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Home Providers Coverage and ClaimsAppeals and Disputes

Cigna Appeals and Disputes Policy and Procedures

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

Cigna strives to informally resolve issues raised by health care providers on initial contact whenever possible. If issues cannot be resolved informally, Cigna 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 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 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

How to Submit an Appeal

Typical Appeals Process

Medicare Customer Appeals Process and Exceptions

Medicare Select Plus Rx Appeals

California-Specific Appeals

More in Coverage and Claims

Prior Authorizations Coverage Policies Claims Payments HIPAA Transaction Standards Referrals ID Cards [PDF]

Appeals Forms

Billing Dispute Resolution Form [PDF] Billing Dispute External Review Form [PDF] Appeal Request Form [PDF] Provider Payment Review [PDF] California Appeal Request Form [PDF] New Jersey Appeal Request Form [PDF] Medicare Provider Appeal Form Medicare Customer Appeal Form

Back to Coverage and Claims

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 or applicable law, the terms of your agreement or the applicable law will supersede this guide.

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Individual and family medical and dental insurance plans are insured by Cigna Health and Life Insurance Company (CHLIC), Cigna HealthCare of Arizona, Inc., Cigna HealthCare of Illinois, Inc., Cigna HealthCare of Georgia, Inc., Cigna HealthCare of North Carolina, Inc., Cigna HealthCare of South Carolina, Inc., and Cigna HealthCare of Texas, Inc. Group health insurance and health benefit plans are insured or administered by CHLIC, Connecticut General Life Insurance Company (CGLIC), or their affiliates (see a listing of the legal entities that insure or administer group HMO, dental HMO, and other products or services in your state). Accidental Injury, Critical Illness, and Hospital Care plans or insurance policies are distributed exclusively by or through operating subsidiaries of Cigna Corporation, are administered by Cigna Health and Life Insurance Company, and are insured by either (i) Cigna Health and Life Insurance Company (Bloomfield, CT); (ii) Life Insurance Company of North America (“LINA”) (Philadelphia, PA); or (iii) New York Life Group Insurance Company of NY (“NYLGICNY”) (New York, NY), formerly known as Cigna Life Insurance Company of New York. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. LINA and NYLGICNY are not affiliates of Cigna.

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