Appeal Policy & Procedures for Health Care Professionals
- Health Care Professional Payment Appeals
- Single Level Appeals
- Additional Payment Appeal Options
- Health Care Professional Termination Appeals
Health Care Professional Payment Appeals
Cigna HealthCare strives to informally resolve issues raised by health care professionals on initial contact whenever possible. If issues cannot be resolved informally, Cigna HealthCare offers a single-level, internal appeal process for resolving contractual disputes regarding post-service payment denials and payment disputes. Processes may vary due to state mandates or contract provisions. Following the internal Cigna HealthCare process, arbitration may be used as a final resolution step.
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. If a claim resubmission is unsuccessful, filing an appeal may be warranted.
Note: If there is conflict between this reference guide and your health care professional agreement with Cigna HealthCare or applicable law, the terms of your agreement or the applicable law will supersede this guide.
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All appeals must be submitted in writing within 180 calendar days of the date of the initial payment or denial notice or, if the appeal relates to a payment that was adjusted by Cigna HealthCare, within 180 calendar days from the date of the last payment adjustment.
Review the Claim Adjustment & Appeals Guidelines for additional information on how to submit an appeal. To allow us the opportunity to provide a full and thorough review, health care professionals should submit complete information with their appeal.
The review will be completed in 60 days and the healthcare professional will receive notification of the dispute resolution within 75 business days of receipt of the original dispute. If a decision is made to uphold the decision, an appeal denial letter will be sent to the health care professional outlining any additional appeal rights, if aplicable. An appeal determination that overturns the initial decision will be communicated through the explanation of payment with the reprocessed claim. Time periods are subject to applicable law and the health care professional agreement.
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Additional Payment Appeal Options
After exhausting the internal appeal process, arbitration may serve as a binding, final resolution step as specified in a health care professional agreement and/or Program Requirements/Administrative Guidelines.
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Health Care Professional Termination Appeals
On occasion, Cigna deems it necessary to terminate a health care professional’s participation. Appeal rights are offered to health care professionals terminated due to Quality of Care or Quality of Service and health care professionals terminated for failure to meet Cigna credentialing requirements in states that mandate appeal rights be offered. To initiate a review of a health care professional’s termination, submit the following information in writing within 30 calendar days of the date of the health care professional’s termination notice.
- A completed health care professional termination appeal letter indicating the reason for the appeal
- A copy of the original termination notice
- Supporting documentation for reconsideration
Payment or termination disputes that are not resolved through internal review appeals process or the additional payment appeal options referenced about and any other disputes between the parties regarding the performance or interpretation of a health care professional agreement will be resolved through arbitration. Either party may initiate arbitration by providing written notice to the other party. With respect to health care professional payment or termination disputes, you must request arbitration within one year of the date of the letter communicating the final internal level review decision.
If an arbitration provision was placed in your health care professional agreement, the terms and conditions of that provision will apply. If your health care professional agreement does not include an arbitration provision, the following will apply.
- The appealing parties prepare a Request for a Dispute Resolution List and submit it to the American Health Lawyers Association Alternative Dispute Resolution Service (AHLA ADR Service) along with the appropriate administrative fee. More information about the AHLA ADR Service can be found on the AHLA website
- Arbitration will be the exclusive remedy for disputes arising under the health care professional agreement
- The decision of the arbitrator(s) will be final, conclusive and binding, and no other recourse may be taken by either party other than to enforce the award of the arbitrator(s)
- This resolution procedure is a private undertaking and may not be consolidated with other health care professionals or third parties and may not be conducted on a class basis
- Judgment of the arbitrator(s) award may be entered in any court of competent jurisdiction
The health care professional agreement remains in force during arbitration unless otherwise terminated in accordance with the terms of the health care professional agreement.
If you do not request an internal appeals review or arbitration of the dispute within the defined timeframes, the last Cigna Healthcare determination will be final. Customers cannot be billed for any amount denied because you failed to submit the request for review or arbitration within the required timelines.
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