Claims Submission, Payments, and Filing
We make it easy for health care providers to submit claims. Learn more about how to file and pay claims with Cigna Healthcare℠.
How to Submit Claims
Submitting medical, dental, and behavioral claims electronically can help save time, money, and paperwork. In addition, electronic claim submissions can improve the accuracy of claim processing.
There are two options for submitting claims electronically to Cigna Healthcare:
Direct Connection
- Free software from Post-N-Track allows providers to use a web-based service to:
- Submit claims directly to Cigna.
- Receive electronic remittance advice (ERA) statements.
- Exchange electronic claim inquiry and response transactions.
- Post-N-Track: 1 (860) 257-2030 or email info@post-n-track.com.
Clearinghouse
- Change Healthcare: 1 (877) 469-3263 or go to www.changehealthcare.com.
Note: The electronic payor ID for claim submissions is 62308.
A Note On Electronic Data Interchange (EDI) Vendors
EDI vendors help automate your claims process and save money. Cigna Healthcare has connections with multiple vendors. Please work directly with your EDI vendor to submit claims electronically and for other EDI transactions.
When to File Your Claims
Filing a claim as soon as possible is the best way to facilitate prompt payment. If you're unable to file a claim right away, please make sure the claim is submitted accordingly.
| If you are... | submit by... |
|---|---|
| A participating health care provider | 90 days after the date of service |
| An out-of-network provider | 180 days after the date of service |
If services are rendered on consecutive days, such as for a hospital confinement, the limit will be counted from the last date of service.
As always, you can appeal denied claims if you feel an appeal is warranted.
Remember: Your contract with Cigna Healthcare prohibits balance billing your patient if claims are denied because they were not submitted within the time frame outlined above.
Deadline Exceptions
There are some exceptions to these deadlines. These include:
- Applicable law requires a longer filing period
- Provider agreement specifically allows for additional time
- In Coordination of Benefits situations, timely filing is determined from the processing date indicated on the primary carrier's explanation of benefits (EOB) or explanation of payment (EOP)
- Medicare (Cigna Healthcare for Seniors): In accordance with Medicare processing rules, non-participating health care providers have 15 to 27 months to file a new claim. Medicare patients' claims must be filed no later than the end of the calendar year following the year in which the services were provided. However, the filing limit is extended another full year if the service was provided during the last three months of the calendar year.
- If Medicare is the primary payer, timely filing is determined from the processing date indicated on the primary carrier's explanation of benefit (EOB)
- If Medicare is the Secondary Payer (MSP), the initial claim must be submitted to the primary payer within our timely filing period. An initial determination on a previously adjudicated claim may be reopened for any reason for one year from the date of that determination. After one year and prior to four years from the date of determination, "good cause" is required for Medicare to reopen the claim. In general, Medicare does not consider a situation where (a) Medicare processed a claim in accordance with the information on the claim form and consistent with the information in the Medicare's systems of records and; (b) a third party mistakenly paid primary when it alleges that Medicare should have been primary to constitute "good cause" to reopen.
- If a claim was timely filed originally, but Cigna Healthcare requested additional information. If a resubmission is not a Cigna Healthcare request, and is not being submitted as an appeal, the filing limit will apply.
- Extraordinary circumstances1
If you are not currently registered for the Cigna for Health Care Professionals website, go to CignaforHCP.com and click on the Login/Register link.
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Cigna Healthcare may request appropriate evidence of extraordinary circumstances that prevented timely submission (e.g., natural disaster).
Clean Claim Requirements
At Cigna Healthcare, our goal is to process all claims at initial submission. Before we can process a claim, it must be a "clean" or complete claim submission, which includes the following information, when applicable:
- Primary carrier explanation of benefits (EOB) when Cigna Healthcare is the secondary payer
- Prescription for physical therapy
- Itemization of dates for physical therapy from facility
- Prosthesis invoice
- Trip notes for ambulance transport
- Standard Diagnostic Related Groupings (DRG) or Revenue codes (facility)
- Standard Health Care Procedure Coding System (HCPCS) code sets and modifiers
- Standard Current Procedural Terminology (CPT®) code sets and modifiers
- Standard International Classification of Diseases (ICD-10) codes, tenth revision
- Accurate entries for all the fields of information contained in the UB04 [PDF]2 or CMS-1500 forms [PDF]2
Claims Requiring Clinical Documentation
Except as noted, we routinely require clinical documentation at the time a claim is submitted for the following categories of claims to be considered complete:
- Codes to which an assistant surgeon modifier (80, 81, or 82), assistant-at-surgery modifier (AS), or co-surgeon modifier (62) is attached that do not normally require surgical assistance or co-surgeons
- An 'unlisted code' as defined in the Index of CPT under 'Unlisted Services and Procedures'
- A code that is not otherwise specified (NOS)
- A code that is not otherwise classified (NOC)
- Procedures that are potentially cosmetic
- Procedures that may be experimental/investigational/unproven
- Procedures that are medically necessary for some indications and not for others
- Services performed in an unexpected place of service, such as office services performed in an outpatient surgery center
- Codes appended with a modifier indicating additional or unusual services (e.g., 22, 23, 24, 53, 59, or 66)
- Modifier 25 - Evaluation & Management (E/M) service codes that disallow with a CMS/NCCI Incidental Edit (also called Column 1/Column 2 Code Edits) designated by CMS as '1'2
- Modifier 59 - Non-Evaluation & Management (E/M) service codes that disallow with a CMS/NCCI Mutually Exclusive Edit designated by CMS as '1'2
The supporting documentation requirement is on selected code edits when modifier 25 or 59 is billed. It is not an across the board requirement for all uses of these modifiers.
A specific list of Cigna Healthcare combinations that require documentation is available on the Cigna for Health Care Professionals online portal at CignaforHCP.com. To view, click on "Resources Claim Editing Procedures."
Types of clinical documentation that may be requested include:
- Emergency room notes
- Facility notes
- Anesthesia notes and time
- Facility/MD notes
- Operative notes
- Radiology interpretation and report
- Lab results
- MD office notes
This policy is not designed to limit our right to require submission of medical records for precertification purposes.3
Editing Claims with Cigna Healthcare
ClaimsXten Clear Claim Connection™, our code edit disclosure tool powered by McKesson, allows users to enter CPT and HCPCS coding scenarios and to immediately view the audit result. Clinical edit rationales, as well as edit sourcing, are provided for any code that is not allowed in Clear Claim Connection.
Clear Claim Connection is accessible through the Cigna for Health Care Providers portal at CignaforHCP.com. Once logged on, you may review the Clear Claim Connection Frequently Asked Questions for more information.
Cigna Healthcare is committed to providing solutions that can minimize your administrative costs while helping to reduce the complexity of doing business with us.
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Claims processing will not be delayed when the submission of supporting documentation is indicated in box 19 of the electronic claim submission or when attached to a paper claim. When supporting documentation is indicated on an electronic claim submission, the supporting documentation can be mailed to Cigna Healthcare address on the back of the patient identification card.
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State legislation and/or plan-specific language supersede Cigna Healthcare administrative guidelines.
