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California Provider Dispute Policy

Overview
 

CIGNA HealthCare strives to informally resolve issues raised by providers on initial contact whenever possible. If issues cannot be resolved informally, CIGNA HealthCare offers an internal process for resolving provider disputes. Providers should submit disputes in writing to CIGNA HealthCare for review and resolution in accordance with CIGNA HealthCare dispute resolution policies and procedures. Participating providers may 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 dispute processes:

  • For medical necessity disputes and disputes related to experimental or investigational exclusions, a provider may have the option to request a binding external review through an independent review organization.
  • For claim denials relating to claim coding and bundling edits, a provider may have the option to request binding external review through the Billing Dispute Administrator.
  • Alternatively, arbitration may serve as a binding, final resolution step if the provider agreement and/or Program Requirements or Administrative Guidelines so require.

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Connecticut General Life Insurance Company Dispute Resolution Policy

For disputes involving Connecticut General Life Insurance Company participants in the state of California, CIGNA HealthCare has a single-level process for disputes involving post-service payment issues. This includes participants in the PPO, EPO, Open Access Plus and other products offered by Connecticut General Life Insurance Company (‘CGLIC’). This dispute process is applicable to both contracted and non-participating (non-contracted) providers.

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Submission Requirements
To initiate a CGLIC dispute, providers must submit their request in writing within 180 calendar days from the date of the initial payment or denial notice, or if the appeal relates to an adjusted payment, within 180 calendar days from the date of the adjustment. Disputes should be submitted to the following address:

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

A complete provider CGLIC dispute must include the following information:

  1. Provider name
  2. Provider tax identification number
  3. Patient name
  4. Insurer's identification information
  5. Dates of service
  6. Billed and paid amounts (if applicable)
  7. Clear and concise explanation of the reason for the dispute (i.e., underpayment, level of care, no authorization, claim bundling, length of stay if different from authorization, opt-out, revised code with modifier, benefit issue, contract issue, member eligibility issue, or stop loss discrepancy)
  8. A copy of the original claim and explanation of payment or explanation of benefits, if applicable
  9. For reviews with a clinical component, such as services denied for no prior authorization for not being medically necessary (and providers are appealing on their own behalf), supporting documentation should include a narrative describing the situation, an operative report and medical records, as applicable.

A form titled Request for Provider Payment Review – All Others* (PDF) is available on this website to help prepare the documentation for an appeal request.

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When CGLIC Dispute Requests are Not Processed as Disputes
When it is determined that CGLIC made an error in processing a claim (that is, not in accordance with the contract and/or a policy), the issue will be tracked and processed as a claim adjustment rather than a provider dispute unless the provider submits the adjustment request after payment has previously been adjusted twice.

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Dispute Notification and Response
Providers will receive notification of the dispute resolution within 45 business days of receipt of the original CGLIC dispute. If approved, the Explanation of Payment will serve as notice of the determination. If the initial payment decision is upheld, providers will receive a letter outlining any additional rights.

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CIGNA HealthCare of California, Inc., Dispute Resolution Policy

For disputes involving CIGNA HealthCare of California, Inc., participants, there is a single-level dispute resolution process. This includes participants in the HMO, POS, Open Access and other products offered by CIGNA HealthCare of California, Inc. (‘CHC of CA’). This dispute process is applicable to both contracted and non-participating (non-contracted) providers.

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Submission Requirements
CIGNA HealthCare must receive CHC of CA disputes in writing, including those relating to payment of claims or compensation, within 365 days of the initial denial as stated on an explanation of payment (EOP). This time period is subject to any different time period required under applicable law. Disputes must be written and submitted to the following address:

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

A complete CHC of CA dispute must include the following information:

  1. Provider's name (i.e., provider of service)
  2. Provider's tax identification number
  3. Name, address and phone number of a contact person at the provider's location
  4. Member's name, CIGNA HealthCare member identification number and date of service
  5. Hard copy of the disputed claim (if not previously submitted)
  6. Clear and concise explanation of the issue and/or reason for the dispute (i.e., underpayment, level of care, no authorization, claim bundling, length of stay if different from authorization, opt-out, revised code with modifier, benefit issue, contract issue, member eligibility issue, or stop loss discrepancy)
  7. Appropriate supporting documentation, including but not limited to original claim (if not previously submitted) and EOP, if applicable; disputes with a clinical component must include a narrative, operative report and medical records

Incomplete disputes will be returned to the provider. Returned disputes may be resubmitted with the missing information within 30 business days from the date the returned dispute is received by the provider.

If a provider is appealing 100 or more claims in a single submission, an electronic Excel spreadsheet that individually numbers each claim is required, along with hard copies of the claims (if not previously submitted) and the appropriate supporting documentation (numbered accordingly). For further information regarding dispute submission requirements, please contact your Provider Services Representative.

A form titled Provider Dispute Resolution Request - CA HMO* (PDF), although not required, is available on this website to help prepare the documentation for an appeal request.

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When CHC-CA Dispute Requests are Not Processed as Disputes
When a large number of claim denials are submitted for review at the same time (‘claim projects’), they are not automatically considered provider disputes. These review requests are tracked as disputes if CIGNA HealthCare determines the original payment was made in accordance with the contract and CIGNA HealthCare policies.

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Dispute Acknowledgement and Response
CIGNA HealthCare will send a letter acknowledging a dispute within 15 business days of receipt by the P.O. Box designated to receive CHC of CA provider disputes. Furthermore, providers will receive a determination letter that will indicate the dispute resolution, explanation for resolution and amount of additional payment, if applicable. CIGNA HealthCare will send this determination letter within 45 business days of its receipt of a CHC of CA dispute.

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External Review

Upon exhaustion of the internal Dispute Resolution process described above, the External Review program is available for disputes involving medical necessity and claim bundling. Providers have the right to appeal the decision through the CIGNA HealthCare External Review Program, by an independent review organization (IRO).

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. 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 several Independent Review Organizations: There is no charge to the provider for this review. To be eligible for this program, providers must first exhaust the internal dispute process. External review requests must be received by CIGNA within 180 calendar days of the date of the denial letter from CIGNA HealthCare for medical necessity issues and within 90 calendar days for claim bundling issues.

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

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How to Request an External Review
If applicable, the 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 Internal Dispute Review.
  3. The request will be reviewed by CIGNA HealthCare to ensure that it meets the criteria for an external review (e.g., meets medical necessity or claim bundling criteria, exhaustion of Internal Dispute 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 within 15 days of receipt of the IRO decision. If approved, the Explanation of Payment will serve as written notification. If the initial payment decision is upheld, providers will receive a letter outlining additional rights.

In the event the parties cannot reach agreement of the dispute, the provider may request arbitration of the dispute. For more information on arbitration, please refer to your provider agreement or CIGNA HealthCare Program Requirements or Administrative Guidelines.

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