Policies and procedures for health care providers submitting or terminating payment 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:
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
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 health care provider agreement remains in force during arbitration unless otherwise terminated in accordance with the terms of the health care provider agreement.
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.
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.
Individual and family medical and dental insurance plans are insured by Cigna Health and Life Insurance Company (CHLIC), Cigna HealthCare of Arizona, Inc., Cigna HealthCare of Illinois, Inc., Cigna HealthCare of Georgia, Inc., Cigna HealthCare of North Carolina, Inc., Cigna HealthCare of South Carolina, Inc., and Cigna HealthCare of Texas, Inc. Group health insurance and health benefit plans are insured or administered by CHLIC, Connecticut General Life Insurance Company (CGLIC), or their affiliates (see a listing of the legal entities that insure or administer group HMO, dental HMO, and other products or services in your state). Accidental Injury, Critical Illness, and Hospital Care plans or insurance policies are distributed exclusively by or through operating subsidiaries of The Cigna Group Corporation, are administered by Cigna Health and Life Insurance Company, and are insured by either (i) Cigna Health and Life Insurance Company (Bloomfield, CT). The Cigna Healthcare name, logo, and other Cigna Healthcare marks are owned by The Cigna Group Intellectual Property, Inc.
All insurance policies and group benefit plans contain exclusions and limitations. For availability, costs and complete details of coverage, contact a licensed agent or Cigna Healthcare sales representative. This website is not intended for residents of Arizona and New Mexico.
Selecting these links will take you away from Cigna.com to another website, which may be a non-Cigna Healthcare website. Cigna Healthcare may not control the content or links of non-Cigna Healthcare websites. Details
La aseguradora publica el formulario traducido para fines informativos y la versión en inglés prevalece para fines de solicitud e interpretación.
The insurer is issuing the translated form on an informational basis and the English version is controlling for the purposes of application and interpretation.