Request for Health Care Professional Payment Review
BEFORE PROCEEDING, NOTE THE FOLLOWING:
- Corrected claims should be submitted to the claim address on the back of the patient’s Cigna identification card (ID card). If the claim in question has had no
payments to date or you are submitting additional information for the initial review of payment, please forward to the address on the back of the patient’s ID
- Fee schedule or reimbursement terms for multiple patients do not require individual appeals. Contact Cigna Customer Service at the toll-free number listed on
the back on the patient’s ID card for further assistance. If you are a contracted health care professional and you feel your contract is being inappropriately
applied, please contact your Experience Manager or Experience Consultant at Cigna.
Step 1: Contact Cigna Customer Service at the toll-free number listed on the back of the patient’s Cigna ID card to review any adverse determinations/payment
reductions. If a Customer Service representative is unable to change the initial decision, you will be advised at that time of your right to request an appeal.
Step2: Complete and mail this form and/or appeal letter along with all supporting documentation to the address identified in Step 3 on this form. Your appeal
should be submitted within 180 days and allow 60 days for processing your appeal, unless other timelines are required by state law.
REQUESTS FOR REVIEW SHOULD INCLUDE:
1. This completed form and/or an appeal letter requesting an appeal review and indicating the reason(s) why you believe the claim payment is incorrect and
should be changed. If submitting a letter, please include all information requested on this form. If only submitting a letter, please specify in the letter this is a
Health Care Professional Appeal.
2. Include a copy of the original claim and the Explanation of Payment (EOP) or Explanation of Benefits (EOB), if applicable.
3. For reviews involving a previous clinical denial, such as denied hospital days, level of care, medical necessity or services denied for no prior authorization,
supporting documentation should include a narrative describing the situation, an operative report and medical records, as applicable.
Are you contracted with Cigna? Yes No
Tax identification number ________________________ National Provider Identifier (NPI) number __________________
Have services been rendered? Yes No
If no, and these services require prior authorization, we will resolve your appeal request for benefit coverage as expeditiously as possible and within the time
permitted by applicable law.
Please check the issue that best describes your appeal. The initial decision was related to:
Mutually exclusive, incidental, or bundling procedure code denial
Your Cigna contract and the fee schedule or reimbursement terms
Modifier reimbursement: List modifier(s):___________________
Inpatient Facility denial (level of care, length of stay, delayed treatment day)
Medical necessity of the service
Timely claim filing (without proof)
Precertification or prior authorization not obtained
Request for in-network benefits
Benefit plan exclusion or limitation
Maximum Reimbursable Amount
Non participating anesthesiologist, radiologist, or pathologist requesting in-network benefits
Other (please indicate) ____________________________________________
Cigna Subscriber Name: _________________________________ Subscriber ID#: _____________________________
Employer Name: _________________________________ Account Number (from Cigna ID card): ___________________________________
Patient Name: ______________________________________________ Date of Birth: __________________State of Residence: ___________
Date(s) of Service: ___________________________________________Procedure/Type of Service: __________________________________
Claim Number/Document Control Number, if payment related appeal: __________________________
Original Claim Amount Billed: _________________ Original Claim Amount Paid: __________________
Indicate below where appeal correspondence should be directed:
Health Care Provider (Practitioner/Facility Name): __________________________________________________________________________
Street/PO Box: _____________________________ City: _____________________ State: ____________ Zip: ____________
Telephone: ________________________________ Fax: _____________________________________
Referring Health Care Professional Name (if applicable): ______________________________________
“Cigna” and the “Tree of Life” logo are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and
services are provided by such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company, Cigna Health and Life
Insurance Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc.
Step3: Refer to the patient’s Cigna ID card to determine the appeal address to use below. Mail this completed form (Request for Health Care Professional
Review) or a letter of appeal along with all supporting documentation to the address below: