Fillable MEDICARE ADVANTAGE APPEALS AND CLAIM DISPUTES (Cigna Medicare Providers)

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MEDICARE ADVANTAGE APPEALS AND CLAIM DISPUTES (Cigna Medicare Providers)

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MEDICARE ADVANTAGE APPEALS AND CLAIM DISPUTES
Complete the top section of this form completely and legibly. Check the box that most closely describes your
appeal reconsideration reason. Be sure to include any supporting documentation, as indicated below.
Requests received without required information cannot be processed.
REQUEST FOR APPEAL OR CLAIM DISPUTES/RECONSIDERATIONS
Customer first Name: MI: Customer last Name: Customer ID:
Customer Date of Birth:
Claim #:
Date of Service:
Provider name/contact name:
Provider NPI:
Phone Number:
Provider Appeal Correspondence Address:
APPEALS
Medical necessity
Notification/precertification Referral denial
Payer policy
CLAIM DISPUTES/RECONSIDERATIONS
Payment Issue Duplicate Claim Retraction of payment
Request for medical records Request for additional information
Coordination of Benefits
Reason for claim disputes:
Reason for appeal:
Include precertification/prior authorization number
.
Submit appeals to:
Cigna
Attn: Appeals Unit
PO Box 24087
Nashville, TN 37202
Fax: 1-800-931-0149
For help, call: 1-800-511-6943
Include copy of letter/request received
.
Include copy of letter/request received
.
Coding dispute
Remittance Advice (RA), Explanation of Benefits (EOB), or other
documentation of filing original claim
.
Timely filing
Provide missing or incomplete information
.
Fax: 1-615-401-4642
For help, call: 1-800-230-6138
Cigna
Attn: Claim Disputes/Reconsiderations
PO Box 20002
Nashville, TN 37202
Submit reconsiderations to:
924548 08/2020 INT_20_89273
Fax Number:
Observation or Inpatient Medical
Necessity Medical Necessity (MN) Denial
No prior authorization
Date of service on claim does not match authorization
Member not effective on date of service
Service or Item not covered
Member in Hospice
Not a covered benefit
Service not covered by Medicare
Service provided before authorization was effective
Quantity billed exceeds amount authorized
Exceeds benefit limit
Invalid or Missing Modifier
NPI/TIN mismatch
Invalid DX/CPT codes
Claim was not paid in accordance with contract allowable
Not within the scope of contract
MUE (medically unnecessary edits)
Post Service Claim Audit or Payment Recovery
Duplicate claim
Itemized bill required
Additional information required
Claim Timely filing Denials
Bundled Service
CLEAR FORM
MEDICARE ADVANTAGE APPEALS AND CLAIM DISPUTES (Continued)
Note: If you have multiple reconsideration requests for the same health care professional and payment issue,
please indicate this in the notes below and include a list of the following: Customer ID #, Claim #, and date of
service. If the issue requires supporting documentation as noted above, it must be included for each individual
claim. If no additional documentation is required for your appeal or reconsideration request, fax in only this
completed coversheet. You may use the space below to briefly describe your reason for appeal or
reconsideration.
DEFINITIONS
Payment issue: Was not paid in accordance with the negotiated terms
Coordination of benefits: Could not fully be processed until information from another insurer has been
received
Duplicate claim: The original reason for denial was due to a duplicate claim
Medical necessity: Medical clinical review
Pre-certification/notification of prior-uuthorization or reduced payment: Failure to notify or pre-
authorize services or exceeding authorized limits
Payer policy clinical: Incorrectly reimbursed because of the payers payment policy
Referral denial: Invalid or missing primary care physician (PCP) referral
Request for additional information: Missing or incomplete information *reply via sender*
Request for medical records: Please include copy of letter/request received
Retraction of payment: Retraction of full or partial payment
Timely filing: The claim whose original reason for denial was untimely filing
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life
Insurance Company. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc. © 2020 Cigna.
924548 08/2020 INT_20_89273
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Completed 20 January 2021

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