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> Policies & Procedures > Claim Appeals > Appeal Policy and Procedures for Providers
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Appeal Policy and Procedures for Providers

Overview
 

NOTE: Items on this page that are preceded by a double asterisk (**) do not apply to hospitals, laboratories and suppliers of medical equipment that do not provide health care services along with the provision of medical equipment or do not bill separately for health care services provided along with medical supplies.

Whenever possible, CIGNA HealthCare strives to informally resolve issues raised by providers at the time of the initial contact. If the issue cannot be resolved informally, CIGNA HealthCare offers a two-level internal appeal process for resolving disputes with providers. Participating providers should refer to their CIGNA HealthCare provider agreement and/or Program Requirements or Administrative Guidelines for further details. In addition, the following dispute resolution mechanisms may be available after exhausting the internal CIGNA HealthCare processes:

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For medical necessity appeals and appeals related to experimental or investigational exclusions, a provider may have the option to request a binding external review through an independent review organization. There are also different external appeal processes offered under various state laws which may include a review by an independent review organization outside of the CIGNA HealthCare External Review Program. An external review is not available when the plan sponsor of a participant's self-insured plan has elected not to participate in such a program.

**     

For claim denials relating to claim coding and bundling edits, a provider may have the option to request binding external review from the Billing Dispute Administrator.
 

 

Alternatively, arbitration may serve as a binding, final resolution if the provider agreement and/or Program Requirements or Administrative Guidelines so require.

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First-Level Provider Payment Review

In general, the First Level of the provider payment review process must be initiated within 180 calendar days from the date of the initial payment or denial decision from CIGNA HealthCare. 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 provider's agreement terms and/or the participant's benefit 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.

Providers who are not satisfied with the First-Level review decision may request a Second-Level Provider Payment Review.

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Filing a First-Level Review

  1. Contact the CIGNA HealthCare Customer Service Department at the toll-free number listed on the back of the CIGNA HealthCare participant's ID card to review any claim denials or payment decisions. If a Customer Service 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.
  2. Download, print, complete and mail the applicable request for payment review form (below) to the designated CIGNA HealthCare office.

    Payment Review Forms

    State Link to Payment Review Form
    California (HMO Only)     Provider Dispute Resolution Request CA HMO
    Texas   Request for Provider Payment Review TX
    All Others   Request for Provider Payment Review All Others    

  3. 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.
  4. For appeals with a clinical component, such as services denied for no prior authorization, submit supporting documentation, including a narrative describing the subject of the appeal, an operative report and medical records, as applicable.
  5. Mail your appeal, payment review form and supporting documentation to:
      CIGNA Appeals Unit
          P.O. Box 188011
  Chattanooga, TN 37422

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Second-Level Provider Payment Review

In general, the Second Level of the provider payment review process must be initiated within 60 calendar days of the date on the First-Level review decision letter. Time periods are subject to applicable law and the provider agreement.

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Provider appeals will be handled by a reviewer who was not involved in the initial decision or First-Level review. In the case of medical necessity denials, a provider in the same specialty1 (but not necessarily the same subspecialty) as the ordering or treating provider will review the appeal and render a decision. If the CIGNA HealthCare member does not pursue an appeal, and the provider employed or contracted to perform the First-Level review was of the same specialty as the appealing provider, no Second-Level review is required, and the appealing provider may proceed to external review. In that event, the provider must submit a form signed by the participant stating that he/she does not intend to pursue his/her own appeal.

 

1 Same specialty means a practitioner with similar credentials and licensure as those who typically treat the condition or health problem in question.
 

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In the case of a medical necessity denial and denials related to experimental or investigational exclusions, in certain circumstances as specified below, providers may have the option to request an External Review by an independent medical review organization. For claim denials relating to claim coding and bundling edits, providers may have the option to request a review from the Billing Dispute Administrator. The process for requesting such a review is described in the Second-Level review decision letter.
 

Participating providers who are not satisfied with the Second-Level review decision may request alternate dispute resolution, pursuant to the terms of their CIGNA HealthCare 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 Second-Level denial letter.

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Filing a Second-Level Review

  1. Download, print, complete and mail the applicable request for payment review form (below) to the designated CIGNA HealthCare office. Be sure to include additional supporting information if not previously submitted at the First-Level Provider Payment Review.

    Payment Review Forms

    State Link to Payment Review Form
    California (HMO Only)     Provider Dispute Resolution Request CA HMO
    Texas   Request for Provider Payment Review TX
    All Others   Request for Provider Payment Review All Others    

  2. Include a copy of the original claim, the Explanation of Payment (EOP) or Explanation of Benefits (EOB), if applicable, and any additional documentation to support the appeal request.
  3. For appeals with a clinical component, such as denials for failure to obtain prior authorization, provide supporting documentation including a narrative describing the subject of the appeal and any additional clinical documentation (e.g., operative report and medical records) that was not previously submitted. It is not necessary to resubmit the same documentation that was included in the First-Level review request.
  4. Mail your appeal, payment review form and supporting documentation to:
      CIGNA Appeals Unit
          P.O. Box 188011
  Chattanooga, TN 37422

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Medical Necessity External Review

For the external review process applicable to claim coding and bundling edits, please use the following link: Billing Dispute External Review.

Upon exhaustion of the two-level process for a medical necessity denial or denials related to experimental or investigational exclusions, providers may have the right to appeal the decision through the CIGNA HealthCare External Review Program, which provides a review of certain medical necessity appeals and denials based upon experimental, investigational or unproven exclusions by an independent review organization (IRO). If the CIGNA HealthCare member does not pursue an appeal, and the provider employed or contracted to perform the First-Level review is of the same specialty as the appealing provider (but not necessarily the same subspecialty), no Second-Level review is required, and the appealing provider may proceed directly to external review. To proceed directly to external review, the provider must submit a form signed by the participant stating that he/she does not intend to pursue his/her own member appeal.

The IROs utilized by CIGNA HealthCare have no affiliation with the company other than a vendor-contract relationship. CIGNA HealthCare will abide by the decision of the IRO. The IRO will utilize a practitioner of the same specialty as the ordering or treating provider. There are also different external appeal processes offered under various state laws which may include a review by an independent review organization outside of the CIGNA HealthCare External Review Program. In addition, an external review is not available when the plan sponsor of a participant's self-insured plan has elected not to participate in this program.

The CIGNA HealthCare External Review Program utilizes two Independent Review Organizations: HAYES Plus®, Inc., and Medical Care Management Corporation (MCMC). There is no charge to the provider for this review. Information about these two organizations is noted below.

To be eligible for this program, providers must first exhaust the internal appeal process and must request the review within 180 days of the date of the Second-Level denial letter or First-Level denial letter if the First-Level review was conducted by a provider in the same specialty.

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How to Request an External Review

If applicable, the Second-Level denial letter will provide an overview of the external review rights and instructions for submitting the request. The following process applies to the CIGNA HealthCare External Review Program:

  1. Submit the external review request to the address below. Under no circumstances should your request be sent directly to the external independent review organization.

          CIGNA Appeals Unit
              P.O. Box 188011
      Chattanooga, TN 37422

  2. Include any additional clinical documentation that was not previously submitted in the First- or Second-Level requests.
  3. The request will be reviewed by CIGNA HealthCare to ensure that it meets the criteria for an external review (e.g. medical necessity appeal, exhaustion of First- and Second-Level review process, as applicable).
  4. CIGNA HealthCare will send an authorization form that must be completed by the provider. In the authorization form, choose which IRO you wish to have handle the appeal. If you do not select an IRO, CIGNA HealthCare will select one for you.
  5. Upon receipt of the authorization form, CIGNA HealthCare will send its appeal file to the IRO vendor for review.
  6. The IRO will return its decision to CIGNA HealthCare within 30 days, and this decision will be forwarded to you.
  7. Approvals will be processed by CIGNA HealthCare within 10 days of receipt of the IRO decision.

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Independent Review Organizations

HAYES Plus® is a national Independent Review Organization (IRO).

HAYES Plus
157 Broad Street
Suite 200
Lansdale, PA 19446

Phone: 215.855.0615

Medical Care Management Corporation (MCMC)

MCMC
5272 River Road
Suite 650
Bethesda, MD 20816-1405

Phone: 301.652.1818

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External Review Statistics

The number and outcome of any External Reviews will be reported on an annual basis. Log in to CIGNA for Health Care Professionals to view our External Review statistics.

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