CIGNA Medicare Select Plus Rx Appeal Policy and Procedure

• First-level Provider Payment Review
• Filing an appeal
• Second-level Provider Payment Review
• Filing an appeal
• Quick Tips

First-level Provider Payment Review

Level 1 of the Provider Appeal process must be initiated within 180 calendar days* from the date of the initial payment denial or decision from CIGNA.

Provider payment appeals include, but are not limited to:

• fee payment disputes
• capitation payment disputes
• untimely claim filing denials
• claim editing denials
• delayed treatment days
• denials for failure to secure authorization for extended length of stay

Your appeal request will be reviewed by someone who was not involved in the initial decision and who can take corrective action. Decisions will be consistent with the terms of the patient's benefit plan. A provider will be involved in the review of appeals related to medical necessity denials. A written response will be sent to you within 30 days* of receipt of the appeal.

*Time periods are subject to, and may be extended by, applicable law or provisions within the provider agreement.

If you are not satisfied with the first appeal review decision, you may request a Second-level Provider Payment Review.

CIGNA reserves the right to reverse a denial decision at any point during the appeal process, without completing all components of the process, if warranted by new information.

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Filing an appeal

Contracted providers seeking to overturn a partial payment or payment denial decision must file the appeal within 180 calendar days of the initial payment.

1. Contact CIGNA HealthCare's Customer Service Department at the toll-free number listed on the front of the CIGNA HealthCare member's ID card to review any coverage denials/payment reductions. A Customer Service representative may be able to quickly resolve your issue outside the formal appeals process. If the Customer Service representative is unable to alter the initial coverage decision, you will be advised of your right to appeal at that time.
2. Download, print, complete and mail a Request for Provider Payment Review (PDF) to the CIGNA HealthCare office designated below.
3. Include a copy of the original claim and the Explanation of Payment (EOP) or Explanation of Benefits (EOB), if applicable.
4. For reviews with a clinical component, such as denied hospital days or services denied for no prior authorization, supporting documentation should include a narrative describing the situation, an operative report and medical records, as applicable.
5. Use the table below to find the correct mailing address for your documentation:

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Second-level Provider Payment Review

Level 2 of the Provider Appeal process must be initiated within 60 calendar days* of the date of the Level 1 appeal decision letter.

As with a First-level Provider Payment Review, your appeal will be reviewed by someone who was not involved in the initial decision and who can take corrective action. For medical necessity denials, another provider in a same or similar specialty** will review the appeal request and render a decision. A written response will be sent to you within 30 days* of receipt of the appeal.

*Time periods are subject to, and may be extended by, applicable law or provisions within the provider agreement.

**Same or similar specialist (a.k.a. clinical peer): an actively practicing provider, dentist or other health care professional who holds a non-restricted license in a state of the United States in the same or similar specialty, and who typically treats the condition, performs the procedure, or provides the treatment under review.

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Filing an appeal

Must be filed within 60 calendar days of the date of the first-level review determination.

1. Contact CIGNA HealthCare's Customer Service Department at the toll-free number listed on the front of the CIGNA HealthCare member's ID card to review any coverage denials/payment reductions. A Customer Service representative may be able to quickly resolve your issue outside the formal appeals process. If the Customer Service representative is unable to alter the initial coverage decision, you will be advised of your right to appeal at that time.
2. Download, print, complete and mail a Request for Provider Payment Review to the CIGNA HealthCare office designated at the bottom of the appeals form. Be sure to include additional supporting information if not previously submitted at First-level Provider Payment Review.
3. Include a copy of the original claim and the Explanation of Payment (EOP) or Explanation of Benefits (EOB), if applicable.
4. For provider appeals with a clinical component, such as denied hospital days or services denied for no prior authorization, supporting documentation should include a narrative describing the situation, an operative report and medical records, as applicable.
5. Use the table below to find the correct mailing address for your documentation:

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Quick Tips

• Please allow 45 days (or time permitted by applicable law) for processing your appeal and communicating the appeal decision. Please submit one appeal form per claim.
• If you provide health care to a CIGNA HealthCare member, and are under contract with a third party, please consult the third party vendor with whom you are contracted.
• If you fail to file your request for an appeal within the timeframes listed above, the last determination by CIGNA HealthCare regarding the disputed issue will be binding (subject to applicable law or a provision within your provider agreement that specifically allows additional time).

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