How to Submit Appeals

Note for Medicare Providers: Only forms and information with an asterisk (*) have to do with Medicare Appeals. If you need information for Cigna Healthcare^SM Medicare Provider Appeals, you can:

• Visit Cigna Healthcare Medicare Providers
• Refer to your Cigna Healthcare Medicare Advantage Provider Manual [PDF]

Questions? Reach us at:
Medicare Advantage Plans: 1 (855) 551-6943
Medicare Advantage Plans (Arizona only): 1 (800) 627-7534
Medicare Prescription Drug Plans (PDP): 1 (866) 845-6962

How to Submit an Appeal

1. Fill out the Request for Health Care Provider Payment Review form [PDF]. The form will help to fully document the circumstances around the appeal request and will also help to ensure a timely review of the appeal. All forms should be fully completed, including selecting the appropriate check box for the reason for the appeal. Appeal Types are available in the National Reference Guide on the CignaforHCP portal.
2. With the form, you'll need to submit:
   • The original explanation of benefits (EOB), explanation of payment (EOP), or letter sent to the health care provider requesting additional information⁴
   • Documentation that supports why the decision should be overturned (e.g., operative reports or medical records)

3. Submit the appeal within 180 calendar days (90 calendar days for Medicare customers*) 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 (90 calendar days for Medicare customers*) from the date of the last payment adjustment, to the following address:

   If the ID card includes the “GWH-Cigna” or “G” indicators	For Cigna Healthcare Medicare Advantage*	For all other appeals
   Cigna Healthcare Inc. National Appeals Unit (NAO) PO Box 188011 Chattanooga, TN 37422	Cigna Healthcare Medicare Attn: Part C Appeals (Medical) PO Box 188081 Chattanooga, TN 37422	Cigna Healthcare Inc. National Appeals Unit (NAO) PO Box 188011 Chattanooga, TN 37422

   For appeals relating to high-tech radiology and diagnostic cardiology services	For appeals relating to radiation therapy and medical necessity	For appeals relating to claim denials
   CareCore | MedSolutions 730 Cool Springs Blvd, Suite 800 Franklin, TN 37067	CareCore | MedSolutions 400 Buckwalter Place Blvd. Bluffton, SC 29910	CareCore | MedSolutions Appeals Department PO Box 698 Lake Katrine, NY 12449

4. The review will be completed in 60 days and the health care provider will receive notification of the dispute resolution within 75 business days of receipt of the original dispute. If a decision is made to uphold the decision, an appeal denial letter will be sent to the health care provider outlining any additional appeal rights, if applicable. An appeal determination that overturns the initial decision will be communicated through the explanation of payment with the reprocessed claim. Time periods are subject to applicable law and the health care provider agreement.

Arbitration

Either party may initiate arbitration by providing written notice to the other party. With respect to health care provider payment or termination disputes, you must request arbitration within one year of the date of the letter communicating the final internal level review decision.⁵

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

The health care provider agreement remains in force during arbitration unless otherwise terminated in accordance with the terms of the health care provider agreement.

Other Types of Appeals

Termination Appeals

On occasion, Cigna Healthcare deems it necessary to terminate a health care provider's participation. Appeal rights are offered to health care providers terminated due to Quality of Care or Quality of Service and health care providers terminated for failure to meet Cigna Healthcare credentialing requirements in states that mandate appeal rights be offered.

To initiate a review of a health care provider's termination, submit the following information in writing within 30 calendar days of the date of the health care provider's termination notice.

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

Customer Reviews

In certain cases, pre- or post-service denials can be appealed directly by a customer (or a health care provider on behalf of a customer). When a health care provider submits an appeal on behalf of their patient, the process remains largely the same as a health care provider driven appeal.

However for certain appeals (e.g., in cases of MNR review), health care providers can be offered an additional external review for their patient by an Independent Review Organization (IRO) after an initial appeal denial. If there is an opportunity for an additional external review through an IRO, the initial appeal denial letter will outline the steps the health care provider must take in order to receive this external review. This includes signing, dating, and returning a “Request for Review by an Independent Review Organization” form. Once this form is returned, the external review process can begin.

Please note that in cases of an external review through an IRO, the health care provider must get their patient’s approval to proceed.

¹ Processes may vary due to state mandates or contract provisions.

² If there is conflict between this reference guide and your health care provider agreement with Cigna Healthcare or applicable law, the terms of your agreement or the applicable law will supersede this guide.

³ Exceptions based on state regulations

⁴ Note: for denials that do not have an associated EOB or EOP (e.g., precertification denial), no EOB or EOP documentation is required.

⁵ If you do not request an internal appeals review or arbitration of the dispute within the defined timeframes, the last Cigna Healthcare determination will be final. Customers cannot be billed for any amount denied because you failed to submit the request for review or arbitration within the required timelines.