2018 CIGNA-HEALTHSPRING CUSTOMER FORMS

If you are enrolled in a Cigna-HealthSpring plan, please find all the forms you will need to help you manage your plan throughout the year. Of course, if you have any questions, please call us at:

Medicare Advantage Plans:

1-800-668-3813 (TTY 711)

Medicare Advantage Plans (Arizona Only):

1-800-627-7534 (TTY 711)

Rx Prescription Drug Plans (PDP):

1-800-222-6700 (TTY 711)

 

Prior Authorization Forms

For certain prescription drugs, Cigna-HealthSpring requires prior authorization. This means that you or your prescriber may request a coverage decision or exception for the prescribed medication. If you or your prescriber do not obtain approval, the drug may not be covered.

These forms are related to your Medicare Advantage plan (Cigna-HealthSpring Advantage plan).

EFT Authorization Form*
Use when you want to authorize us to automatically deduct your premium from your bank account.
EFT Form - English
EFT Form - en Español

Print and send form to:
Cigna-HealthSpring
Attn: MAS - Premium Billing
P.O. Box 20012
Nashville, TN 37202-9919

 

Appointment of Representative Form

Use when you want someone other than yourself to represent you in all matters concerning your coverage determination or appeal (see below).
Appointment of Rep Form - English
Appointment of Rep Form - Español

Send this form to the same location where you are sending your appeal if you are filing an appeal, grievance if you are filing a grievance, or initial determination or decision if you are requesting an initial determination or decision. If additional help is needed, contact your Medicare plan or 1-800-MEDICARE (1-800-633-4227, 24 hours a day, 7 days a week).

 

Medical Pre-service Appeal

You or your appointed representative may request an appeal when you want to have us reconsider coverage of a medical item or service that you have not yet received after it has been denied via the initial organization determination process.

You can call, fax or write to us (see information to the right).
You can find more information about the appeals process here

Write:

Cigna-HealthSpring
Attn: Precertification
P.O. Box 20002
Nashville, TN 37202-4087

Call: 1-800-668-3813, TTY 711, 8 am to 8 pm (your local time), 7 days a week

Fax:1-800-931-0149

 

Medical Payment Appeal 

You or your appointed representative may request an appeal when you want to have us reconsider coverage of a medical item or service that you have already received and paid for after your initial request has been denied.

You can call, fax or write to us (see information to the right).
You can find more information about the appeals process here.

Write:

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

Call: 1-800-668-3813, TTY 711, 8 am to 8 pm (your local time), 7 days a week

Fax: 1-800-931-0149

1-800-633-4227

These forms are related to your Medicare Advantage plan with prescription drug coverage (Cigna-HealthSpring Achieve, Preferred, Preferred Plus, Premier, PreventiveCare, Primary, TotalCare or Traditions plan).

As indicated below, some forms are available for online submission. To send a form via the web, simply click on the Online Form link and follow the instructions to enter the appropriate information.

 

Prescription Drug Claim Form 
Use when you want to request reimbursement for a medication for which you have already paid.

Claim Form - English
Claim Form - en Español

Print form and send to:

Cigna-HealthSpring Pharmacy Services
Attn: Direct Member Reimbursement
P.O. Box 20002
Nashville, TN 37202

 

EFT Authorization Form*

Use when you want to authorize us to automatically deduct your premium from your bank account.

EFT Form - English
EFT Form - en Español

Print and send form to:

Cigna-HealthSpring
Attn: MAS - Premium Billing
P.O. Box 20012
Nashville, TN 37202-9919

 

Coverage Determination Request Form*
Use when you want to request coverage for a medication that is not covered or has limitations on its coverage.

Coverage Determination Form

Online Form

If not using online form, send to:

Cigna-HealthSpring Pharmacy Services
Attn: Part D Coverage Determinations and Exceptions
P.O. Box 20002
Nashville, Tennessee 37202
Or fax to: 1-866-845-7267

 

Redetermination Request Form*
Use when you want to have us reconsider coverage of a medication after it has been denied via the initial coverage determination process, or when reimbursement has been denied if you have already received the medication.

Redetermination Form

Online Form

If not using online form, send to:

Cigna-HealthSpring
Attn: Part D Appeals
PO Box 24207
Nashville, TN 37202
Or fax to: 1-866-593-4482

 

Appointment of Representative Form
Use when you want someone other than yourself to represent you in all matters concerning your coverage determination or appeal (see below).

Appointment of Rep Form - English 
Appointment of Rep Form - Español 

Send this form to the same location where you are sending your appeal if you are filing an appeal, grievance if you are filing a grievance, or initial determination or decision if you are requesting an initial determination or decision. If additional help is needed, contact your Medicare plan or 1-800-MEDICARE (1-800-633-4227) 24 hours a day, 7 days a week.

 

Medical Pre-service Appeal

You or your appointed representative may request an appeal when you want to have us reconsider coverage of a medical item or service that you have not yet received after it has been denied via the initial organization determination process.

You can call, fax or write to us (see information to the right).

You can find more information about the appeals process here.

 

Write:

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

Call: 1-800-668-3813, TTY 711, 8 am to 8 pm (your local time), 7 days a week

Fax: 1-800-931-0149

 

Medical Payment Appeal

You or your appointed representative may request an appeal when you want to have us reconsider coverage of a medical item or service that you have already received and paid for after your initial request has been denied.

You can call, fax or write to us (see information to the right).

You can find more information about the appeals process here.

 

Write:

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

Call: 1-800-668-3813, TTY 711, 8 am to 8 pm (your local time), 7 days a week

Fax: 1-800-931-0149

These forms are related to your Medicare Advantage plan with prescription drug coverage (Cigna-HealthSpring Achieve Plus, Preferred or Preferred Plus plan - in Arizona ONLY).

As indicated below, some forms are available for online submission. To send a form via the web, simply click on the Online Form link and follow the instructions to enter the appropriate information.

 

Prescription Drug Claim Form 
Use when you want to request reimbursement for a medication for which you have already paid.

Claim Form - English
Claim Form - en Español

Print form and send to:

Cigna Medicare Services
Attn: Direct Member Reimbursement
P.O. Box 20002
Nashville, TN 37202

 

EFT Authorization Form*

Use when you want to authorize us to automatically deduct your premium from your bank account.

EFT Form - English
EFT Form - en Español

Credit Card Form - English
Credit Card Form - en Español

Print and send form to:

Cigna
Attn: Attn: Payment Control Department
P.O. Box 29030
Phoenix, AZ 85038

 

Coverage Determination Request Form*
Use when you want to request coverage for a medication that is not covered or has limitations on its coverage.

Coverage Determination Form

Online Form

If not using online form, send to:

Cigna-HealthSpring
Attn: CDE
P.O. Box 20002
Nashville, Tennessee 37202
Or fax to: 1-866-845-7267

 

Redetermination Request Form*
Use when you want to have us reconsider coverage of a medication after it has been denied via the initial coverage determination process, or when reimbursement has been denied if you have already received the medication.

Redetermination Form

Online Form

If not using online form, send to:

Cigna Medicare Services
Attn: Medicare Appeal Department
PO Box 29030
Phoenix, AZ 85038
Or fax to: 1-866-567-2474

 

Appointment of Representative Form
Use when you want someone other than yourself to represent you in all matters concerning your coverage determination or appeal (see below).

Appointment of Rep Form - English 
Appointment of Rep Form - Español 

Send this form to the same location where you are sending your appeal, grievance or initial determination or decision.

 

Medical Pre-service Appeal
Use when you want to have us reconsider coverage of a medical item or service that you have not yet received after it has been denied via the initial organization determination process.

Medical Pre-Service Appeal Form

Online Form

If not using online form, send to:

Cigna Medicare Services
Attn: Medicare Appeal Department
PO Box 29030
Phoenix, AZ 85038
Or fax to: 1-866-567-2474

 

Medical Payment Appeal
Use when you want to have us reconsider coverage of a medical item or service that you have already received and paid for after your initial request has been denied.

Medical Payment Appeal Form

Online Form

If not using online form, send to:

Cigna Medicare Services
Attn: Medicare Appeal Department
PO Box 29030
Phoenix, AZ 85038
Or fax to: 1-866-567-2474

These forms are related to your stand-alone Part D plan (Cigna-HealthSpring Rx Secure or Secure-Extra plan).

As indicated below, some forms are available for online submission. To send a form via the web, simply click on the Online Form link and follow the instructions to enter the appropriate information.

 

Prescription Drug Claim Form 
Use when you want to request reimbursement
for a medication that you have already paid for.

Claim Form - English
Claim Form - en Español

Print form and send to:

Cigna-HealthSpring Pharmacy Services
Attn: Direct Member Reimbursement
P.O. Box 20002 
Nashville, TN 37202

 

EFT Authorization Form* 

Use when you want to authorize us to
automatically deduct your premium from your bank account or charge your credit card.

EFT Form 
EFT Form - en Español

Credit Card Form
Credit Card Form - en Español

Print form and send to:

Cigna-HealthSpring
PO Box 269005 
Weston, FL 33326-9927

 

Coverage Determination Request Form*
Use when you want to request coverage for a medication that is not covered or has limitations on its coverage.

Coverage Determination Form

Online Form

If not using online form, send to:

Cigna-HealthSpring Pharmacy Services
Attn: Part D Coverage Determinations and Exceptions
PO Box 20002
Nashville, TN 37202
Or fax to: 1-866-845-7267

 

Redetermination Request Form*
Use when you want to have us reconsider coverage of a medication after it has been denied via the initial coverage determination process, or when reimbursement has been denied if you have already received the medication.

Redetermination Form

Online Form

 

If not using online form, send to:

Cigna-HealthSpring
Attn: Part D Appeals
PO Box 24207
Nashville, TN 37202
Or fax to: 1-866-593-4482

 

Appointment of Representative Form 
Use when you want someone other than yourself to represent you in all matters concerning your coverage determination or appeal.

Links directly to the Centers for Medicare & Medicaid Services form:

Appointment of Rep Form - English
Appointment of Rep Form - Español  

 

Send this form to the same location where you are sending your appeal if you are filing an appeal, grievance if you are filing a grievance, or initial determination or decision if you are requesting an initial determination or decision.

If additional help is needed, contact your Medicare plan or 1-800-MEDICARE (1-800-633-4227) 24 hours a day, 7 days a week.

These forms are related to your business dealings with Cigna-HealthSpring. To use a form, please print and send to the address noted on the form.

Accounting of PHI Disclosures Form

Use when you want an itemized list of each time we have disclosed your protected health information

 

Disagreement/Denial of Amendment Form

Use when you want to formally disagree with our denial of your request to amend your protected health information that we maintain.

 

Restriction of Use and Disclosure of PHI Form

Use when you want to request a restriction on the use and disclosure of your protected health information.

 

Authorization for Disclosure Form

Use when you want to authorize the disclosure of specific protected health information to a specific person or entity.

 

Permission To Discuss Limited Health Information With Family And Friends - Medicare Advantage: English / Español

Permission To Discuss Limited Health Information With Family And Friends - Part D: English / Español

Use when you want to give permission to Cigna-HealthSpring to discuss limited information with family and friends.

 

Amend Protected Health Information Form

Use when you want to request an amendment to the protected health information that we maintain.

 

Confidential Communication Form

Use when you want to have communications containing protected health information sent to a different address than the one we have on file.

If you reside in Oregon or Vermont, please use one of the forms below:


Confidential Communication Form - Oregon 

 

Confidential Communication Form - Vermont

 

Access to HealthCare Information Form

Use when you want to request access to protected health information that we have created or received.

 

Confidentiality and Disclosure Protocol Forms for Victims of Domestic Violence

Request for Confidentiality

 

Request to Revoke a Reasonable Request

 

Please Note: Forms marked with an asterisk (*) may NOT be used if you are in a group-sponsored plan. If you are in a group plan, please call the phone number on your Cigna ID card or contact your plan administrator if you have questions.