are calculated in the following way:

1 procedure = 100% reimbursement up to the CIGNA fee limit for this procedure
2 procedures = 100% of the primary procedure +25% of the primary procedure
3 procedures = 100% of the primary procedure +40% of the primary procedure

For hospitals
Unless the hospital agreement precludes additional charges for multiple procedures where more than one procedure is carried out, the theatre fee will be reimbursed at 100 percent of the most complex procedure and 50 percent of the next most complex procedure only.

Bilateral procedures

Some procedures are invariably performed bilaterally and are referred to in the Schedule as "...and bilateral". In these instances, benefit for the bilateral procedure is already taken into account. 

For example: CCSD code - D1530 Myringotomy (and bilateral)

Other procedures which may be performed bilaterally have been given separate bilateral procedure codes within the CIGNA fee schedule.

All providers should use the relevant codes that are available on the Cigna fee schedule.

Unbundling is defined as the breaking down of a surgical procedure into component parts and then charging for each component separately.

As a result, certain combinations of codes cannot be billed together. Below are a few examples of unbundling that CIGNA would consider as inappropriate:

Procedures considered integral to a specific procedure:

• Cardiac catheterisation prior to coronary angioplasty
• Radiographic imaging for procedures usually performed under X-ray control
• Osteotomy of long bone during total hip replacement
• Clearance of impacted wax prior to myringotomy
• Laparoscopic cholecystectomy converted to an open procedure

Procedures integral to a wide range of procedures or to gain access to perform the procedure:

• • Charging for in-patient care or intensive treatment unit (ITU) care routinely considered part of the procedure
  • A surgeon charging for an anaesthetic when an anaesthetist has provided anaesthetic services
  • Primary suturing of a wound and removal of sutures
  • Wound infiltration with local anaesthesia
  • Application and management of post-operative dressings and analgesic devices (e.g. patient controlled analgesia)
  • Billing of procedure codes that has a narrative of ‘as sole procedure’ in combination with any other code

  CIGNA applies the unbundling rules as per industry standard Clinical Coding & Schedule Development (CCSD) Group Schedule. Unbundling rules for every code can be found at: www.ccsd.org.uk/CCSDSchedule .

  Where CCSD creates new unbundling combinations, CIGNA aims to introduce these the following month.
  Please contact CCSD (www.ccsd.org.uk/contactus ) if you have any queries about unbundling combinations, including requests for additions and removals. If you have questions about CIGNA’s unbundling combinations, please email us at provider.affairs@cigna.co.uk.

Unless there is an in-force agreement, CIGNA will not cover any separate billing from consultants or physicians for diagnostic tests, pathology and diagnostic radiology or for reporting on the results of these diagnostics. CIGNA reimburses the hospital, clinic or facility directly for these services. Where appropriate, consultants and physicians should negotiate appropriate payment for their services directly with the facility where the test was performed.

Chemotherapy

Charges for the prescribing and supervision of chemotherapy should be made in accordance with the CIGNA fee schedule.

A fee for an initial consultation may be charged before treatment commences. Further consultation fees should not be charged during the course of treatment and will not be covered by Cigna.

The following codes relate to the clinical supervision and planning of the delivery of chemotherapy. Please use one of the following: X0001, X0002, X0003, X0004 or X0005 depending on the regimen.

The fees related to each code include the following:

• regime prescription;
• supervision of planning and treatment delivery;
• expected side effects management and the prescription of an alternative regimen;
• supervision of all outpatient, day patient, and inpatient care.

One supervision fee will be paid for any course of treatment regardless of whether a single or multiple drug combination is used. Invoices for chemotherapy and biological supervision should be made at the end of each treatment cycle.

Radiotherapy

Charges for the prescribing and supervision of radiotherapy should be made in accordance with the CIGNA fee schedule.

As per CCSD guidance, it is intended that planning codes (X6000-X6099) are to be used by both consultants and hospital providers. Delivery codes (X7000-X7099) are to be used by hospital providers only and clinical supervision codes (X0007-X0011) are to be used by consultants only for delivery.

A fee for initial consultation may be charged before treatment commences. Further consultation fees should not be charged during the course of treatment. The fees related to each code includes the following:

• supervision of all outpatient, day patient, and inpatient care, including any transfusion of blood/blood products;
• regime prescription;
• supervision of planning and treatment delivery;
• expected side effects management and the prescription of an alternative regimen

One supervision fee will be paid for any course of treatment.

Invoices for radiotherapy supervision and treatment delivery should be made at the end of each treatment cycle.

The fees below are fees for Cigna recognised providers but can also be used as reasonable and customary guideline fees for other providers. If you bill according to these guidelines, the Cigna member will not be subject to any shortfall.

The following fees are reimbursable per session of treatment. No more than one session can be charged on the same day.

Your CIGNA Provider Number is for your exclusive use and should only be used to identify and bill for treatment and services that you have carried out personally. It must not be used to invoice for any treatment or services provided by colleagues. The only exception is where there is a written contractual agreement between you and CIGNA that includes the services of these colleagues and/or third parties.

Invoices should follow CIGNA’s billing rules and fee structure that are explained in greater detail in this document.

Providers should submit their invoices to CIGNA electronically, either via Healthcode (www.healthcode.co.uk) or directly to us by email to bills@cigna.com. 

We ask providers to:

i. Invoices are submitted promptly following treatment. Invoices dated six months or more from the date of treatment may be rejected.

ii. Invoices include all the necessary information needed to process them (guidance below).

iii. Invoices must include the full and final fee for the service undertaken, you must not bill the patient for any shortfall until Cigna have assessed the invoice and notified you of any member liability.

iv. Codes from the latest version of the CIGNA Schedule of Procedures are used and follow the billing rules as explained. CIGNA is unable to process invoices that do not use the codes and follow the billing rules. Providers who believe additional procedures should be listed are advised to contact CCSD (http://www.ccsd.org.uk/contactus ) directly.

Data needed to process an invoice

In order to process an invoice, we need the following information:
1. Invoice date
2. CIGNA Provider Number
3. CIGNA Membership Number
4. Member’s full name
5. Member’s date of birth
6. Member’s full address
7. Total Fees
 
We need the following information for each procedure code invoiced:
1. Procedure code from the CIGNA Schedule of Procedures
2. Pre-authorisation number (please state “no pre-authorisation” if treatment was not pre-authorised)
3. Date of treatment
4. Whether the care is delivered as an in-patient, day-patient, or out-patient, or in a consulting room, nursing home or the patient’s home
5. Fee for each individual procedure code
 
The following information is only needed if the place of service is in-patient:
1. Hospital/facility name
2. Admission date
3. Discharge date

The CIGNA Schedule of Procedures includes some treatments that, in line with our customers’ policies, are not eligible for cover.

We expect you to be aware of the major categories of ineligible treatment. We also expect you not to invoice Cigna us for these and to make our members aware that these are not eligible for cover with under their Cigna policy.

Examples include, but are not restricted to the following:

• Ongoing management of chronic conditions
• Cosmetic treatment
• Alcohol and drug related problems
• Treatment unlicensed in the UK
• Treatment considered to be unproven or experimental in the UK
• Family planning / fertility problems

Cigna acts in good faith on the basis of information that members and providers provide to us. We work in partnership with providers; the vast majority of which are honest and transparent in their relationship with us.

However, we take fraud or the misrepresentation of claims very seriously and will take appropriate actions if we believe that a provider has engaged in fraudulent or misleading behaviour.

Inaccurate billing is a matter of serious concern across the insurance industry and we work closely with other insurers to combat this. Cigna is an active member of the Health Insurance Counter Fraud Group (HICFG) and routinely shares information with other insurers for the detection and prevention of fraud; subject to the provisions of Data Protection Legislation.

Examples of inappropriate billing include, but are not limited to, the following billing practices;

• Submitting invoicing for procedures that you have not performed (false representation)
• Billing procedure codes that do not represent the actual procedure performed; including exaggeration of the complexity of procedures performed (upcoding)
• Invoicing separate codes where one of those codes already includes the other (unbundling)
• Inappropriate or unethical repetitive treatments (over servicing)
• Systematic duplicate billing for treatment already billed (by you or another provider)

Other misleading behaviours include, but are not limited to:

• Misrepresenting the medical history of the patient
• Deliberately misleading Cigna or withholding material facts
• Referring patients to a facility in which you have direct or indirect financial interest; without declaration and where this may not be in the best interests of the patient

Cigna routinely monitors and analyses claims, undertakes audits and reviews medical records for claims validation. Where it appears that a provider is engaging in fraudulent or misleading behaviour, the matter will be fully investigated.

If it is found that you have submitted fraudulent claims, misrepresented the circumstances of a claim, or deliberately misled Cigna in order to obtain or facilitate benefit that would not otherwise be eligible under the terms of our members’ policies, this will be construed as a material breach of these terms and conditions. As such, Cigna reserves the right to remove your recognition and / or refer you to the relevant Regulatory Body or Law Enforcement Agency.

For any questions or scenarios that are not mentioned in these notes, please contact the Provider Services team on provider.affairs@cigna.com