Eligibility verification enhancement for patients with plans administered by a third party

April 1, 2024

On October 31, 2023, we implemented an enhancement that allows you to verify eligibility for your patients with Cigna Healthcare plans administered by a third-party administrator (TPA) via electronic data interchange (EDI).

You can now verify eligibility by submitting a health care eligibility benefit inquiry and response (ANSI 270/271) transaction through your practice management system or clearinghouse. The 271 response will use information from both Cigna Healthcare and the TPA to indicate whether or not your patient is covered. It will also provide the TPA name and telephone number that you can contact to confirm further eligibility or benefit information, if needed.

What are plans administered by TPAs?

Employer groups that require a high level of customization and flexibility may choose to have a TPA administer their benefit plans. Cigna Healthcare Payer Solutions, which has relationships with select TPAs to help meet the needs of these employer groups, provides a wide range of complementary product solutions. These include access to providers who participate in our LocalPlus®, Preferred Provider Organization, and Open Access Plus medical networks.

How to identify a patient with a TPA-administered plan

You have two options to determine if your patient has a TPA plan: View their Cigna Healthcare ID card or log in to the Evernorth provider website (Provider.Evernorth.com) to review their coverage details. 

ID card

Patients with a plan administered by a TPA will have “Shared Administration” (or the letter “S”) at the bottom right corner of their Cigna Healthcare ID card (see sample below). This designates that Cigna Healthcare shares the administration of the plan with a TPA.

The ID card includes:

  • Paper and electronic claims submission addresses.
  • TPA telephone number and address(es) for inquiries.

Providers should contact the TPA for questions related to:

  • Eligibility.
  • Benefits administration.
  • Claim status, payment, and administrative appeals.
  • Precertification and prior authorization requests.

Note that Evernorth Behavioral Health is not able to answer these questions.

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