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Coverage and Claims
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.
|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|
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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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 The Cigna Group 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 Healthcare name, logo, and other Cigna Healthcare marks are owned by The Cigna Group Intellectual Property, Inc. LINA and NYLGICNY are not affiliates of Cigna Healthcare.
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