In the event you have a dispute with Cigna Behavioral Health of California, Inc. ("Cigna Behavioral Health") concerning the performance of your Cigna Behavioral Health provider contract, you may access the Cigna Behavioral Health Provider Dispute Resolution Mechanism. The following describes the key steps for the submission and resolution of disputes.

Step One—Dispute Submission

Within 365 days of the initial denial, CIGNA Behavioral Health must receive disputes, including those relating to payment of claims or compensation, as stated on the Remittance Advice. This time period is subject to any different time period required under applicable law. Disputes must be written and submitted to the following address:

Provider Disputes
Cigna Behavioral Health of California, Inc.
450 North Brand Boulevard, Suite 500
Glendale, CA 91203

Step Two—Complete Dispute

Only complete disputes will be processed. A complete dispute must include the following information:

• Provider’s name (i.e., provider of service).
• Provider tax identification number.
• Name, address and phone number of the contact person at the Provider’s location. Provider is defined as a physician, behavioral health practitioner, clinic, facility or ancillary entity.
• Participant’s Name, Cigna Behavioral Health participant identification number and date of service.
• Hard copy of the disputed claim (if not previously submitted).
• Clear and concise explanation of the issue and/or reason for the dispute (e.g., underpayment, level of care, no authorization, length of stay if different from authorization, benefit issue, contract issue, participant eligibility issue).
• Appropriate supporting documentation including, but not limited to, original claim (if not previously submitted) and Remittance Advice, if applicable. Disputes with a clinical component must include a narrative and medical records. Incomplete disputes will be returned to the Provider. Returned disputes may be resubmitted with the missing information within thirty (30) business days from the date the returned dispute is received by the Provider. If the Provider is disputing 100 or more claims in a single submission, an electronic Excel spread-sheet, which individually numbers each claim, along with hard copies of the claims (if not previously submitted) and the appropriate supporting documentation (numbered accordingly) are required.

Step Three—Communication

Cigna Behavioral Health will send a letter acknowledging the dispute within 15 business days of receipt of the Provider dispute. Furthermore, the Provider will receive a determination letter that will indicate dispute resolution, explanation for resolution and amount of additional payment, if applicable. Cigna Behavioral Health will send this determination letter within 45 business days of its receipt of the dispute.

In the event the Provider is dissatisfied with the resolution of the dispute through the dispute resolution process, and the parties cannot otherwise reach agreement on the dispute, the Provider may request arbitration of the dispute.