Appeal Policy and Procedures for Health Care Professionals

Overview

Whenever possible, Cigna HealthCare strives to informally resolve issues raised by health care professionals at the time of the initial contact. If the issue cannot be resolved informally, Cigna offers a single level internal appeal process for resolving disputes with practitioners. Participating health care professionals should refer to their Cigna provider agreement and/or Program Requirements or Administrative Guidelines for further details. After exhausting Cigna's internal appeal process, arbitration may serve as a binding, final resolution step if the Provider agreement and/or Program Requirements so requires. Processes may vary due to state mandates or contract provisions.

Single Level Health Care Professional Payment Review

In general, the Single Level of the health care professional payment review process must be initiated in writing within 180 calendar days from the date of the initial payment or denial decision from Cigna. If the appeal relates to a payment that we adjusted, the appeal should be initiated within 180 calendar days of the date of the last payment adjustment. The review will be completed in 60 days and the healthcare professional will receive notification of the dispute resolution within 75 business days of receipt of the original dispute. If approved, the Explanation of Payment will serve as notice of the determination. If the initial payment decision is upheld, health care professionals will receive a letter outlining any additional rights if applicable. Time periods are subject to applicable law and the provider agreement.

Appeal requests will be handled by a reviewer who was not involved in the initial decision. Decisions will be consistent with the physician's agreement terms and/or the participant's coverage plan. With respect to medical necessity appeals and appeals related to experimental or investigational exclusions, a nurse can review and may reverse a denial, but may not uphold a denial.

Health care professionals who are not satisfied with the Single Level review decision may request alternate dispute resolution, pursuant to the terms of their Cigna provider agreement and/or its Program Requirements or Administrative Guidelines. In general, such requests for alternate dispute resolution must be submitted within one year from the date of the Single Level denial letter.

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Filing a Single Level Review

  1. Contact the Cigna Customer Support Department at the toll-free number listed on the back of the Cigna customer's ID card to review any claim denials or payment decisions. Note: Fee Schedule or reimbursement terms for multiple patients may not require individual appeals.
  2. If a Customer Support Representative is unable to determine that an error was made with the claim adjudication decision and correct it, you have the right to appeal the decision by following the remaining steps below.
  3. Review the Claim Adjustment & Appeals Guidelines prior to submitting an appeal.
  4. Download, print, complete and mail the applicable request for payment review form (below) to the designated Cigna office.

    5. Payment Review Forms
    State Link to Payment Review Form
    California (HMO Only) Health Care Professional Dispute Resolution Request – CA HMO
    All Others Request for Health Care Professional Payment Review – HCP
    Request for Health Care Professional Payment Review – Member
  5. Include a copy of the original claim, the Explanation of Payment (EOP) or Explanation of Benefits (EOB), if applicable, and any supporting documentation to support the appeal request.
  6. For appeals with a clinical component, including precertification administrative denials, please submit all supporting documentation, including a narrative describing the subject of the appeal, an operative report and medical records, as applicable. Note: Additional clinical information may be requested before authorization can be given. All documentation should be submitted immediately to avoid delays. Cigna may deny certification of an admission, procedure or service, if all necessary information is not provided.
  7. To allow us the opportunity to provide a full and thorough review, health care professionals should submit complete information with their appeal.
  8. Mail your appeal, payment review form and supporting documentation to:

    If the ID card indicates: Cigna Network:

    Cigna Appeals Unit
    PO Box 188011
    Chattanooga, TN 37422

    If the ID card indicates: GWH-Cigna or “G”:

    Cigna
    PO Box 188062
    Chattanooga, TN 37422 - 8062

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