Provider Complaint and Appeal Process
Cigna-HealthSpring is committed to providing excellent service to its participating providers. In the event a provider feels Cigna-HealthSpring is falling short of this goal, he/she should contact the Provider Services Department immediately by calling 1-877-653-0331. Provider Services is available to assist providers with their concerns at any time.
A Complaint means an expression of dissatisfaction expressed by a Complainant, orally or in writing to the HMO, about any matter related to the HMO other than an Action. As provided by 42 C.F.R. 438.400, possible subjects for Complaints include, but are not limited to, the quality of care of services provided, and aspects of interpersonal relationships such as rudeness of a provider or employee, or failure to respect the Medicaid Member's rights.
An Action means
- The denial or limited authorization of a requested Medicaid service, including the type or level of service;
- The reduction, suspension, or termination of a previously authorized service;
- The denial in whole or in part of payment for service;
- The failure to provide services in a timely manner;
- The failure of an HMO to act within the time frames set forth in the Contract and 42 C.F.R 438.408(b); or
- For a resident of a rural area with one HMO, the denial of a Medicaid Member's request to obtain services outside of the network.
An Adverse Determination is one type of Action.
An Appeal is a formal process by which a Member or his or her representative requests a review of the HMO's Action as defined above.
Provider Complaints to Cigna-HealthSpring
Provider Complaints can be filed verbally, in writing or through our Provider Portal by contacting Cigna- HealthSpring as follows:
To submit to the state, send to HPM_Compliants@hhsc.state.tx.us.
If a provider Complaint is received verbally, Cigna-HealthSpring's Provider Services Representatives collect detailed information about the Complaint and route the Complaint electronically to the Appeals and Grievances Complaint Department for handling. Within five (5) business days from receipt of a Complaint, Cigna-HealthSpring will send an acknowledgement letter to the provider. Cigna-HealthSpring will resolve the Complaint within thirty (30) days from the date the Complaint was received by Cigna-HealthSpring.
How to Appeal a Medical Claim
Cigna-HealthSpring's Appeal Form is linked below for your use. The Appeal Form is not required to file appeals with us, but it is provided for your convenience as an option to help capture the needed information to process your appeals. This form may be particularly helpful if you need to appeal many claims for the same reason - you can use just one form: Provider Claims Appeal Form.
There are three ways to Appeal a previously processed claim:
- Fax the request to Cigna-HealthSpring at 1-877-809-0783.
- Mail the request to:
Attn: Appeals and Complaints Department
P.O. Box 211088
Bedford, TX 76095
- File individual electronic appeals through Cigna-HealthSpring's Provider Portal.
Requests for claim appeals must be made within 120 days from the date of remittance of the Explanation of Payment (EOP).
Within five (5) business days of receiving a written claim appeal, Cigna-HealthSpring will send an acknowledgement letter to the appealing provider. Provider Claim Appeals are resolved within thirty (30) days of receipt. Cigna-HealthSpring will send written notification of the resolution to the Provider. Providers can refer to the Cigna-HealthSpring Provider Manual for more information about claims filing and claims appeals.
For further assistance, call Provider Services toll-free at 1-877-653-0331 Monday to Friday 8 a.m. to 5 p.m. Central Time (TTY: 711 Monday to Friday 8 a.m. to 8 p.m. Central Time) or email Provider Relations at ProviderRelationsCentral@healthspring.com