2019 CIGNA-HEALTHSPRING CUSTOMER FORMS

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

Appointment of Representative Form
Nombramiento de un Representante

Send this form to the same location where you are sending your grievance, coverage determination or 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 you need more help, you can:

• Contact your Medicare plan
• Call 1-800-MEDICARE (1-800-633-4227, 24 hours a day, 7 days a week)
• Contact Us

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

Medicare Advantage Only Plans – Except Arizona

EFT Form – Except Kansas City and Arizona

EFT Form – Kansas City Only

Formulario de Transferencia Electrónica de Fondos

Print and send form to:

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

Medicare Advantage Plans with Prescription Drug Coverage – Except Arizona

EFT Form – Except Kansas City and Arizona

EFT Form – Kansas City Only

Formulario de Transferencia Electrónica de Fondos

Print and send form to:

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

Medicare Advantage Plans with Prescription Drug Coverage - Arizona only

EFT Form

Formulario de Transferencia Electrónica de Fondos

Credit Card Form

Acuerdo de autorización para débito mensual con tarjeta de crédito

Print and send form to:

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

Medicare Part D Prescription Drug Plans

Automatic Payment Form (Recurring Direct Debit)

Formulario de autorización de débito directo periódico

Credit Card Form

Acuerdo de autorización para débito mensual con tarjeta de crédito

Print and send form to:

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

Use when you want to request coverage for a medication that is not covered by your plan or has limitations on its coverage.

Medicare Advantage Plans with Prescription Drug Coverage – Except Arizona

Coverage Determination Form

Online Form

If not using online form, send to:

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

Medicare Advantage Plans with Prescription Drug Coverage - Arizona only

Coverage Determination Form

Online Form

If not using online form, send to:

Cigna Medicare Services
Pharmacy Coverage
Determinations & Exceptions
P.O. Box 20002
Nashville, Tennessee 37202
Or fax to: 1-866-845-7267

Medicare Part D Prescription Drug Plans

Coverage Determination Form

Online Form

If not using online form, send to:

Cigna-HealthSpring
Attn: Coverage Determinations & Exceptions
PO Box 20002
Nashville, TN 37202
Or fax to: 1-866-845-7267

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.

Medicare Advantage Only Plans – Except Arizona

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

Medicare Advantage Plans with Prescription Drug Coverage – Except Arizona

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

Medicare Advantage Plans with Prescription Drug Coverage - Arizona only

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

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.

Medicare Advantage Only Plans – Except Arizona

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

Medicare Advantage Plans with Prescription Drug Coverage – Except Arizona

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

Medicare Advantage Plans with Prescription Drug Coverage - Arizona only

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

Use when you want to request reimbursement of covered medical expenses.

Medicare Advantage Only Plans – Except Arizona

Medical Reimbursement Claim Form

Formulario de reclamo para solicitud de reembolso del miembro inscrito

Print and send form to:

Cigna-HealthSpring
Attn: Claims
P.O. Box 20002
Nashville, TN 37202-9640

Medicare Advantage Plans with Prescription Drug Coverage – Except Arizona

Medical Reimbursement Claim Form

Formulario de reclamo para solicitud de reembolso del miembro inscrito

Print and send form to:

Cigna-HealthSpring
Attn: Claims
P.O. Box 20002
Nashville, TN 37202-9640

Use when you want to request reimbursement for a medication that you have already paid for.

Medicare Advantage Plans with Prescription Drug Coverage – Except Arizona

Drug Claim Form

Forma de Reclamo de Medicamentos

Print form and send to:

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

Medicare Advantage Plans with Prescription Drug Coverage - Arizona only

Drug Claim Form

Forma de Reclamo de Medicamentos

Print form and send to:

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

Medicare Part D Prescription Drug Plans

Drug Claim Form

Forma de Reclamo de Medicamentos

Print form and send to:

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

Privacy forms help manage your protected health information. To use a form, please print and send to the address noted on the form.

Accounting of PHI Disclosures Form / Solicitud de historial de divulgaciones de información sobre la salud protegida
Use when you want an itemized list of each time we have disclosed your protected health information

Disagreement/Denial of Amendment Form / Manifestación de desacuerdo/Solicitud para que se envíe el rechazo de la solicitud de modificación
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 / Solicitud de restricción de uso y divulgación de Información sobre la salud protegida
Use when you want to request a restriction on the use and disclosure of your protected health information.

Authorization for Disclosure Form / Autorización de divulgación de Información sobre la salud protegida
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 / en Español

Permission To Discuss Limited Health Information With Family And Friends - Part D: English / en Español
Use when you want to give permission to Cigna-HealthSpring to discuss limited information with family and friends.

Amend Protected Health Information Form / Solicitud para modificar Información sobre la salud protegida
Use when you want to request an amendment to the protected health information that we maintain.

Confidential Communication Form / Solicitud de comunicaciones confidenciales
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 Health Care Information Form / Solicitud de acceso a Información sobre atención médica
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

Use when you want us to reconsider coverage of a medication or a payment/reimbursement request after it has been denied.

Medicare Advantage Plans with Prescription Drug Coverage – Except Arizona

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

Medicare Advantage Plans with Prescription Drug Coverage - Arizona only

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

Medicare Part D Prescription Drug Plans

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