California Health Care Professional Dispute Policy
- Connecticut General Life Insurance Company Dispute Resolution Policy
Cigna HealthCare strives to informally resolve issues raised by health care professionals on initial contact whenever possible. If issues cannot be resolved informally, Cigna HealthCare offers an internal process for resolving health care professional disputes. Health care professionals should submit disputes in writing to Cigna HealthCare for review and resolution in accordance with Cigna HealthCare dispute resolution policies and procedures. Participating health care professionals may refer to their Cigna HealthCare health care professional agreement and/or Program Requirements or Administrative Guidelines for further details.
Cigna maintains a single level appeal process for disputes involving Cigna HealthCare of California, Inc. participants. This includes HMO, Network, POS, Open Access, and other Cigna HealthCare of California, Inc. products.
In addition, the following dispute resolution mechanisms may be available after exhausting the internal Cigna HealthCare dispute processes:
- For claim denials relating to claim coding and bundling edits, a health care professional may have the option to request binding external review through the Billing Dispute Administrator.
- Alternatively, arbitration may serve as a binding, final resolution step if the health care professional agreement and/or Program Requirements or Administrative Guidelines so require.
Note: If you wish "Members may appeal non provider" -payment disputes to Cigna directly, or you may appeal on their behalf. To learn about the member appeal process for non-payment disputes go to Cigna.com > Member Rights and Responsibilities > Appeals and Grievances.
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Connecticut General Life Insurance Company and Cigna Health and Life Insurance Company Dispute Resolution Policy
For disputes involving Connecticut General Life Insurance Company and Cigna Health and Life Insurance Company participants in the state of California, Cigna HealthCare has a single-level process for disputes involving post-service payment issues. This includes participants in the PPO, EPO, Open Access Plus, HMO and POS Products. This dispute process is applicable to both the contracted and non-participating (non-contracted) health care professionals are appealing on behalf of the customer.
If you are not satisfied with this decision, please refer to the dispute resolution provisions of your health care professional Contract and/or Program Requirements with Cigna HealthCare of California, Inc. Requests for alternate dispute resolution must be submitted within one year from the date of this letter, subject to applicable law and your health care professional agreement.
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To initiate a dispute, health care professionals must submit their request in writing within 365 calendar days from the date of the initial payment or denial notice, or if the appeal relates to an adjusted payment, within 365 calendar days from the date of the adjustment.
A complete health care professional dispute must include the following information:
- Health care professional's name (i.e., provider of service)
- Health care professional's tax identification number
- Name, address and telephone number of a contact person at the health care professional's office
- Participant's name, Cigna identification number and date of service
- Hard copy of the disputed claim (if not previously submitted)
- Clear and concise explanation of the issue and/or reason for the appeal (i.e., underpayment, level of care, no authorization, claim bundling, length of stay if different from authorization, opt-out, revised code with modifier, benefit issue, contract issue, participant eligibility issue, or stop loss discrepancy). See Appeal Types in the National Reference Guide.
- Appropriate supporting documentation including, but not limited to, the original claim (if not previously submitted) and the EOP. If applicable; appeals with a clinical component must include a narrative, operative report and medical records. See Appeal Types in this section for guidance.
- Appeals should be submitted to:
Cigna HealthCare of California, Inc.
National Appeals Unit
PO Box 188011
Chattanooga, TN 37422
The PPO, EPO, Open Access Plus form titled Request for Health Care Professional Payment Review is available on this website to help prepare the documentation for an appeal request.
The CA HMO form titled Health Care Professional Dispute Resolution Request - CA HMO, although not required, is available on this website to help prepare the documentation for an appeal request.
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100 or More Claim Disputes
If a health care professional is appealing 100 or more claims in a single submission, an electronic Excel spreadsheet that individually numbers each claim is required, along with hard copies of the claims (if not previously submitted) and the appropriate supporting documentation (numbered accordingly). For further information regarding dispute submission requirements, please contact your health care professional Services Representative.
When a large number of claim denials are submitted for review at the same time ('claim projects'), they are not automatically considered health care professional disputes. These review requests are tracked as disputes if Cigna HealthCare determines the original payment was made in accordance with the contract and Cigna HealthCare policies.
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When Dispute Requests are Not Processed as Disputes
When it is determined that an error was made in processing a claim (that is, not in accordance with the contract and/or a policy), the issue will be tracked and processed as a claim adjustment rather than a health care professional dispute unless the health care professional submits the adjustment request after payment has previously been adjusted twice.
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PPO, EPO and Open Access Plus Products Dispute Notification and Response
Health care professionals will receive notification of the dispute resolution within 75 business days of receipt of the original dispute. If approved, the Explanation of Payment will serve as notice of the determination. If the initial payment decision is upheld, health care professionals will receive a letter outlining any additional rights, if applicable.
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California HMO and POS Dispute Acknowledgement and Response
Cigna HealthCare will send a letter acknowledging a dispute within 15 business days of receipt by the P.O. Box designated to receive CHC of CA health care professional disputes. Furthermore, health care professionals will receive a determination letter that will indicate the dispute resolution, explanation for resolution and amount of additional payment, if applicable. Cigna HealthCare will send this determination letter within 45 business days of its receipt of a CHC of CA dispute.
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