Cigna Appeal Form PDF Details

Cigna is the third largest health insurance company in the United States. They provide services to employers, individuals and their dependents through employer-sponsored plans or individual market coverage. Cigna has a few different types of appeals that can be submitted if an individual feels they were unfairly declined for coverage based on medical history or other factors. The first type is called "Cigna Appeal Form." This appeal form should only be used when you are appealing a decision made by Cigna's underwriting department to decline your application for insurance because of conditions related to medical history. If you do not know what condition caused the denial, click here to find out more about how it works before submitting this form.

You will discover info about the type of form you would like to complete in the table. It will tell you the amount of time you'll need to finish cigna appeal form, what parts you will need to fill in and a few further specific facts

QuestionAnswer
Form NameCigna Appeal Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namescigna appeals address, cigna appeal letter, cigna insurance appeal, cignas provider appeal form

Form Preview Example

Customer Appeal Request

An appeal is a request to change a previous adverse decision made by Cigna. You or your representative (Including a physician on your behalf) may appeal the adverse decision related to your coverage.

STEP 1:

Contact Cigna's Customer Service Department at the toll-free number listed on the back of your ID card to review any adverse coverage determinations/payment reductions. We may be able to resolve your issue quickly outside of the formal appeal process. If a Customer Service representative cannot change the initial coverage decision, he or she will advise you of your right to request an appeal.

STEP 2:

Complete and mail this form and/or appeal letter along with any supporting documentation to the address identified below. Complete and accurate preparation of your appeal will help us perform a timely and thorough review. In most cases your appeal should be submitted within 180 days, but your particular benefit plan may allow a longer period.

You will receive an appeal decision in writing.

REQUESTS FOR AN APPEAL SHOULD INCLUDE:

1.If you submit a letter without a copy of the Customer Appeal form, please specify in your letter this is a "Customer Appeal". Please include all the information that is requested on this form.

2.A copy of the original claim and explanation of payment (EOP), explanation of benefit (EOB), or initial adverse decision letter, if applicable.

3.Any documentation supporting your appeal. For adverse decisions based upon lack of medical necessity, additional documentation may include a statement from your healthcare professional or facility describing the service or treatment and any applicable medical records.

Cigna Participant Name (Last)

 

(First)

 

 

(MI)

Participant ID #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer Name

 

 

 

 

 

 

 

 

 

Account Number (from Cigna ID card)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient Last Name

 

(First)

 

 

(MI)

Date of Birth

 

State of Residence

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Health Care Professional or Facility Name)

 

 

 

 

 

Is Health Care Professional Contracted?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Service

 

 

Procedure/Type of Service

 

 

 

 

 

Claim Number/Document Control Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Appeal is being filed by:

 

 

 

 

 

 

 

 

 

 

 

Participant

 

 

 

Primary Care Physician

 

Specialist/Ancillary Physician

 

Health Care Facility

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other Representative (Indicate relationship to Participant): _______________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of person filling out the form

 

 

 

 

 

 

Today's Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Home Phone #

 

 

 

 

 

 

Business Phone #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Have you already received services?

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If no, and these services require prior authorization, we will resolve your appeal request for coverage as quickly as possible, within 30 calendar days.

"Cigna" is a registered service mark and the "Tree of Life" logo is a service mark of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company, Cigna Health and Life Insurance Company, Cigna Health Management, Inc. and HMO or service company subsidiaries of Cigna Health Corporation. Please refer to Member's ID card for the subsidiary that insures or administers your benefit plan.

865556a Rev. 06/2014

(Continued on next page)

©2014 Cigna

If allowed by your Plan, is this a second appeal or external review request?

Yes

No

Please check off the selection that best describes your appeal:

Request for in-network coverage

Coverage Exclusion or Limitation

Maximum Reimbursable Amount

Inpatient Facility Denial (Level of Care, Length of Stay)

Mutually Exclusive, Incidental procedure code denials

Additional reimbursement to your out of network health care professional for a procedure code modifier

Experimental/Investigational Procedure

Medical Necessity

Timely Claim Filing (without proof)

Benefits reduced due to re-pricing of billed procedures (Viant, Beech Street, Multiplan, etc.)

Reason why you believe the adverse coverage decision was incorrect and what you feel the expected outcome should be. As a reminder, please attach any supporting documentation (for medical necessity-related denials, include medical records documentation from your health care professional or facility).

Additional Comments:

Refer to your ID card to determine the appeal address to use below.

Mail the completed Appeal Request Form or Appeal Letter along with all supporting documentation to the address below:

If the ID card indicates: Cigna Network

If the ID card indicates: GW - Cigna Network

Cigna Appeals Unit

Cigna Appeals Unit

P.O. Box 188011

P.O. Box 188062

Chattanooga, TN 37422-8011

Chattanooga, TN 37422-8062

IMPORTANT: This address is intended only for appeals of coverage denials. Any other requests sent to this address will be forwarded to the appropriate Cigna location, which may result in a delay in handling your request or processing your claim.

865556a Rev. 06/2014

Clear Form

How to Edit Cigna Appeal Form Online for Free

It is a breeze to complete the cignas provider appeal form. Our software was meant to be easy-to-use and assist you to fill in any PDF easily. These are the basic steps to follow:

Step 1: The first thing would be to choose the orange "Get Form Now" button.

Step 2: At this point, you are on the file editing page. You can add content, edit current information, highlight certain words or phrases, insert crosses or checks, insert images, sign the template, erase unwanted fields, etc.

The following segments are in the PDF document you'll be completing.

completing cigna insurance appeal stage 1

Please type in the crucial information in the If allowed by your Plan is this a, Yes, Please check off the selection, Request for innetwork coverage, Coverage Exclusion or Limitation, Maximum Reimbursable Amount, Inpatient Facility Denial Level of, Mutually Exclusive Incidental, Additional reimbursement to your, ExperimentalInvestigational, Medical Necessity, Timely Claim Filing without proof, Benefits reduced due to repricing, and Reason why you believe the adverse area.

If allowed by your Plan is this a, Yes, Please check off the selection, Request for innetwork coverage, Coverage Exclusion or Limitation, Maximum Reimbursable Amount, Inpatient Facility Denial Level of, Mutually Exclusive Incidental, Additional reimbursement to your, ExperimentalInvestigational, Medical Necessity, Timely Claim Filing without proof, Benefits reduced due to repricing, and Reason why you believe the adverse in cigna insurance appeal

In the area dealing with Reason why you believe the adverse, and Additional Comments, you should write down some necessary data.

part 3 to entering details in cigna insurance appeal

The a Rev section allows you to indicate the rights and obligations of both parties.

part 4 to completing cigna insurance appeal

Step 3: Hit the button "Done". The PDF form can be transferred. It's possible to upload it to your device or send it by email.

Step 4: You can generate duplicates of your file tokeep away from different forthcoming troubles. You need not worry, we do not share or track your data.

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