Cigna reimbursing inconsistently for Transition of Care; what does "in-network coverage levels" mean? I cannot get any answers, and I think Cigna owes me a lot of money.

Hello,

This year, my company switched from Blue Cross Blue Shield of Massachusetts to Cigna of Maryland.

None of my mental health care providers were in-network under Cigna, so I filled out Transition of Care forms for each of them, and they were approved.

I have been going back and forth with Cigna for months now trying to get reimbursed adequately for my care, and I have no idea what’s going on. The language in the EOBs, what Cigna representatives are telling me, and my reprocessed claims are all inconsistent. I could really use some help.

My understanding of the Transition of Care was that I would pay “in-network coverage levels” for my out-of-network care for the specified period, and that I would submit the superbills myself for reimbursement. The way I understood it, this meant a $40 copayment per appointment. I understand that “in-network coverage levels” is vague; I could not find clarification on it. Out-of-network providers do not sign contracts with Cigna to have contracted rates, but, according to my schedule of benefits, I have a $40 copayment for mental health visits in-network and that’s it. I thought Cigna would cover the amount necessary for me to only have a $40 copayment if they were covered at “in-network” levels. Was this a wrong assumption? If so, what is correct? Nevertheless, the amount I am being reimbursed is all over the place.

Here is the language from the Cigna website.

With Transition of Care, you may be able to continue to receive services for specified medical and behavioral conditions with health care providers who are not in your plan’s network at in-network coverage levels.

After submitting my claims, Cigna first reimbursed me ONLY the allowed amount up to the maximum reimbursable charge (MRC) for the appointment; this was “What CIGNA plan paid” in my EOB. “What I owe” in my EOB was for the $40 copayments. “Amount not covered” in my EOB was everything over the MRC and the copayment. I received a reimbursement check only for “What CIGNA plan paid.” For example, for a $900 bill, “What CIGNA plan paid” was $444, “Amount not covered” was $296, and “What I owe” was $160. I received a check for $444.

But the EOB says, next to “Amount not covered”,

This is the portion of your bill that’s not covered by your CIGNA plan. You may or may not need to pay this amount. See the Notes section on the following pages for more information. The total amount of what is not allowed and/ or not covered is $296 of which you owe $0.00 .

This is the “note” in the aforementioned “Notes section”,

A0 – HEALTH CARE PROFESSIONAL: THE PATIENT SHOULD NOT BE LIABLE IF YOU ACCEPT THE ALLOWABLE AMOUNT. CUSTOMER: CALL CIGNA AT THE NUMBER ON YOUR CIGNA ID CARD IF YOUR HEALTH CARE PROFESSIONAL BILLS YOU MORE THAN THE “WHAT I OWE” AMOUNT ON THE FRONT OF THIS EXPLANATION OF BENEFITS.

The total of “Amount not covered” at this point exceeds $3,000.

I called Cigna and had the claims reprocessed in February based on the belief that I should not owe the $296. A few weeks later, I received checks for the “Amount not covered” amount, leaving the “What I owe”, which made sense to me – it was for the $40 copayments. Effectively, I only paid a $40 copayment. I received $296.

Since February, I had to submit more claims. Again, I was only reimbursed up to the allowed amount. When I called Cigna and had them reprocessed, this time they kept determining that no changes were necessary. They would not issue me new checks. This took months – submitting them for reprocessing, calling to check in on the status repeatedly, and learning that they were not reprocessed. Cigna did not communicate with me at all throughout the process. I had to do all the work. It took a really long time, and it was hard for me to stay organized.

Finally, a month ago a representative sent the claims back for a “balance billing process”, which no one had told me about until that point. I recently received checks in the mail for a portion of those claims but it was for the “What I owe” amounts, not the “Amount not covered”. For example, for the claim for $900, I was reimbursed $444 the first time and $160 the second time. This makes no sense to me, especially because previously reprocessed claims were reimbursed for $444 + $296.

What is going on? I cannot get a straight answer from anyone, and I cannot rationalize these inconsistencies. Obviously, I would love to be reimbursed the “Amount not covered”, especially because I was reimbursed that amount a few times. Whenever I try to file a complaint, nothing happens. My claims have been processed three different ways at this point, and I just want to know what money I am owed so I know whether to bother continuing to fight with Cigna. I have spent hours on the phone with Cigna, and I cannot get a straightforward answer from anyone. I am tearing my hear out. Can anyone please advise how to proceed? Do I contact the attorney general’s office?

Thank you very much in advance for the help.