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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. 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.
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.
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. 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.
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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