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.
865556a Rev. 06/2014
"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.
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.
©2014 Cigna
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.
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Procedure/Type of ServiceDate of Service
Date of BirthPatient Last Name
Account Number (from Cigna ID card)Employer Name
Participant ID #(MI)(First)Cigna Participant Name (Last)
State of Residence(First) (MI)
Claim Number/Document Control Number
Health Care Professional or Facility Name) Is Health Care Professional Contracted?
Yes
No
Appeal is being filed by:
Other Representative (Indicate relationship to Participant): _______________________________________
Health Care FacilitySpecialist/Ancillary PhysicianParticipant
Primary Care Physician
Signature
Business Phone #Home Phone #
Today's DateName of person filling out the form
Have you already received services?
If no, and these services require prior authorization, we will resolve your appeal request for coverage as quickly as possible, within 30 calendar days.
Yes
No
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Yes
No
If allowed by your Plan, is this a second appeal or external review request?
Additional reimbursement to your out of network health care professional for a procedure code modifier
Inpatient Facility Denial (Level of Care, Length of Stay)
Mutually Exclusive, Incidental procedure code denials
Maximum Reimbursable Amount
Coverage Exclusion or Limitation
Request for in-network coverage
Please check off the selection that best describes your appeal:
Benefits reduced due to re-pricing of billed procedures (Viant, Beech Street, Multiplan, etc.)
Timely Claim Filing (without proof)
Medical Necessity
Experimental/Investigational Procedure
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:
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.
If the ID card indicates: GW - Cigna Network
Cigna Appeals Unit
P.O. Box 188062
Chattanooga, TN 37422-8062
If the ID card indicates: Cigna Network
Cigna Appeals Unit
P.O. Box 188011
Chattanooga, TN 37422-8011
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:
Clear Form
