Skip to main navigation Skip to main content Skip to footer For Individuals & Families For Providers For Brokers For Employers Español For Medicare: For Medicare Medicare Overview Medicare Advantage (Part C) Medicare Part D Prescription Drug Plans (PDP) Medicare Supplement Insurance Choosing a Medicare Plan What is Medicare Advantage (Part C)? What is Medicare Supplement? What is Medicare Part D? See all topics Overview Customer Forms Find Your Plan Documents Health Risk Assessment Premium Payment Options Provider and Pharmacy Directories Group Plans Resources Group Plans Provider Network Log in to myCigna Overview Medicare Advantage Eligibility and Enrollment Medicare Part D Eligibility and Enrollment Medicare Supplement Eligibility and Enrollment Choosing a Medicare Plan What is Medicare Advantage (Part C)? What is Medicare Supplement? What is Medicare Part D? See all topics Find a Doctor Log in to myCigna
Home Medicare Member Resources and ServicesMedicare Appeals Process & Exceptions Medicare

Medicare Appeals Process and Exceptions

Learn what an appeal is, fast track appeals, how to file, and what to do if your appeal is denied.

What is an appeal?

An appeal, or redetermination, is a formal way to ask the plan to review a coverage decision about health care services and/or prescription drugs. You may ask for a review when you are not satisfied with our initial coverage decision. You may ask for an appeal if:

  • You were denied payment for services and/or covered prescription drugs you already received or paid for.
  • You do not agree with a decision to stop getting a particular service.
  • Cigna doesn't pay for a drug, item, or service you think you should be able to get.

You must make your request within 60 days from the date of the coverage determination.

Part C - Regulated Medical Appeals

Who can file?

You or your appointed representative (someone you name to act for you) may ask for a medical appeal. You can name a relative, friend, attorney, doctor, or someone else to act for you with an Appointment of Representative form. Under state law, others may already be allowed to act for you. A physician who is giving you treatment may, upon giving you notice, ask for a standard reconsideration on your behalf without submitting a representative form.

Get an Appointment of Representative form [PDF]

Types of Medical Appeals
  • Standard Claim Appeals
    If you are asking for reimbursement for medical care you have already received, this is a Standard Claim Appeal. We will give you an answer within 60 days of your filing.
  • Standard Medical Pre-Service Appeals
    If you are asking for coverage for medical care you have not yet received, this is a Standard Medical Pre-Service Appeal. We will give you an answer within 30 days of your filing. We can take up to 14 more days if you ask for more time or if we need information that may help you. If we decide to take extra time, we will tell you in writing.
  • Fast Medical (Expedited) Appeals
    You or your doctor (without an appointment of representative form) can request a Fast Medical Appeal by phone or mail if waiting for a Standard Appeal could harm your health or your ability to function. You can get one:
    • For medical care you have not yet received
    • If you're getting Medicare services from a hospital, skilled nursing facility, home health agency, comprehensive outpatient rehabilitation facility, or hospice, and you think your Medicare-covered services are ending too soon. Your doctor will give you a notice before your services end that will tell you how to ask for a Fast Medical Appeal in your area. An independent reviewer, called a Quality Improvement Organization (QIO), will decide if your services should continue.
    We will give you an answer within 72 hours. We can take up to 14 more days if you ask for more time or if we need information that may help you. If we decide to take extra time, we will let you know.
  • Non Contracted Provider Dispute
    A disagreement about the amount that a non-contracted provider could have collected if the beneficiary were in original Medicare.
  • Non Contracted Provider Appeal
    The process used when a party (for example, a patient, provider, or supplier) disagrees with an initial health care items or services determination or a revised determination. If Plan is denying or recouping part or all of a payment for which the non-contracted provider asked, such as for DRG coding, clinical validation, inpatient level of care determination, bundling rules, or emergency facility charges, the Plan must issue an appealable organization determination. Appeals (reconsiderations) from a non-contracted provider must follow the regulations outlined at 42 CFR §422 Subpart M.
How do I file my appeal?

For customers enrolled in a Cigna Medicare Advantage Plan with or without Prescription Drug Coverage

Mail
Cigna Medicare
Attn: Part C Regulated Medical Appeals
PO Box 188081
Chattanooga, TN 37422

Phone (Expedited Appeals Only):  (TTY 711)

Phone (Arizona Expedited Appeals Only):  (TTY 711)

Fax: 

Hours for phone and fax:
October 1-March 31: 8 am-8 pm, 7 days a week
April 1-September 30: Monday-Friday 8 am-8 pm, Saturday 8 am-6 pm
Messaging service used weekends, after hours, and federal holidays.

Find Appeal, Claim, and Dispute Forms

Part D - Pharmacy Appeals

Who can file a Pharmacy appeal?

You, your representative, or your prescriber may request a pharmacy appeal. You can name a relative, friend, attorney, doctor, or someone else to act for you with an Appointment of Representative form. Under state law, others may already be allowed to act for you.

Get an Appointment of Representative form [PDF]

You must make your request within 60 days from the date of the coverage determination. A coverage determination is the first decision made by your Medicare drug plan (not the pharmacy) about your drug benefits.

Types of Pharmacy Appeals
  • Standard Pharmacy Appeals
    If you’re asking for a Standard Appeal for prescription drugs, we will give you an answer within 7 calendar days of receipt of your request.
  • Fast Pharmacy Appeals
    You may also ask for a Fast Appeal for prescription drugs, if waiting for a Standard Appeal could seriously harm your health or your ability to function. If you are asking for a Fast Appeal for prescription drugs, we will give you an answer within 72 hours of receipt of your request.
How do I file my appeal?

For customers enrolled in a Cigna Medicare Advantage Prescription Drug Plan (except Arizona)

Mail
Cigna Medicare Part D Appeals (Pharmacy)
PO Box 24087
Nashville, TN 37202

Phone: (TTY 711)

Fax:

Hours:
October 1 - March 31: 8 am - 8 pm, 7 days a week
April 1 - September 30: Monday - Friday 8 am - 8 pm, Saturday 8 am - 6 pm
Messaging service used weekends, after hours, and federal holidays.

If you are calling us to start a standard or Fast appeal after normal business hours, please include all of the following information in your message:

  • Customer's name
  • Phone number
  • Prescription being appealed with the strength
  • Your doctor's name and phone number
  • Clarification that you are requesting a Standard or Fast appeal

For Arizona customers enrolled in a Cigna Medicare Advantage Prescription Drug Plan

Mail
Cigna Medicare Services
Attn: Medicare Appeal Dept.
PO Box 29030
Phoenix, AZ 85038

Phone: (TTY 711)

Fax:

Hours:
8 am - 6 pm, Monday - Friday

If you are calling us to start a standard or Fast appeal after normal business hours, make sure you have all the information below in your message:

  • Customer's name
  • Phone number
  • Prescription being appealed with the strength
  • Your doctor's name and phone number
  • Whether you are asking for a Standard or Fast appeal

For customers enrolled in a Cigna Medicare Standalone Part D Prescription Drug Plan

Mail
Cigna Medicare Part D Appeals (Pharmacy)
PO Box 24207
Nashville, TN 37202

Phone: (TTY 711)

Fax:

Hours:
8 am - 8 pm, 7 days a week
Our automated phone system may answer your call during weekends from April 1 - September 30.

If you are calling us to start a standard or Fast appeal after normal business hours, make sure you have all of the information below in your message:

  • Customer's name
  • Phone number
  • Prescription being appealed with the strength
  • Your doctor's name and phone number
  • Whether you are asking for a Standard or Fast appeal

Denied Appeals

What if my appeal is denied?

If Cigna denies your appeal for medical care, we will send you an explanation of our decision in writing, and your case will automatically be sent to Level 2 of the appeals process. At Level 2, the Independent Review Organization reviews our plan's decision to decide if it is correct or if it should be changed. If you had a Fast Track Appeal at Level 1, you will have a Fast Track Appeal at Level 2. The time frames for a Fast and Standard Appeal at Level 2 are the same as for the initial appeal.

If our plan denies your appeal for a Part D prescription drug, you will need to choose whether to accept this decision or appeal it to Level 2. The notice we send you denying your Level 1 Appeal will include instructions on how to make a Level 2 Appeal. They will tell you who can make the appeal, deadlines you must follow, and how to reach the review organization.

At Level 2, the Independent Review Organization reviews our plan's decision and decides if it is correct or if it should be changed. If you had a Fast Appeal at Level 1, you will have a Fast Appeal at Level 2. The time frames for a Fast and Standard Appeal at Level 2 are the same as for the initial appeal. If the answer to your Level 2 Appeal is no, it means the review organization agrees with our decision not to approve your request.

Appeal Levels 3, 4, and 5

To reach a Level 3 Appeal, the dollar value of the drug or medical care you are asking for must meet a minimum amount. If the dollar value is too low, you cannot make another appeal and the decision at Level 2 is final. The notice you get denying your Level 2 Appeal will tell you if the dollar value is high enough to move on to Level 3. If you qualify for a Level 3 Appeal, an Administrative Law Judge will review your appeal and make a decision. If you do not agree with the decision the judge makes, you can move on to a Level 4 Appeal.

At the Level 4 Appeal, the Medicare Appeals Council, who works for the federal government, will review your appeal and give you an answer. If you do not agree with the decision at Level 4, you may be able to move on to the next level of review.

A Level 5 Appeal is reviewed by a judge at the Federal District Court. This is the last stage of the appeals process. To learn more about these additional levels of appeal, see the Chapter named "What to do if You Have a Problem or Complaint" in your Evidence of Coverage.

Questions and Complaints

If you have questions about appeals, exceptions, and/or grievances or if you want to get an aggregate total of appeals/exceptions/grievances filed with the plan, please call us at the numbers listed for your plan above.

If you have a complaint, you can send feedback straight to Medicare using the Medicare Complaint form.


Page Footer

Customer Plan Links

Choosing a Medicare Plan Community Resources Disaster Policy Enrollment and Eligibility Filing a Grievance Medicare Appeals Process and Exceptions Medicare Coverage Decisions Medicare Disenrollment Organization Determination Pre-Enrollment Disclaimers

Other Cigna Websites

Leon Medical Centers Health Plans Texas Medicaid STAR+PLUS Texas Medicare-Medicaid Plan

Audiences

Individuals and Families Medicare Employers Brokers Providers About Cigna

Solutions for

Health Care Providers Pharmacists Pharmacy Residents Group Plans

Medicare Links

Medicare.gov Medicare Ombudsman Medicare Complaint Form

 Cigna. All rights reserved.

Privacy Legal Medicare Supplement State Disclosures Customer Rights Accessibility Notice of Non-Discrimination Language Assistance [PDF] Report Fraud Sitemap

Medicare Advantage Policy Disclaimers

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. All clinical products and services of the LivingWell Health Centers are either provided by or through clinicians contracted with HealthSpring Life & Health Insurance Company, Inc., HealthSpring of Florida, Inc., Bravo Health Mid-Atlantic, Inc., and Bravo Health Pennsylvania, Inc. or employees leased by HS Clinical Services, PC, Bravo Advanced Care Center, PC (PA), Bravo Advanced Care Center, PC (MD) and not by Cigna Corporation. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. All pictures are used for illustrative purposes only.

Cigna contracts with Medicare to offer Medicare Advantage HMO and PPO plans and Part D Prescription Drug Plans (PDP) in select states, and with select State Medicaid programs. Enrollment in Cigna depends on contract renewal.

Medicare Supplement Policy Disclaimers

Medicare Supplement website content not approved for use in: Minnesota, Missouri, North Carolina, North Dakota, Oregon, Virginia.

AN OUTLINE OF COVERAGE IS AVAILABLE UPON REQUEST. We'll provide an outline of coverage to all persons at the time the application is presented.

Our company and agents are not connected with or endorsed by the U.S. Government or the federal Medicare program. This is a solicitation for insurance. An insurance agent may contact you. Premium and benefits vary by plan selected. Plan availability varies by state. Medicare Supplement policies are underwritten by Cigna National Health Insurance Company, Cigna Health and Life Insurance Company, American Retirement Life Insurance Company or Loyal American Life Insurance Company. Each insurer has sole responsibility for its own products.

The following Medicare Supplement Plans are available to persons eligible for Medicare due to disability: Plan A in Arkansas, Connecticut, Indiana, Maryland, Oklahoma, Texas, and Virginia; Plans A, F, and G in North Carolina; and Plans C and D in New Jersey for individuals aged 50-64. Medicare Supplement policies contain exclusions, limitations, and terms under which the policies may be continued in force or discontinued. For costs and complete details of coverage, contact the company.

This website is designed as a marketing aid and is not to be construed as a contract for insurance. It provides a brief description of the important features of the policy. Please refer to the policy for the full terms and conditions of coverage.

American Retirement Life Insurance Company, Cigna National Health Insurance Company and Loyal American Life Insurance Company do not issue policies in New Mexico.

Kansas Disclosures, Exclusions and Limitations

Medicare Supplement Policy Forms: Plan A: CNHIC-MS-AA-A-KS, CNHIC-MS-AO-A-KS; Plan F: CNHIC-MS-AA-F-KS, CNHIC-MS-AO-F-KS; Plan G: CNHIC-MS-AA-G-KS, CNHIC-MS-AO-G-KS; Plan N: CNHIC-MS-AA-N-KS, CNHIC-MS-AO-N-KS

Exclusions and Limitations:

The benefits of this policy will not duplicate any benefits paid by Medicare. The combined benefits of this policy and the benefits paid by Medicare may not exceed one-hundred percent (100%) of the Medicare Eligible Expenses incurred. This policy will not pay benefits for the following:

(1) the Medicare Part B Deductible;

(2) any expense which You are not legally obligated to pay; or services for which no charge is normally made in the absence of insurance;

(3) any services that are not medically necessary as determined by Medicare;

(4) any portion of any expense for which payment is made by Medicare or other government programs (except Medicaid); or for which payment would have been made by Medicare if You were enrolled in Parts A and B of Medicare;

(5) any type of expense not a Medicare Eligible Expense except as provided previously in this policy;

(6) any deductible, Coinsurance or Co-payment not covered by Medicare, unless such coverage is listed as a benefit in this policy; or

(7) Preexisting Conditions: We will not pay for any expenses incurred for care or treatment of a Preexisting Condition for the first six (6) months from the effective date of coverage. This exclusion does not apply if You applied for and were issued this policy under guaranteed issue status; if on the date of application for this policy You had at least six (6) months of prior Creditable Coverage; or, if this policy is replacing another Medicare Supplement policy and a six (6) month waiting period has already been satisfied. Evidence of prior coverage or replacement must have been disclosed on the application for this policy. If You had less than six (6) months prior Creditable Coverage, the Preexisting Conditions limitation will be reduced by the aggregate amount of Creditable Coverage. If this policy is replacing another Medicare Supplement policy, credit will be given for any portion of the waiting period that has been satisfied.

Selecting these links will take you away from Cigna.com to another website, which may be a non-Cigna website.

Y0036_22_101121_M | Page last updated 06/01/2022 .