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.
|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
1Processes may vary due to state mandates or contract provisions.
2If 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.