November 22, 2024
Effective January 13, 2025, Cigna HealthcareTM will implement a new reimbursement policy, R46 Coding and Billing Accuracy, which outlines types of reported charges and billing errors that are not eligible for reimbursement. These include, but are not limited to, services billed without supporting documentation, services billed with insufficient supporting medical documentation, and services that do not adhere to correct coding and billing guidelines.
Complete and accurate medical documentation is necessary to support the payment integrity process and ensure proper reimbursement. Medical documentation may be requested to support appropriate reimbursement of reported charges.
The policy is effective for claims with dates of service on or after January 13, 2025. The table below identifies types of charges that are not reimbursable or may affect reimbursement. This list may not be inclusive.
| Duplicate charges | Incorrect coding |
| Services with no or insufficient supporting medical documentation | Charges unrelated or inconsistent with documented care |
| Misrepresentation of services performed | Clinically Inappropriate |
| Quantity, units, or charge errors (e.g., data entry errors) | Wasted, broken, destroyed items or services |
| Services outside of claim date range | Informational services |
| Services related to a documented primary service when the primary service is erroneously not reported and is otherwise not payable | Billed charges that are not documented/ordered |
| Omission of documented diagnosis codes | Cloned records or documentation |
| Impossible/Excessive units of service | Incorrect provider/group reported |
| Documented services are inconsistent with definition and/or description of code reported | Unlisted codes not supported |
| Modifiers not supported by medical documentation | Invalid site of service |
| Non-covered services | Unidentifiable services |
For additional information, view the R46 Coding and Billing Accuracy reimbursement policy on the Cigna for Health Care Professionals portal (CignaforHCP.com).
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