Seeing Your Doctor
Cigna HealthCare wants you to be satisfied with your health care plan. That's why we have a process to address your concerns and complaints and an appeal process to request review of coverage decisions.
Member Services can help
If you have questions about coverage or services or are experiencing a problem, start by calling Member Services at the toll-free number on your Cigna HealthCare ID card. A representative will try to answer your questions or resolve your concerns/complaints during the call, but not including requests for coverage-review decisions. If Member Services cannot resolve your concerns, ask the representative for more information about how to have your concerns addressed.
How to request an appeal of a coverage decision
The specific appeal process that applies to you is determined by the type of benefits plan your employer has chosen and follows state and/or federal rules that apply to that type of benefits plan. If you request review of a coverage decision, you will be given information in writing about the appeal process. You can also refer to your Group Service Agreement, Group Insurance Certificate or other benefits-plan document or call Member Services for additional information.
Following is a general description of the two-level appeal process for coverage decisions. To begin the process, call Member Services at the number on your Cigna HealthCare ID card. Indicate why you believe the first decision should be reviewed again. Include any documentation that supports your appeal with your written appeal request or promptly after you request an appeal by phone.
Your request will be reviewed by someone who was not involved in the initial decision and who can take corrective action. Decisions will be based upon the terms of your benefits plan. A physician will be involved in any review related to medical necessity. If your situation requires urgent care, the review and response will be expedited.
You will be notified of the appeal decision. If you're not satisfied with the first-level decision, you may request another review, called a "second level appeal." If the appeal involves a coverage decision based on issues of medical necessity or experimental treatment, a committee will conduct this appeal review. The committee will usually consist of at least three people: a physician reviewer, nurse reviewer, and a non-clinician. All committee members will not have been involved in any prior decision of your issue nor be subordinates of previous decision makers. You will be notified in advance as to when the committee meeting will occur, and you or your representative can present your position to the committee by phone or in writing. For benefit coverage related appeals, a full and fair review will be conducted by someone who was not involved in any previous decision. Provide all relevant documentation with your second level appeal request that supports your position that the previous benefit coverage decision should be changed. In urgent cases, the review and response will be expedited.
An Independent External Review May Be Available
You will be notified of the second-level appeal decision. If you are not satisfied with the decision, other remedies may be available to you, depending on the type of plan that your employer has chosen.
If the appeal involves a coverage decision based on issues of medical necessity or experimental treatment, you can request independent review by an external review organization. If external review is available to you, you will be provided with instructions, after the final internal appeal, on how to request this review. The decision of the external reviewer is binding upon Cigna HealthCare or your employer, but not upon you.
If you are covered under an insurance policy offered by an HMO, the state insurance department or other government agency may be able to assist you in resolving your dispute. If your benefits plan is self-insured by your employer, your employer may have elected not to offer external review. Check with your employer or in your summary plan description for more options.
In most cases, you must complete the two-level Cigna HealthCare appeal process described above before pursuing arbitration or legal action. You should consider taking advantage of the independent external review that may be available. To learn more about the appeal process, call Member Services.