Home Providers Coverage and Claims Appeals and Disputes

Appeals and Disputes Policy and Procedures

How, why, and what health care providers can expect when filing an appeal or dispute.

Cigna HealthcareSM strives to informally resolve issues raised by health care providers on initial contact whenever possible. If issues cannot be resolved informally, Cigna Healthcare offers two options:

  • An appeal process for resolving contractual disputes regarding post-service payment denials and payment disputes1
  • For claim denials relating to claim coding and bundling edits, a health care provider may have the option to request binding external review through the Billing Dispute Administrator
  • Following the internal Cigna Healthcare process, arbitration may be used as a final resolution step

Why Submit an Appeal

The payment appeal process is different from routine requests for follow-up inquiries on claim processing errors or missing claim information. Most claim issues can be remedied quickly by providing requested information to a claim service center or contacting us.

Before beginning the appeals process, please call Cigna Healthcare Customer Service at 1(800) 88Cigna (882-4462) to try to resolve the issue. 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 [PDF].2 The following services can be appealed.

Scenario Appeal Path
Precertification (authorization) denial (for services not yet rendered) Customer appeal
Precertification (authorization) not obtained – services denied Health care provider appeal
Claim reimbursement denial (including mutually exclusive, incidental, or bundling denials, and modifier reimbursements) Health care provider 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

1 Processes may vary due to state mandates or contract provisions.

2 If there is conflict between this reference guide and your health care provider agreement with Cigna Healthcare or applicable law, the terms of your agreement or the applicable law will supersede this guide.

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