CIGNA Medicare Provider Appeal Policy and Procedures

• 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 or denial decision from CIGNA.

Provider payment appeals include, but are not limited to:

• fee payment disputes
• untimely claim filing denials
• claim editing denials

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 (i.e., Evidence of Coverage). A written response will be sent to you within 30 days of receipt of the appeal.

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

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 CIGNA Medicare member ID card to review any organization determinations/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. Include a copy of the original claim and the Explanation of Payment (EOP) or Explanation of Benefits (EOB), if applicable.
3. For reviews with a clinical component supporting documentation should include a narrative describing the situation, an operative report and medical records, as applicable.
4. 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. A written response will be sent to you within 30 days of receipt of the appeal.

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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 CIGNA Medicare member ID card to review any organization determinations/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. 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 reviews with a clinical component 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

• If the appeal is overturned in your favor, it may take up to 15 additional days to process the adjustment. This means that you may not receive any payment for up to 45 days from the date we received your appeal request.
• If you fail to file your request for an appeal within the timeframes listed above, the last determination by CIGNA Medicare Access regarding the disputed issue will be binding.

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