Appeal Policy and Procedures

Overview

This policy applies to all MD's and Doctors of Osteopathy.

Whenever possible, Cigna HealthCare strives to informally resolve issues raised by physicians at the time of the initial contact. If the issue cannot be resolved informally, Cigna HealthCare offers a two-level, internal appeal process for resolving disputes with physicians. Participating physicians should refer to their Cigna HealthCare physician agreement and/or its Program Requirements. In addition, the following dispute resolution mechanisms may be available after exhausting the internal Cigna HealthCare processes:

• For medical necessity appeals, a physician may have the option of requesting a binding external review through an independent review organization. There are also different external appeal processes offered under various state laws which may include a review by an independent review organization outside of the Cigna HealthCare External Review Program.
• For claim denials relating to claim coding and bundling edits, a physician may have the option to request binding external review from the Billing Dispute Administrator.
• Alternatively, arbitration may serve as a binding, final resolution step if the physician agreement and/or Program Requirements so require.

First-level Physician Payment Review

In general, the First Level of the physician appeal process must be initiated within 180 calendar days from the date of the initial payment or denial decision from Cigna HealthCare. Time periods are subject to, and may be extended by, applicable law or the physician agreement.

Appeal requests will be handled by a reviewer who was not involved in the initial decision. Decisions will be consistent with the physician’s contract terms and/or the participant’s benefit plan. With respect to medical necessity appeals, a nurse can review and may grant, but may not deny the appeal.

Physicians who are not satisfied with the First-level appeal review decision may request a Second-level Physician Payment Review.

Filing a First-level Appeal

1. Contact Cigna HealthCare's Customer Service Department at the toll-free number listed on the back of the Cigna HealthCare participant ID card to review any claim denials or payment decisions. If a Customer Service Representative is unable to determine that an error was made with the claim adjudication decision and correct it, you have the right to appeal Cigna HealthCare's decision by following the remaining steps below.
2. Download, print, complete and mail the applicable request for payment review form (below) to the designated Cigna HealthCare office.

   State	Link to Payment Review Form
   California (HMO Only)	Provider Dispute Resolution Request – CA HMO
   Texas	Request for Provider Payment Appeal – TX
   All Others	Request for Physician Payment Review – All Others

3. Include a copy of the original claim, the Explanation of Payment (EOP) or Explanation of Benefits (EOB), if applicable, and any supporting documentation to support your appeal request.
4. For appeals with a clinical component, such as services denied for no prior authorization, submit supporting documentation, including a narrative describing the subject of the appeal, an operative report and medical records, as applicable.
5. Use the table below to find the correct mailing address for your documentation:

   Appeal Mailing Address for First-level Post-service Appeals (service has already been rendered) by Cigna HealthCare CONTRACTED Physicians

   If the participant's ID card indicates he or she is covered under an HMO, HMO Open Access, POS or POS Open Access plan, submit your appeal to:

   Physician State of Operations	Appeal Submission Address
   AK, AL, AR, AZ, CO, DE, FL, GA, ID, KS, KY, LA, MS, MT, NM, NV, OK, OR, TN, TX, UT, WA	Cigna HealthCare PO Box 182223 Chattanooga, TN 37422-7223
   CT, DC, IA, IL, IN, MA, MD (non-clinical), ME (non-clinical), MI, MN, MO, NC, NH, NY, OH, RI, SC, VA, VT, WI, WV	Cigna HealthCare PO Box 5200 Scranton, PA 18505-5200
   MD (clinical), ME (clinical), NJ, PA	Cigna HealthCare PO Box 5225 Scranton, PA 18505-5225
   CA	Cigna HealthCare PO Box 49 Glendale, CA 91209-0049

   If the participant’s ID card indicates he or she is covered under a PPO, Indemnity or Open Access Plus plan, submit your appeal to:

   Physician State of Operations	Appeal Submission Address
   AK, AL, AR, AZ, CO, DE, FL, GA, GU, HI, ID, KS, KY, LA, MS, MT, NM, NV, OK, OR, PR, TN, TX, UT, VI, WA, WY	Cigna HealthCare PO Box 182223 Chattanooga, TN 37422-7223
   CT, DC, IA, IL, IN, MA, MD, ME, MI, MN, MO, NC, ND, NE, NH, NY, OH, PA, RI, SC, SD, VA, VT, WI, WV	Cigna HealthCare PO Box 5200 Scranton, PA 18505-5200
   NJ	Cigna HealthCare PO Box 5225 Scranton, PA 18505-5225
   CA	Cigna HealthCare PO Box 49 Glendale, CA 91209-0049

   Appeal Mailing Address for First-level Post-service Appeals (service has already been rendered) by Physicians NOT CONTRACTED with Cigna HealthCare

   If the participant's ID card indicates he or she is covered under an HMO, HMO Open Access, POS, POS Open Access, PPO, Indemnity, or Open Access Plus plan, submit your appeal to:

   Residence State of Participant	Appeal Submission Address
   All	Cigna HealthCare PO Box 5225 Scranton, PA 18505-5225

   Appeal Mailing Address for All First-level Pre-service Appeals (service has not been rendered yet)

   If the participant’s ID card indicates he or she is covered under an HMO, HMO Open Access, POS, POS Open Access, PPO, Indemnity or Open Access Plus plan, submit your appeal to:

   Residence State of Participant	Appeal Submission Address
   All	Cigna HealthCare PO Box 5225 Scranton, PA 18505-5225

Second-level Physician Payment Review

For the external review process applicable to claim coding and bundling edits, please use the following link: Billing Dispute External Review.

Upon exhaustion of the two-level process for a medical necessity denial, physicians have the right to appeal the decision through the Cigna HealthCare External Review Program, which provides a review of certain medical necessity appeals and denials based upon experimental, investigational or unproven exclusions by an independent review organization (IRO). If the Cigna HealthCare member does not pursue an appeal, and the physician employed or contracted to perform the First level review is of the same specialty as the appealing physician (but not necessarily the same subspecialty), no Second-level is required, and the appealing physician may proceed directly to external review. To proceed directly to external review, the physician must submit a form signed by the participant stating that he/she does not intend to pursue his/her own member appeal.

The IRO's utilized by Cigna HealthCare have no affiliation with the company other than a vendor-contract relationship. Cigna HealthCare will abide by the decision of the IRO. The IRO will utilize a practitioner of the same specialty as the ordering or treating physician. There are also different external appeal processes offered under various state laws which may include a review by an independent review organization outside of the Cigna HealthCare External Review Program.

The Cigna HealthCare External Review Program utilizes two Independent Review Organizations; HAYES PLUS®, Inc. and Medical Care Management Corporation (MCMC). There is no charge to the physician for this review. Information about these two organizations is noted below.

To be eligible for this program, physicians must first exhaust the internal appeal process and must request the review within 180 days of the date fn the Second-level denial letter or First-level denial letter if the First-level review was conducted by a physician in the same specialty.

How to Request an External Review
The Second-level medical necessity denial letter will provide an overview of the external review rights and instructions for submitting the request. The following process applies to the Cigna Healthcare External Review Program:

1. Submit your external review request to the address below. Under no circumstances should your request be sent directly to the external independent review organization.
   Cigna HealthCare
   PO Box 5225
   Scranton, PA 18505-5225
2. Include any additional clinical documentation that was not previously submitted in your First-level or Second-level requests.
3. Your request will be reviewed by Cigna HealthCare to ensure that it meets the criteria for an external review (e.g. medical necessity appeal, exhaustion of First-level and Second-level appeals process, as applicable).
4. Cigna HealthCare will send an authorization form that must be completed by the physician. In the authorization form, choose which IRO you wish to have handle your appeal. If you do not select an IRO, Cigna HealthCare will select one for you.
5. Upon receipt of the authorization form, Cigna HealthCare will send its appeal file to the IRO vendor for review.
6. The IRO will return its decision to Cigna HealthCare within 30 days and this decision will be forwarded to you.
7. Approvals will be processed by Cigna HealthCare within 10 days of receipt of the IRO decision.

Independent Review Organizations

HAYES Plus, is a national Independent Review Organization (IRO).

HAYES PLUS®
157 Broad Street
Suite 200
Lansdale, PA 19446

Phone: (215) 855.0615

Medical Care Management Corporation (MCMC)

MCMC
5272 River Road
Suite 650
Bethesda, MD 20816-1405

Phone: (301) 652-1818

External Review Statistics

The number and outcome of any External Reviews completed in calendar year 2004 will be reported in January 2005.