Fillable Appeal Request Form printable pdf download

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:

This completed form and/or an appeal letter requesting a review and indicating the reason(s) why you believe the adverse decision is incorrect and

should be changed. If you submit a letter, please include all the information that is requested on this form.

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

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:

Participant ID#:

______________________________________________

______________________________

Employer Name

Account Number_ (from CIGNA ID card)

_____________________________________________

____________________________

Patient Name:

Date of Birth

State of Residence

_____________________________________________

___________________

________________

Healthcare Professional or facility Name:

Date(s) of Service:

_____________________________________________

__________________________

Claim Number /Document Control Number:

_ Procedure/Type of Service:

____________________________

Appeal is being filed by:

Participant

_, Primary Care Physician

_, Specialist/Ancillary Physician

_, Healthcare Facility

___

Other Representative (indicate relationship to participant)

____________________________

Name of person filing out the form

_____________________________________________

Signature:

_____________________________________________

Phone #: (Home) _

(Business)

Date:

________________

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 15 calendar days.

Is this a second appeal? Yes____

No____

Please check off the selection that best describes your appeal:

⎯

Request for in-network coverage

⎯

Coverage Exclusion or Limitation

⎯

Coverage Administration (i.e. co-pay, deductible, etc.)

⎯

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 healthcare professional for a procedure code modifier

⎯

Experimental/Investigational Procedure

⎯

Medical Necessity

⎯

Timely Claim Filing

⎯

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 healthcare professional or

facility).

_____________________________________________________________________________________________________________________________________________________________________________________________________

“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 exclusively by such operating subsidiaries, including Connecticut General Life Insurance

Company and CIGNA Health and Life Insurance Company and not by CIGNA Corporation.

Appeal Request Form

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