Claim Adjustment & Appeals Guidelines

• Electronic: Submit to the Payer ID that the original claim was submitted to
• Paper: Submit to the claim address on the back of the Member's ID card.

A corrected claim is a claim that was originally submitted with incorrect information and is being resubmitted.

When submitting a corrected claim electronically, update the Claim Frequency Code with:

• 7 = Replacement (replacement of prior claim).
• 8 = Void (void/cancel of prior claim).

When submitting a corrected claim on paper, the following must be included:

• A completed CMS 1500 (PDF 361k) or UB-04 (PDF 149k) claim form with the corrected information.
• The words "Corrected Claim" written or stamped in Field 19 (Reserved for Local Use) of the CMS 1500 (PDF 361k) claim form or Field 84 (Remarks) on the UB-04 (PDF 149k) claim form.

When submitting a request for reconsideration for timely filing, the following must be included:

• Valid proof of timely filing, such as the EDI Acceptance Report for electronic claim(s), etc.

For more information, please refer to CIGNA's Timely Filing Policy.

When submitting an appeal for a claim that has been denied as a duplicate, the following must be included:

• The Explanation of Benefits (EOB), Explanation of Payment (EOP) or Claim Control number of the claim being disputed.
• Reason why you are disputing the claim.

When submitting an appeal for a claim has been denied for incomplete information, the following must be included:

• The original Explanation of Benefits (EOB), Explanation of Payment (EOP) or letter requesting the additional information.
• The requested information, such as operative reports, test results, admission/discharge summary, etc.

When submitting an appeal for a claim that has been denied for no authorization, the following must be included:

• The original Explanation of Benefits (EOB), Explanation of Payment (EOP) or letter requesting the additional information.
• The documentation that supports why the decision needs to be overturned, such as operative reports, medical records, etc.
• Completed Provider Payment Appeal form (PDF 167k). Select:
• Medical Necessity.

When submitting an appeal for Medical Necessity claim denial, the following must be included:

• The original Explanation of Benefits (EOB), Explanation of Payment (EOP).
• The documentation that supports why the decision needs to be overturned, such as operative reports, medical records, etc.
• Completed Provider Payment Appeal form (PDF 167k). Select:
• Medical Necessity.

When submitting an appeal for a denied authorization (for services not yet rendered), complete the Provider Payment Appeal form (PDF 167k) and answer "yes" to the following question:

Is this an Appeal for a service that has not been rendered that requires authorization?

When submitting an appeal for claim reimbursement, complete the Provider Payment Appeal form (PDF 167k) and select:

• Mutually Exclusive, Incidental or Bundling Denial.
• Modifier Reimbursement.

Include supporting documentation including clinical information, if needed.

When submitting an appeal for a contract or fee schedule dispute, complete the Provider Payment Appeal form (PDF 167k) and select:

• Provider Fee Schedule /Contract Language.

Include the specific contract element you disagree with and a copy of the contract page.

When submitting an appeal for an experimental/investigational procedure that was denied, complete the Provider Payment Appeal form (PDF 167k) and select:

• Experimental/Investigational Procedure.

When submitting an appeal for an inpatient facility denial or reduced payment, complete the Provider Payment Appeal form (PDF 167k) and select:

• Inpatient Facility Denial (Level of Care, Length of Stay, Delayed Treatment Day).

When submitting an appeal related to application of the member's benefits (i.e.: exclusion, limitation, administration), complete the Provider Payment Appeal form (PDF 167k) and select:

• Benefit Exclusion or Limitation.
• Benefit Administration (i.e. co-payment, deductible, etc).

When submitting an appeal for the maximum reimbursable amount, complete the Provider Payment Appeal form (PDF 167k) and select:

• Maximum Reimbursable Amount.

When submitting a second level appeal for any reason, complete the Provider Payment Appeal form (PDF 167k) and answer "yes" to the following question:

• Is this a 2nd request for Appeal?