When providers reach out to us about claim payment disputes, we strive to resolve them informally on that initial contact. If this isn’t possible, we offer a single-level, internal appeal process for resolving post-service payment denials and payment disputes.* Arbitration is also available, if needed, as a final resolution step.

Provider appeals

Time frame for submissions

Providers must submit all appeals in writing within 180 calendar days from the date of the initial payment or denial notice or the last payment adjustment if the appeal relates to a payment that was adjusted by Cigna Healthcare^sm.

Submission methods

You may request an appeal via the Cigna for Health Care Professionals website (CignaforHCP.com), the Request for Health Care Professional Payment Review form, or an appeal letter. To help ensure your appeal will receive a full and thorough review, it’s important that you submit complete information.

• CignaforHCP.com. Registered users of CignaforHCP.com who can view claims on the website and have access to the “Reconsideration” entitlement can submit appeal requests online, which is the recommended method. For more information, refer to the Online Claims Reconsideration video tutorial and step-by-step guide.
• Request for Health Care Professional Payment Review form. To help you fully document the circumstances around the appeal request and expedite a timely review, we encourage you to download and complete this form — including checking off the appropriate box that best describes the reason for the appeal.
• Letter. If you submit your appeal by letter instead of using the form, be sure to include all of the same information that is requested on the form and specify that it is for a health care provider appeal.

When submitting appeals via fax or mail, be sure to include:

• A copy of the original claim.
• A copy of the explanation of payment or explanation of benefits, if applicable.
• A narrative describing the situation, an operative report, and the medical records, as applicable, if the appeal involves a previous clinical denial, such as denied hospital days, level of care, medical necessity, or services denied for no precertification.
• The name of the service or drug you are appealing. (If using the form, you can include this information in the space on the second page.)

Additional information

Review the Cigna Healthcare Appeals and Disputes Policy and Procedures for additional information on how to submit an appeal.

Customer appeals

Time frame for submissions

In most cases, the appeal should be submitted within 180 calendar days from the date of the last determination of whether or not to authorize, approve, or reimburse a health care service, treatment, or supply.** Examples of a last determination include the date:

• A claim was last handled.
• A utilization review was completed.
• An appeal decision letter was issued.

Submission methods

You may submit an appeal on behalf of your patient via CignaforHCP.com, the Customer Appeal Request form, or a letter, along with any supporting documentation, and mail it to the address at the bottom of the form. You can download and print a copy of this form in English, Spanish, or Chinese at Cigna.com.

Registered users of CignaforHCP.com who can view claims on the website and have access to the “Reconsideration” entitlement can submit appeal requests online. For more information, refer to the Online Claims Reconsideration video tutorial and step-by-step guide.

Expedited appeals

Under certain circumstances, we may perform an expedited review, such as when:

• A service was not rendered.
• A service requires precertification.
• The treating provider believes the standard time frame for processing an appeal request may jeopardize the patient’s life, health, or ability to regain maximum functionality, or in the case of a patient with severe pain.
• There is an admission or continuing inpatient hospital stay for a patient who has received emergency services but has not been discharged from a facility.

To request an expedited appeal, check the “No” box to the question, “Have you already received services?” on the Customer Appeal Request form. You will receive a written response from Cigna Healthcare within 30 days. Expedited appeals cannot be submitted via CignaforHCP.com.

*    Processes may vary due to state mandates or contract provisions.

** Your patient’s particular Cigna Healthcare benefit plan may allow for a longer period.