- Claim Adjustments
Before a health care professional starts the appeals process described below, we encourage them to call Cigna Customer Service at 1.800.88Cigna (882.4462) to try to resolve the issue first. Many issues, including denials related to timely filing, incomplete claim submissions, and contract and fee schedule disputes may be quickly resolved through a real-time adjustment by providing requested or additional information.
If our Customer Service team cannot adjust the issue during that call, then our appeal process can be initiated through a written request.
- Timeframe for requesting an adjustment or submitting an appeal
The request for an adjustment or appeal must be initiated in writing within 180 calendar days of the date of the initial payment or denial decision. If the appeal relates to a payment that we adjusted, the appeal must be initiated within 180 calendar days of the date of the last payment adjustment. Please note that processes and timelines may vary due to state mandates or contract provisions.
- How to initiate an appeal
When an appeal is warranted, health care professionals should submit all appeal requests on a Request for Health Care Professional Payment Review form. The form will help to fully document the circumstances around the appeal request and will also help to ensure a timely review of the appeal. All forms should be fully completed, including selecting the appropriate check box for the reason for the appeal.
- Information to submit with an appeal
All appeals should be submitted with the following information:
- A completed Request for Health Care Professional Payment Review form.
- The original explanation of benefits (EOB), explanation of payment (EOP), or letter sent to the health care professional requesting additional information
- Documentation that supports why the decision should be overturned (e.g., operative reports, medical records, etc.)
Note: for denials that do not have an associated EOB or EOP (e.g., precertification denial), no EOB or EOP documentation is required.
- Where to submit appeals
Please submit appeals to:
Cigna Healthcare Inc. National Appeals Unit (NAO)
PO Box 188011
Chattanooga, TN 37422
If the ID card includes the “GWH-Cigna” or “G” indicators, please submit to:
P.O. Box 188062
Chattanooga TN 37422-8062
If the ID card includes the “Cigna-HealthSpring” indicator, please submit to:
Cigna-HealthSpring AZ Medicare Appeals Unit
25500 N Norterra Dr.
Phoenix, AZ 85085-8200
- Denials that can be appealed
As a reminder, certain services, including denials related to timely filing, incomplete claim submissions, and contract and fee schedule disputes may be quickly resolved through a real-time adjustment by providing requested or additional information to our Customer Service team (1.800.88Cigna).
The following services, however, can be appealed through the process outlined in the previous sections. They may be handled as a health care professional or customer appeal depending upon the scenario, as follows:
Scenario Appeal Path Precertification (authorization) denial (for services not yet rendered) Customer appeal Precertification (authorization) not obtained – services denied Health care professional appeal
(exceptions based on state regulations)
Claim reimbursement denial (including mutually exclusive, incidental, or bundling denials, and modifier reimbursements) Health care professional appeal Experimental or investigational procedure denial Customer appeal Benefit denials (e.g., exclusion, limitation, administration [e.g., copay, deductible, etc.]) Customer appeal Maximum reimbursable amount Customer appeal Inpatient facility denial (e.g., level of care, length of stay, delayed treatment day) Either Medical necessity denial Either
Please note that certain state regulations may dictate appeals process, including if an appeal should be customer or health care professional driven. In these cases, those state regulations supersede our appeals processes and Cigna follows those regulations.
- Customer Reviews
In certain cases, pre- or post-service denials can be appealed directly by a customer (or a health care professional on behalf of a customer). When a health care professional submits an appeal on behalf of their patient, the process remains largely the same as a health care professional driven appeal.
How it can be different
For certain appeals (e.g., in cases of MNR review), health care professionals can be offered an additional external review for their patient by an Independent Review Organization (IRO) after an initial appeal denial. If there is an opportunity for an additional external review through an IRO, the initial appeal denial letter will outline the steps the health care professional must take in order to receive this external review. This includes signing, dating, and returning a “Request for Review by an Independent Review Organization” form. Once this form is returned, the external review process can begin.
Please note that in cases of an external review through an IRO, the health care professional must get their patient’s approval to proceed.
- Appeals for our national ancillary partners
Please note that Cigna uses ancillaries (e.g., CareCore | MedSolutions) to manage certain services (e.g., high-tech radiology and radiation therapy), including appeals. As such, in these cases, the health care professional should appeal directly through those ancillaries.
High-tech radiology and diagnostic cardiology services
CareCore | MedSolutions
730 Cool Springs Blvd, Ste 800
Franklin, TN 37067
Medical necessity Appeals
CareCore | MedSolutions
400 Buckwalter Place Blvd.
Bluffton, SC 29910
CareCore | MedSolutions Appeals Department
PO Box 698
Lake Katrine, NY 12449