Medicare Appeals Process and Exceptions

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

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

  • 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.

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): 1 (800) 668-3813 (TTY 711)

Phone (Arizona Expedited Appeals Only): 1 (800) 627-7534 (TTY 711)

Fax: 1 (855) 350-8671

Hours for phone:
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

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

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.

  • 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.

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: 1 (866) 845-6962 (TTY 711)

Fax: 1 (866) 593-4482

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: 1 (800) 973-2580 (TTY 711)

Fax: 1 (866) 567-2474

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: 1 (800) 222-6700 (TTY 711)

Fax: 1 (866) 593-4482

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

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.

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.

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.