 Fill out the Out-of-Network Claim Form and mail it to:
Cigna Behavioral Health
PO Box 46270
Eden Prairie, MN 55344
Claims must be
submitted within 180 days of date of service.
Mental Health and Substance Abuse Benefits
Duke offers both outpatient and inpatient mental health and substance abuse
benefits under each of our health plans. Beginning January 1, 2008, all mental
health and substance abuse benefits will be administered by CIGNA Behavioral
Health.
To find a network provider, call CIGNA Behavioral Health toll-free at
1-888-253-8552 or log on to the CIGNA Behavioral Health web
site.
Employer ID: Duke
PIN: employee
Plan Chart
Details about these benefits are outlined in the chart below:
|
CIGNA Behavioral Health |
In-Network |
Out-of-Network |
Outpatient |
Covered in full after $35 co-pay per visit for individual/ family therapy |
$100 annual deductible
You pay 50% UCR1,4 costs |
| |
Limit of 20 unmanaged1,2 visits per calendar year |
Limit of 20 visits per calendar year2 |
| |
Precertification required for
psychological testing, electroshock therapy, hypnosis |
Precertification required for psychological testing, electroshock therapy,
hypnosis |
| |
Lab and outpatient
charges and ECT, you pay 20%4
|
Lab and outpatient charges and ECT, you pay 50% after deductible1,4
|
Inpatient |
You pay 20% after $250 annual deductible
|
You pay 50% of UCR1,4 after $250 per
admission co-pay |
| |
$1,000 annual out-of-pocket maximum |
Alternative care limited to
non-residential programs |
| |
Limit of 30 days per calendar year |
Limit of 20 days per calendar year3 |
| |
Must be precertified prior to admission
|
Must be
precertified prior to admission
|
-
"Unmanaged" means that no precertification is required. However,
precertification is required for psychological testing, electroconvulsive
therapy (ECT), and hypnosis.
-
The limit of 20 visits for outpatient in-network and out-of-network
benefits is combined.
-
The limits for inpatient in-network and out-of-network benefits are
combined and not mutually exclusive.
-
All payments are based on the usual, customary, and reasonable (UCR)
allowable charge. You are liable for charges over UCR when receiving
out-of-network services. For a definition of UCR, see
the glossary.
|