Appeal Policy & Procedures for Providers

• Provider Payment Appeals
• First-Level Appeals
• Second-Level Appeals
• Additional Payment Appeal Options
• Provider Termination Appeals
• Arbitration

Provider Payment Appeals

CIGNA HealthCare strives to informally resolve issues raised by providers on initial contact whenever possible. If issues cannot be resolved informally, CIGNA HealthCare offers a two-level, internal appeal process for resolving contractual disputes regarding post-service payment denials and payment disputes unless a single level appeal process is required by state law. Following the internal CIGNA HealthCare process, arbitration may be used as a final resolution step.

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. If a claim resubmission is unsuccessful, filing an appeal may be warranted.

Note: If there is conflict between this reference guide and your provider agreement with CIGNA HealthCare or applicable law, the terms of your agreement or the applicable law will supersede this guide.

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First-Level Appeals

All first-level appeals must be submitted in writing 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.

Review the Claim Adjustment & Appeals Guidelines for additional information on how to submit an appeal.

If a decision is made to uphold the initial decision, an appeal-denial letter will be sent to the provider outlining any additional appeal rights. An appeal determination that overturns the initial decision will be communicated through the explanation of payment with the reprocessed claim.

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Second-Level Appeals

If you are not satisfied with the resolution of the first-level review, you may submit the appeal to a second-level review within 60 calendar days of the date of the first-level review determination. For Second-Level appeals, follow the same guidelines as outlined for First-Level Appeals but indicate "Second-Level Appeal Request" on the appeal form or letter.

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Additional Payment Appeal Options

After exhausting the internal appeal process, arbitration may serve as a binding, final resolution step as specified in a provider agreement and/or Program Requirements/Administrative Guidelines.

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Provider Termination Appeals

On occasion, CIGNA HealthCare deems it necessary to terminate a provider's participation. To initiate a first-level review of a provider termination, submit the following information in writing within 30 calendar days of the date the provider termination notice.

• A completed provider-termination appeal letter indicating the reason for the appeal
• A copy of the original termination notice
• Supporting documentation for reconsideration

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Arbitration

Payment or termination disputes that are not resolved through first- and second-level review appeals or the additional payment appeal options referenced about and any other disputes between the parties regarding the performance or interpretation of a provider agreement will be resolved through arbitration. Either party may initiate arbitration by providing written notice to the other party. With respect to provider payment or termination disputes, you must request arbitration within one year of the date of the letter communicating the second-level-review decision.

If an arbitration provision was placed in your provider agreement, the terms and conditions of that provision will apply. If your 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 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 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

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