Coverage Decisions, Appeals & Grievances

Part D Exceptions and Coverage Determinations

Customers or their doctors have the option to request exceptions to the plan's prior authorization rules, step therapy rules or tiered cost-sharing structure. For more detailed information regarding the criteria for exceptions, call Cigna Medicare Select Plus Rx Customer Service. To request an exception, complete and submit the appropriate form provided and follow the instructions. If you need help in completing the form, Customer Service will be happy to assist you.

The following are examples of Part D coverage determinations:

  • You ask for a Part D drug that is not on your plan's list of covered drugs (called a "formulary"). This is a request for a "formulary exception."
  • You ask for an exception to our plan's utilization management tools - such as dosage limits, quantity limits, prior authorization requirements or step therapy requirements. Requesting an exception to a utilization management tool is a type of formulary exception.
  • You ask for a non-preferred Part D drug at the preferred cost-sharing level. This is a request for a "tiering exception."
  • You ask us to pay our portion of a covered drug you have purchased at an out-of-network pharmacy or other times you have paid the full price for a covered drug under special circumstances. Prescription Drug Claim Form
Who may ask for a coverage determination?

You can ask us for a coverage determination yourself, or your prescribing doctor (or other prescriber) or someone you name may do it for you. The person you name would be your appointed representative. You can name a relative, friend, advocate, doctor, or anyone else to act for you. If you want someone to act for you, then you and that person must sign and date the Appointment of Representative Form that gives the person legal permission to act as your appointed representative. This statement must be faxed or mailed to us at the designated number or address. The Appointment of Representative Form does not have to be completed if a doctor or other prescriber is submitting a request.

Appointment of Representative Form

To request an Exception, Prior Authorization or Step Therapy Exception please use the forms below.

Medication Coverage Determination Form

This form is intended for prescriber use to request an Exception, Prior Authorization or Step Therapy Exception for Cigna Medicare Select Plus Rx plan customers. Failure to complete this form in its entirety may result in an adverse determination for insufficient information. Customers should take this form to their doctor (or other prescriber) for completion when requesting an exception.

Coverage Determination Form

Part C Organization Determinations (Medical)

An organization determination is a decision we make about your medical benefits and coverage or about the amount we will pay for your medical services. This includes asking our plan to authorize, provide, or pay for medical services, including the type or level of services, you believe you should receive. For more detailed information regarding the process, call Cigna Medicare Select Plus Rx Customer Service.

Who may ask for an organization determination?

You can ask us for an organization determination yourself, or your doctor or someone you name may do it for you. The person you name would be your appointed representative. You can name a relative, friend, advocate, doctor, or anyone else to act for you. If you want someone to act for you, then you and that person must sign and date the Appointment of Representative Form that gives the person legal permission to act as your appointed representative. This statement must be faxed or mailed to us at the designated number or address. This form does not have to be completed if your doctor is submitting a request.

Appointment of Representative Form

Asking for an Organization Determination

Preservice

Start by calling, writing, or faxing our plan to request a decision about the services you want. You, your doctor, or a representative can do this. If your health requires a quick response, you should ask our plan to make a Fast Decision. To get a Fast Decision, you must meet two requirements:

1. You are asking for coverage for medical care you have not yet received; and
2. Using the standard deadlines could cause serious harm to your health or hurt your ability to function. If your doctor tells us that your health requires a Fast Decision, we will automatically agree to give you a Fast Decision.

If you ask for a Fast Decision on your own, our plan will decide whether your health requires that we give you a Fast Decision. Unless you ask for a Fast Decision, we will use the Standard Decision deadlines for giving you our decision.

You can expect our plan to give you an answer within 14 calendar days for standard decisions and 72 hours for fast decisions. We will give you an answer sooner if your health requires us to do so.

You may fax or mail a request to:

Cigna Medicare Services
Attn: Prior Authorization Dept.
25500 N. Norterra Drive
Phoenix, AZ 85085

Fax: 1-800-558-4316

If you have questions about our organization determination process, you may call us at 1-800-558-4314, Monday - Friday, 8 am to 5 pm MST. TTY users should call 711.

 

Claim Payment

Start by writing our plan to ask us to pay you back for medical care or services you have already received and paid for. You or a representative can do this. If the medical care you paid for is covered and you followed all the rules, we will send you the payment for our share of the cost of your medical care within 60 calendar days after we receive your request. Or, if you haven't paid for the services, we will send the payment directly to the provider.

You may mail a request to:

Cigna Medicare Services
Attn: Medicare Claims Department
PO Box 38639
Phoenix, AZ 85069

 

More information

For more information regarding the Cigna Medicare Appeal, Grievance and Organization Determination process, please refer to your Evidence of Coverage booklet. For information regarding Cigna Medicare Services' aggregate number of appeals, quality of care grievances and exceptions filed annually, please call 1-800-627-7534 (TTY: 711), 7 days a week 8 am to 8 pm. (From February 15, - September 30, 2014: Monday - Friday 8 am to 8pm. A voicemail system is available on weekends and holidays.)

 

Looking for a plan?

Already enrolled? Call:

By email:

By mail:

1-800-592-9231

TTY:
711

8 am to 8 pm

1-800-627-7534

TTY:
711

8 am to 8 pm

7 days a week

Monday - Friday only from February 15 -
September 30 (a voicemail system is available on weekends and holidays.)

seniors@cigna.com

Cigna Medicare Services
25500 N. Norterra Drive
Phoenix, AZ 85085

 

Standard Appeals

If you received a denial notice and are unhappy with our coverage decision, you can submit your appeal request to Cigna. The appeal process deals with the review of an adverse coverage decision (denial) for a requested drug, service or claims payment by Cigna.

A standard appeal must be submitted in writing within 60 calendar days from the date on the denial notice. When submitting your appeal you may include information which you believe may help us with the processing of your appeal or help us rule in your favor.

Upon receipt, the Cigna Medicare Appeal Department will gather pertinent information regarding your request and review your appeal. We will notify you of our decision in writing as follows:

  • Part D (drug) appeal decisions will be provided to you within seven (7) calendar days from the date we received your appeal. Appeal Form
  • Part C (medical pre-service) appeal decisions will be mailed to you within 30 calendar days of receiving your appeal. A 14-calendar day extension can be requested by a customer or Cigna if additional information is needed. If an extension is approved, you will be notified in writing. Pre-Service Appeal Form
  • Part C (claim) appeal decisions will be mailed to you within 60 calendar days of receiving your appeal. Claim Appeal Form

If you are dissatisfied with an appeal decision, you have additional appeal options (details are included in the decision letter).

Expedited Appeals

An expedited appeal can be requested orally, in writing (mail) or by fax. Appeals may be submitted by you, your representative or a doctor acting on your behalf. Please see below for more information on who may ask for an appeal. If the plan determines that the request meets the expedited criteria, the plan will render a decision as quickly as your health condition requires but not more than 72 hours after your request is received. If the request does not meet the expedited criteria, you will be notified orally and in writing; and the plan will render a decision within the standard time frame of 30 calendar days for medical appeals and seven (7) calendar days for drug appeals. For medical appeals, a 14-calendar day extension can be requested by a customer or Cigna if additional information is needed. If an extension is approved, you will be notified in writing.

Who may ask for an appeal?

If you have received a Notice of Denial, and you disagree with the decision rendered, you can ask us for an appeal yourself, or your doctor or someone you name may do it for you. The person you name will be your appointed representative. You can name a relative, friend, advocate, doctor or anyone else to act for you. If you want someone to act for you, then you and that person must sign and date the Appointment of Representative statement that gives the person legal permission to act as your appointed representative. This statement must be faxed to us at the number below, or you may mail the Appointment of Representative Form to us at the address below. This does not have to be completed if a doctor or other prescriber is submitting a request.

If you have not received a Notice of Denial, you must file a request for a coverage decision before filing an appeal.

Where to send an Appeal

 

To contact us by mail:

Call our Medicare Appeal Coordinator:

Cigna Medicare Services

Attn: Medicare Appeal Department

25500 N. Norterra Dr.

Phoenix, AZ 85085

 

Phone Number:

1-800-973-2580, option 2

TTY/TDD:

711

Toll-Free Fax Number:

1-866-567-2474


Monday - Friday, 8 am to 6 pm Arizona time
(a voicemail system is available on weekends and holidays).

 

Grievances

A grievance is any dispute expressing dissatisfaction with any aspect of the health plan's operations or activities. Plan grievances can be received by customer service representatives via mail, telephone or fax.

In order to exercise this right, you must file your grievance no later than 60 calendar days after the event or incident that brought about the grievance. Every effort will be made to resolve your concern within five (5) calendar days. If we are unable to resolve your complaint to your satisfaction, your complaint will be transferred to the health plan for further investigation and you will receive a response no later than 30 calendar days from the date your grievance was received. A 14-calendar-day extension can be requested by you or by Cigna if additional information is needed. If an extension is approved, you will be notified in writing.

Where to file a grievance

Cigna Medicare Services
Attention: Medicare Grievance Department
P.O. Box 42005
Phoenix, AZ 85080-2005

Phone Number:

1-800-627-7534

TTY/TDD:

711

Toll-Free Fax Number:

1-866-567-2474

October 1, 2013 - February 14, 2014: 7 days a week, 8 am to 8 pm, Arizona time.

February 15, 2014 - September 30, 2014:
Monday - Friday, 8 am to 8 pm Arizona time
(a voicemail system is available on weekends and holidays).

 

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The Office of the Medicare Ombudsman (OMO) helps you with complaints, grievance and information requests.

Medicare Ombudsman  |  Medicare Complaint Form

For more information regarding the Cigna Medicare Appeal, Grievance and Organization Determination process, please refer to your Evidence of Coverage booklet. For information regarding Cigna Medicare Services' aggregate number of appeals, quality of care grievances and exceptions filed annually, please call 1-800-627-7534 (TTY: 711), 7 days a week 8 am to 8 pm. (Hours apply Monday – Friday February 15 – September 30. A voicemail system is available on weekends and holidays.)