California Dispute Resolution Policy

Policies and procedures for resolving disputes in California

In California, health care providers may choose to enter dispute resolution once the appeals have been exhausted, or the issues is not related to a claim.

To initiate a dispute, health care providers in California must submit their request in writing within 365 calendar days from the date of the initial payment or denial notice, or if the appeal relates to an adjusted payment, within 365 calendar days from the date of the adjustment.

  1. Fill out the Request for Health Care Professional Payment Review [PDF]. The form will help to fully document the circumstances around the appeal request and will also help to ensure a timely review of the appeal. All forms should be fully completed, including selecting the appropriate check box for the reason for the appeal. Appeal Types are available in the National Reference Guide available on the CignaforHCP portal
  2. Gather appropriate supporting documentation, listed within Health Care Professional Dispute Resolution Request - CA HMO [PDF]1, including:
    1. The original claim (if not previously submitted)
    2. The EOP
    3. Appeals with a clinical component must include a narrative, operative report and medical records.
  3. Submit appeals to:
    Cigna HealthCare of California, Inc.
    National Appeals Unit
    PO Box 188011
    Chattanooga, TN 37422
  4. Health care providers will receive notification of PPO, EPO and Open Access Plus Products dispute resolutions within 75 business days of receipt of the original dispute. If approved, the Explanation of Payment will serve as notice of the determination. If the initial payment decision is upheld, health care providers will receive a letter outlining any additional rights, if applicable.
  5. Cigna will send a letter acknowledging a California HMO and POS dispute within 15 business days of receipt by the P.O. Box designated to receive Cigna HealthCare of California, Inc. health care provider disputes. Furthermore, health care providers will receive a determination letter that will indicate the dispute resolution, explanation for resolution and amount of additional payment, if applicable. Cigna will send this determination letter within 45 business days of its receipt of a Cigna HealthCare of California, Inc. dispute.

Exceptions

  • While members may appeal non provider-payment disputes to Cigna directly, you may appeal on their behalf.
  • When it is determined that an error was made in processing a claim (that is, not in accordance with the contract and/or a policy), the issue will be tracked and processed as a claim adjustment rather than a health care provider dispute, unless the health care provider submits the adjustment request after payment has previously been adjusted twice.
  • For disputes involving Connecticut General Life Insurance Company and Cigna Health and Life Insurance Company participants in the state of California, Cigna has a single-level process for disputes involving post-service payment issues. This includes participants in the PPO, EPO, Open Access Plus, HMO and POS Products. This dispute process is applicable to both the contracted and non-participating (non-contracted) health care providers that are appealing on behalf of the customer. If you are not satisfied with this decision, please refer to the dispute resolution provisions of your health care provider Contract and/or Program Requirements with Cigna HealthCare of California, Inc. Requests for alternate dispute resolution must be submitted within one year from the date of this letter, subject to applicable law and your health care provider agreement.
  • If a health care provider is appealing 100 or more claims in a single submission, an electronic Excel spreadsheet that individually numbers each claim is required, along with hard copies of the claims (if not previously submitted) and the appropriate supporting documentation (numbered accordingly). For further information regarding dispute submission requirements, please contact your health care provider Services Representative. When a large number of claim denials are submitted for review at the same time ("claim projects"), they are not automatically considered health care provider disputes. These review requests are tracked as disputes if Cigna determines the original payment was made in accordance with the contract and Cigna policies.

1The California HMO form titled Health Care Professional Dispute Resolution Request - CA HMO [PDF], although not required, is available to help prepare the documentation for an appeal request.