Cigna announces change to appeal process

May 13, 2013

In April, Cigna announced via a website posting that beginning July 1, 2013, it will no longer offer second-level appeals. The notice, posted in its Network News, states that all appeals will “follow a thorough single appeal review process and will be completed within 60 days.” The payor says that the change will establish a consistent approach for all providers.

The California Medical Association (CMA) has expressed concerns to Cigna regarding the notice. Specifically, the notice states that all appeals must be submitted in writing within 180 calendar days of the date of the initial payment or denial, which is not consistent with California law. State law states that payors can’t impose a deadline for the receipt of a provider dispute that is less than 365 days from the date of the last action.

Additionally, California law requires that health plans and their contracting medical groups/IPAs provide a minimum of 45 days advance notice of a material change to a contract, manual, policy or procedure (28 C.C.R. 1300.71(m)). A change is “material” if “a reasonable person would attach importance [to it] in determining the action to be taken upon the provision.” Physicians have the right to terminate the agreement prior to the implementation of the change if they do not agree to the proposed change. CMA is concerned that the posting of a website notification does not meet the prior notification requirement.

CMA has raised our concerns with Cigna and will publish an update when we have more information.


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