Clinical Information Dispute Process

• Background
• Overview
• How to Submit a Clinical Information Dispute

Background

CIGNA HealthCare is establishing a process to resolve a provider's dispute of a CIGNA HealthCare requirement that clinical information accompany a provider's claim submission.

CIGNA HealthCare has reduced its overall requirements for clinical information to accompany submission of claims as a condition for review and payment, and does not routinely require submission of clinical information before or after claim processing. Please refer to clean claim requirements for the categories of claims that may require clinical information.

Back to top

Overview

A provider may submit a Clinical Information Dispute Form* (PDF) to the CIGNA HealthCare address on the form. The form will be reviewed for completeness, and to ensure all attachments are included. The documents will be reviewed to determine whether the clinical information was required for the purpose of investigating fraudulent, abusive or other inappropriate billing practices. If the requirement for information relates to the investigation of potentially fraudulent, abusive or inappropriate practices, the dispute will be forwarded to the Clinical Information Officer (fraud) for review.

If the requirement for information relates to any reason other than an investigation of fraudulent, abusive or inappropriate billing practices, the dispute will be forwarded to the Clinical Information Officer (non-fraud). Both Clinical Information Officers (CIO's) are independent reviewers agreed upon by plaintiffs' attorneys and CIGNA HealthCare. Either CIO may request information from both CIGNA HealthCare and the provider. The provider may receive a letter from the CIO requesting documents or other information.

The responsibility of the CIO (non-fraud) is to make a determination, that is binding on both parties, of whether CIGNA HealthCare has complied with section 7.8(c)(i) of the Settlement Agreement. Section 7.8(c)(i) of the Settlement Agreement states that CIGNA HealthCare may require submission of clinical information before or after payment of certain categories of claims and shall disclose those categories of claims that may require submission of clinical information. The responsibility of the CIO (fraud) shall be to make a binding determination whether CIGNA HealthCare has reasonable grounds for its action in requesting clinical records.

If the CIO (non-fraud) determines that CIGNA HealthCare complied with the Settlement Agreement, or if the CIO (fraud) determines that reasonable grounds exist for the requirement that clinical information be submitted, he will notify the parties that the matter has been closed and that CIGNA HealthCare may request records to complete the processing of the claim. If the CIO (non-fraud) determines that CIGNA HealthCare did not comply with the Settlement Agreement, or if the CIO (fraud) determines that reasonable grounds do not exist for the request for clinical records, he will notify the parties that the requirement for submission of clinical information is to cease for this claim submission. This process and the time allowed to complete it are outlined below.

Back to top

How to Submit a Clinical Information Dispute

1. Be sure that you're disputing a requirement from CIGNA HealthCare that clinical information accompany a claim. For claims already processed, review your Explanation of Payments (EOP) and their remark codes. Submit only for those claims in which the reason code for denial relates to a requirement that clinical information accompany the submission.
   
   If you're challenging something other than a request for clinical notes, CIGNA HealthCare has alternative processes. If you're challenging a claim-coding denial or a denial of payment for any other reason, do not use this process.
   
   
2. Complete the Clinical Information Dispute Form* (PDF) and attach the appropriate information. Also attach a check for $50 made payable to CIGNA HealthCare.
   
   
3. CIGNA HealthCare will forward the dispute to the appropriate CIO within 10 days of receipt of a completed form.
   
   
4. The CIO may request information from you and CIGNA HealthCare within 20 days of receipt of the form from CIGNA HealthCare. You'll receive a letter from the CIO requesting such information, which will state when the information must be provided.
   
   
5. The CIO will make a decision and notify you and CIGNA HealthCare directly by mail.
   
   
6. If the CIO determines there is no basis for the requirement of clinical information, CIGNA HealthCare will reprocess the submission based upon the information originally provided.
   
   
7. If the CIO upholds CIGNA HealthCare's request for clinical information, you'll need to submit clinical records to complete the processing of the claim. Or, if the claim has been already processed, you should submit through the provider appeals process.

Back to top