Maine Inter-Agency Council on HMO Quality
Review of
CIGNA HealthCare of Maine, Inc.
Findings and Recommendations
The Bureau of Insurance (DPFR) and the Bureau of Medical Services (DHHS)
completed a joint triennial examination of CIGNA HealthCare of Maine,
Inc., hereafter "CIGNA", for compliance with 24-A M.R.S.A.,
Chapters 56 and 56A, Bureau of Insurance Rule Chapter 850, and Department
of Human Services Rule Chapter 109. This report represents the finding
of State surveyors as of November 15-16, 2006. CIGNA scored a "Pass"
for this triennial examination.
Acknowledgement of cooperation and assistance extended to the examiners
by all CIGNA representatives is hereby expressed.
This section highlights the findings associated with the examination
of CIGNA:
- Quality Management Program was determined to be in full compliance
with Rule 109.
- Credentialing Program was determined to be in full compliance with
Rule 850.
- Utilization Review Program was determined to be in full compliance
with Rule 850 except for UR 23 (File Review). UR 23 received a “significant”
rating, because 7 of 8 (29/30) UR denial files contained determinations
within the time limit, had clinical peer reviews, had all pertinent
clinical information, contained the reason for denial, information
on the appeal process, information re: clinical rationale, and phone
number. CIGNA is encouraged to ensure that all files meet all Maine
requirements.
- Six of the eight elements re: Grievance and Appeals policies were
determined to be in full compliance with Rule 850.
Recommendation, GA 1, “UR Appeals Procedure:”
CIGNA received a “significant” rating re: reviewing
adverse utilization review determinations because in cases involving
CIGNA Behavioral Health (“CBH”), the covered person
may not appeal directly to CIGNA rather than through CBH at the
first level. CIGNA is encouraged to modify their policies to allow
appealing directly to CIGNA rather than its delegate.
Recommendation, GA 1, “UR Appeals Procedure:”
CIGNA was given credit for its description of the second level process
in the adverse determination notification, in spite of the fact
that the policy did not refer to review by clinical peers (instead
using the term “physician”), because clinical peers
were mentioned in the letters. CIGNA is encouraged to modify their
policies from “physicians” to “clinical peers.”
Recommendation, GA 3, “First Level Non-UR Procedures,”
CIGNA itself received credit for all 7 requirements. However, CBH
did not provide the covered person with a written explanation of the
grievance process within 3 working days of receiving the grievance.
CBH is encouraged to modify relevant policies to decrease the acknowledgement
time from 5 calendar days to 3 working days.
Recommendation, GA 3, “First Level Non-UR Procedures,”
CIGNA was given credit for including the Superintendent of Insurance’s
contact information, in spite of the fact that the policy did not
mention this, because it was mentioned in the letters. CIGNA is
encouraged to modify their policies to include this information.
Recommendation, GA 4, “Second Level Procedures:”
CIGNA was given credit for including the Superintendent of Insurance’s
contact information, in spite of the fact that the policy did not
mention this, because it was mentioned in the letters. CIGNA is
encouraged to modify their policies to include this information.
Recommendation, GA 6, “File Review 2nd Level UR:”
CIGNA received a “significant” rating for this element
because 1 file did not meet the requirements that the majority of
panel consisted of appropriate clinical peers, and that at least
one clinical peer was not previously involved. CIGNA is encouraged
to ensure that all files meet all Maine requirements.
- Seven of the eight elements re: Access, Availability, and Continuity
of Care policies were determined to be in full compliance with Rule
850.
Recommendation, AC 7, “Appointment/Waiting Times:”
CIGNA received a “partial” rating for this element because
it did not demonstrate compliance with the following requirements:
- Steps to ensure that its members could obtain symptomatic primary
care services within 7 days
- Steps to ensure that its members could obtain urgent primary
care services within 24 hours. Note: CIGNA had such a policy,
but CBH’s policy had a 48 hour deadline. CBH has drafted
a new policy reflecting the 24-hour deadline; it will go before
the appropriate committee for ratification at its 12/8/06 meeting.
- Steps to ensure that its members were not kept waiting longer
than 45 minutes for a scheduled appointment with a primary care
or specialty provider.
CIGNA is encouraged to modify its policies to comply with these
requirements.
