APPEALS

An appeal is a formal way to ask the plan to review a coverage decision about health care services and/or prescription drugs when you are not satisfied with our initial coverage decision. This includes a decision to deny payment for services and/or covered prescription drugs you already received or paid for. You may also file an appeal if you disagree with a decision to stop services that you are receiving. For example, you may ask for an appeal if our plan doesn’t pay for a drug, item, or service you think you should be able to receive.

Part C - Medical Appeals

You or your appointed representative (someone you name to act for you) may request an appeal. You can name a relative, friend, attorney, doctor, or someone else to act for you. Others may already be authorized under state law to act for you.  You may download the Appointment of Representative form. For standard pre-service reconsiderations, a physician who is providing treatment to you may, upon providing notice to you, request a standard reconsideration on your behalf without submitting a representative form. A non-contract provider, on his or her own behalf, is permitted to file a standard appeal for a denied claim only if the non-contract provider completes a waiver of liability statement, which provides that the non-contract provider will not bill the enrollee regardless of the outcome of the appeal.

Part D - Pharmacy Appeals

An enrollee, an enrollee’s representative, or an enrollee's prescribing physician or other prescriber may request an appeal. You can name a relative, friend, attorney, doctor, or someone else to act for you. Others may already be authorized under state law to act for you. You may download the Appointment of Representative form.

If you disagree with your plan's initial denial, you can request a redetermination, but you must make your request within 60 days from the date of the coverage determination.

It is best to file an appeal as soon as you decide that you disagree with a coverage decision or payment decision our plan has made. However, except in special situations, you have up to 60 days from the date of the coverage decision to file your appeal.

If you are asking for a Fast Medical (Expedited) Appeal you or your appointed representative (someone you name to act for you) may request an appeal. You can name a relative, friend, attorney, doctor, or someone else to act for you. Others may already be authorized under state law to act for you. You may download the Appointment of Representative form . For medical care you have not yet received and if waiting for a Standard Appeal could seriously harm your health or your ability to function, you or your doctor (without an appointment of representative form) may request an appeal by calling 1-800-668-3813, TTY 711, faxing 1-800-931-0149, or writing to Cigna-HealthSpring, Attn: Appeals, P.O. Box 24087, Nashville, TN 37202-4087. If you are asking for a Fast Appeal for medical care, we will give you an answer within 72 hours; however, we can take up to 14 more days if you ask for more time or if we need information that may benefit you. If we decide to take extra time, we will tell you orally and in writing.

If you are asking for a Standard Medical (Pre Service) Appeal you or your appointed representative (someone you name to act for you) may request an appeal. You can name a relative, friend, attorney, doctor, or someone else to act for you. Others may already be authorized under state law to act for you. You may download the Appointment of Representative form . A physician who is providing treatment to you may, upon providing notice to you, request a standard reconsideration on your behalf without submitting a representative form. You may fax 1-800-931-0149, or write  to Cigna-HealthSpring, Attn: Appeals, P.O. Box 24087, Nashville, TN 37202-4087. If you are requesting coverage for medical care you have not yet received, we will give you an answer within 30 days. However, we can take up to 14 more days if you ask for more time or if we need information that may benefit you. If we decide to take extra time, we will tell you in writing.

If you are asking for a Standard Claim Appeal or a request for reimbursement you or your appointed representative (someone you name to act for you) may request an appeal. You can name a relative, friend, attorney, doctor, or someone else to act for you. Others may already be authorized under state law to act for you. You may download the Appointment of Representative form . You may fax 1-800-931-0149, or write  to Cigna-HealthSpring, Attn: Appeals, P.O. Box 24087, Nashville, TN 37202-4087. If your request is for payment for medical care you have already received, we will give you an answer within 60 days.

If you are asking for a Standard Pharmacy Appeal, you, your prescribing physician or other prescriber may call or write to our plan:

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

Mail:

Cigna-HealthSpring Part D Appeals (Pharmacy)
PO Box 24207
Nashville, TN 37202

Phone:

1-866-845-6962 TTY: 711
Fax: 1-866-593-4482

Hours (Local Time): October 1st – February 14th: 8:00 am - 8:00 pm, 7 days a week. 
February 15 – September 30: Monday – Friday 8:00 am - 8:00 pm, Saturday 8:00 am - 6:00 pm.
Messaging service used weekends, after hours, and Federal holidays.

For ARIZONA CUSTOMERS enrolled in a Cigna-HealthSpring Medicare Advantage Prescription Drug Plan

Mail:

Cigna Medicare Services
Attn: Medicare Appeal Dept.
P.O. Box 29030
Phoenix, AZ 85038

Phone:

1-800-973-2580 TTY: 711
Fax: 1-866-567-2474

Hours (AZT):

Option 2, 8 a.m. to 6 p.m., Monday – Friday.

For customers enrolled in a Cigna-HealthSpring standalone Part D Prescription Drug Plan

Mail:

Cigna-HealthSpring Part D Appeals (Pharmacy)
PO Box 24207
Nashville, TN 37202

Phone:

1-800-222-6700 TTY: 711
Fax: 1-866-593-4482

Hours (Local Time):

8am-8pm, 7 days a week.
Our automated phone system may answer your call during weekends from Feb. 15 – Sept. 30.

You can find a pharmacy appeal form (as well as an online form) on our forms page. Use of this form is optional. If you are requesting coverage for a Standard Appeal for prescription drugs, we will give you an answer within 7 calendar days of receipt of your request. If you are calling us to start a Standard Appeal after normal business hours (Monday - Friday, 8 am to 8 pm), 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, and please provide clarification that you are requesting a Standard Appeal.

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. You, your prescribing physician or other prescriber may call or write to our plan (please see contact information for your plan above). You can find a pharmacy appeal form (as well as an online form) on our forms page. Use of this form is optional. If you are requesting coverage for a Fast Appeal for prescription drugs, we will give you an answer within 72 hours of receipt of your request. If you are calling us to start a Fast Appeal after normal business hours (Monday - Friday, 8 am to 8 pm), 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, and please provide clarification that you are requesting a Fast Appeal.

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

Mail:

Cigna-HealthSpring
Attn: Appeals (Medical)
P.O. Box 24087
Nashville, TN 37202-4087

Phone (Expedited Appeals Only):

1-800-668-3813 TTY: 711

Fax: 1-800-931-0149

Hours (Local Time):

October 1st – February 14th: 8:00 am - 8:00 pm, 7 days a week. 

February 15 – September 30: Monday – Friday 8:00 am - 8:00 pm, Saturday 8:00 am - 6:00 pm. 

Messaging service used weekends, after hours, and Federal holidays.

 

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

Mail:

Cigna-HealthSpring Part D Appeals (Pharmacy)
PO Box 24207
Nashville, TN 37202

Phone:

1-866-845-6962 TTY: 711

Fax: 1-866-593-4482

Hours (Local Time):

October 1st – February 14th: 8:00 am - 8:00 pm, 7 days a week. 

February 15 – September 30: Monday – Friday 8:00 am - 8:00 pm, Saturday 8:00 am - 6:00 pm.

Messaging service used weekends, after hours, and Federal holidays.

 

For ARIZONA customers enrolled in a Cigna-HealthSpring Medicare Advantage Prescription Drug Plan

Mail:

Cigna Medicare Services
Attn: Medicare Appeal Dept.
P.O. Box 29030
Phoenix, AZ 85038

Phone:

1-800-973-2580 TTY: 711

Fax: 1-866-567-2474

Hours (AZT):

Option 2, 8 a.m. to 6 p.m., Monday – Friday

 

For customers enrolled in a Cigna-HealthSpring standalone Part D Prescription Drug Plan

Mail:

Cigna-HealthSpring Part D Appeals (Pharmacy)
PO Box 24207
Nashville, TN 37202

Phone:

1-800-222-6700 TTY: 711

Fax: 1-866-593-4482

Hours (Local Time):

8am-8pm, 7 days a week.

Our automated phone system may answer your call during weekends from Feb. 15 – Sept. 30.

If our plan 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 determine 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 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, including 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 determines 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 continue to a Level 3 Appeal, the dollar value of the drug or medical care you are requesting 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 continue 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 disagree with the decision the judge makes, you can move on to a Level 4 Appeal. At the Level 4, the Medicare Appeals Council, who works for the federal government, will review your appeal and give you an answer. If you disagree with the decision at Level 4, you may be able to move on to the next level of the review process. A Level 5 Appeal is reviewed by a judge at the Federal District Court. This is the last stage of the appeals process. For more information about these four 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 regarding appeals, exceptions, and/or grievances or if you wish to obtain an aggregate total of appeals/exceptions/grievances filed with the plan, please call us at one of the numbers listed under "Where to file an appeal" that is appropriate to your plan.

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, you have the right to a fast appeal. Your provider will give you a notice before your services end that will tell you how to ask for a fast appeal. You should read this notice carefully. If you don’t get this notice, ask your provider for it. With a fast appeal, an independent reviewer, called a Quality Improvement Organization (QIO), will decide if your services should continue.

  • You may ask your doctor for any information that may help your case if you decide to file a fast appeal.
  • You must call your local QIO to request a fast appeal no later than the time shown on the notice you get from your provider. Use the telephone number for your local QIO listed on your notice.
  • If you miss the deadline, you still have appeal rights.  Contact Cigna-HealthSpring for more information