Appeals and Disputes Policy and Procedures
Learn how to file an appeal or dispute and what providers can expect during the process.
Appeals Process at Cigna Healthcare
Cigna Healthcare℠ strives to informally resolve issues raised by health care providers on initial contact whenever possible. If issues cannot be resolved informally, we offer the following options:
- An appeal process for resolving contractual disputes regarding post-service payment denials and payment disputes1
- If a claim was denied or not processed as expected due to claim coding edits, a CignaforHCP.com or Provider.Evernorth.com user with claims/reconsideration access can submit a reconsideration request on the claim.
- Following the internal Cigna Healthcare process, arbitration may be used as a final resolution step
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Processes may vary due to state mandates or contract provisions.
Why Submit an Appeal
The payment appeal process is different from routine requests for follow-up inquiries on claim processing errors or missing claim information. Most claim issues can be remedied quickly by providing requested information to a claim service center or contacting us.
Before beginning the appeals process, please call Cigna Healthcare Customer Service at 1(800) 88Cigna (882-4462) to try to resolve the issue. Many issues, including denials related to timely filing, incomplete claim submissions, and contract and fee schedule disputes may be quickly resolved through a real-time adjustment by providing requested or additional information.
If our Customer Service team cannot adjust the issue during that call, then our appeal process can be initiated through a written request [PDF].2
The following services can be appealed:
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If there is conflict between this reference guide and your health care provider agreement with Cigna Healthcare or applicable law, the terms of your agreement or the applicable law will supersede this guide.
| Scenario | Appeal Path |
|---|---|
| Precertification (authorization) denial (for services not yet rendered) | Customer appeal |
| Precertification (authorization) not obtained – services denied | Health care provider appeal |
| Claim reimbursement denial (including mutually exclusive, incidental, or bundling denials, and modifier reimbursements) | Health care provider appeal |
| Experimental or investigational procedure denial | Either |
| Benefit denials (e.g., exclusion, limitation, administration [e.g., copay, deductible, etc.]) | Customer appeal |
| Maximum reimbursable amount | Customer appeal |
| Inpatient facility denial (e.g., level of care, length of stay, delayed treatment day) | Either |
| Medical necessity denial | Either |
How to Submit an Appeal
- Fill out the Request for Health Care Provider Payment Review form [PDF]. The form will help to fully document the circumstances around the appeal request and will also help to ensure a timely review of the appeal. All forms should be fully completed, including selecting the appropriate check box for the reason for the appeal. Appeal Types are available in the National Reference Guide on the Cigna for Health Care Professionals portal.
- With the form, you'll need to submit:
- The original explanation of benefits (EOB), explanation of payment (EOP), or letter sent to the health care provider requesting additional information3
- Documentation that supports why the decision should be overturned (e.g., operative reports or medical records)
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Submit the appeal within 180 calendar days of the date of the initial payment or denial notice or, if the appeal relates to a payment that was adjusted by Cigna Healthcare, within 180 calendar days from the date of the last payment adjustment, to the following address:
If the ID card includes the “GWH-Cigna” or “G” indicators:
Cigna Healthcare Inc. National Appeals Unit (NAO)
PO Box 188062
Chattanooga, TN 37422For appeals relating to EviCore Services:
Claim Appeals
EviCore Claim Appeals
P.O. Box 5620
Hartford, CT 06102For all other appeals:
Cigna Healthcare Inc. National Appeals Unit (NAO)
PO Box 188011
Chattanooga, TN 37422 - The review will be completed in 60 days and the health care provider will receive notification of the dispute resolution within 75 business days of receipt of the original dispute. If a decision is made to uphold the decision, an appeal denial letter will be sent to the health care provider outlining any additional appeal rights, if applicable. An appeal determination that overturns the initial decision will be communicated through the explanation of payment with the reprocessed claim. Time periods are subject to applicable law and the health care provider agreement.
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Note: for denials that do not have an associated EOB or EOP (e.g., precertification denial), no EOB or EOP documentation is required.
Arbitration
Either party may initiate arbitration by providing written notice to the other party. With respect to health care provider payment or termination disputes, you must request arbitration within one year of the date of the letter communicating the final internal level review decision.4
If an arbitration provision was placed in your health care provider agreement, the terms and conditions of that provision will apply. If your health care provider agreement does not include an arbitration provision, the following will apply:
- The appealing parties prepare a Request for a Dispute Resolution List and submit it to the American Health Lawyers Association Alternative Dispute Resolution Service (AHLA ADR Service) along with the appropriate administrative fee. More information about the AHLA ADR Service can be found on the AHLA website
- Arbitration will be the exclusive remedy for disputes arising under the health care provider agreement
- The decision of the arbitrator(s) will be final, conclusive and binding, and no other recourse may be taken by either party other than to enforce the award of the arbitrator(s)
- This resolution procedure is a private undertaking and may not be consolidated with other health care providers or third parties and may not be conducted on a class basis
- Judgment of the arbitrator(s) award may be entered in any court of competent jurisdiction
The health care provider agreement remains in force during arbitration unless otherwise terminated in accordance with the terms of the health care provider agreement.
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If you do not request an internal appeals review or arbitration of the dispute within the defined timeframes, the last Cigna Healthcare determination will be final. Customers cannot be billed for any amount denied because you failed to submit the request for review or arbitration within the required timelines.
Other Types of Appeals
Termination Appeals
On occasion, Cigna Healthcare deems it necessary to terminate a health care provider's participation. Appeal rights are offered to health care providers terminated due to Quality of Care or Quality of Service and health care providers terminated for failure to meet Cigna Healthcare credentialing requirements in states that mandate appeal rights be offered.
To initiate a review of a health care provider's termination, submit the following information in writing within 30 calendar days of the date of the health care provider's termination notice:
- A completed health care provider termination appeal letter indicating the reason for the appeal
- A copy of the original termination notice
- Supporting documentation for reconsideration
Customer Reviews
In certain cases, pre- or post-service denials can be appealed directly by a customer (or a health care provider on behalf of a customer). When a health care provider submits an appeal on behalf of their patient, the process remains largely the same as a health care provider driven appeal.
However for certain appeals (e.g., in cases of MNR review), health care providers can be offered an additional external review for their patient by an Independent Review Organization (IRO) after an initial appeal denial. If there is an opportunity for an additional external review through an IRO, the initial appeal denial letter will outline the steps the health care provider must take in order to receive this external review. This includes signing, dating, and returning a “Request for Review by an Independent Review Organization” form. Once this form is returned, the external review process can begin.
Please note that in cases of an external review through an IRO, the health care provider must get their patient’s approval to proceed.
Medicare Appeals
Medicare customers must submit the appeal within 90 calendar days of the date of the initial payment or denial notice or, if the appeal relates to a payment that was adjusted by Cigna Healthcare, within 90 calendar days from the date of the last payment adjustment.
If you need additional information for Cigna Healthcare Medicare Provider Appeals, you can:
- Visit Cigna Healthcare Medicare Providers
- Refer to your Cigna Healthcare Medicare Advantage Provider Manual [PDF]
Medicare Advantage HMO Payment Dispute Process
Cigna Healthcare offers a two-level for Medicare Advantage HMO appeals. Before beginning an appeal, please note:
- Level 1 of the Provider Appeal process must be initiated within 180 calendar days5 from the date of the initial payment denial or decision from Cigna Healthcare.
- Level 2 of the Provider Appeal process must be initiated within 60 calendar days5 of the date of the Level 1 appeal decision letter.
- Please allow 45 days (or time permitted by applicable law) for processing your appeal and communicating the appeal decision. Please submit one appeal form per claim.
- If you provide health care to a Cigna Healthcare customer, and are under contract with a third party, please consult the third-party vendor with whom you are contracted.
- If you fail to file your request for an appeal within the time frames listed below, the last determination by Cigna Healthcare regarding the disputed issue will be binding (subject to applicable law or a provision within your provider agreement that specifically allows additional time).
Questions on Medicare Appeals?
- Medicare Advantage Plans: 1 (855) 551-6943
- Medicare Advantage Plans (Arizona only): 1 (800) 627-7534
- Medicare Prescription Drug Plans (PDP): 1 (866) 845-6962
Mailing Address
Cigna Healthcare Medicare
Attn: Part C Appeals
(Medical)
PO Box 188081
Chattanooga, TN 37422
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Time periods are subject to, and may be extended by, applicable law or provisions within the provider agreement.
