Complex Claim Review

Cigna routinely evaluates claims for coding, billing accuracy, and appropriateness.* In these reviews, we look at applicable coverage and reimbursement policies, as well as your patient’s benefit plan, and we review utilization of services and items, such as supplies, durable medical equipment and implants. As a part of the review, we may request supporting claim payment information, such as itemized bills and medical records – for example, operative and procedure reports, implant logs, histories and physicals, office notes, laboratory and radiology reports, or other documents.

What to submit Instances when supporting documentation is required
Itemized bill+ only
  • Claims are paid based on billed charges or a percentage of billed charges.
Itemized bill and medical records++
  • Complex procedures and services require an operative or procedure report, and supporting medical records.
  • Implant charges require an operative or procedure report, and an intraoperative record with an implant log and description.
+ An itemized bill sorted by revenue code will expedite the claim review.
++ In some instances, we may request other supporting documentation in addition to the itemized bill.
Medical records and itemized bills may be required to support claim reviews for other programs. Example: Medical necessity reviews.

Send documentation to expedite processing

Please send requested documentation to our dedicated mailing address or fax number:

Complex Claim Review
PO Box 188015
Chattanooga, TN 37422
Fax: 1.859.410.2421

Once we complete our review, we will process and reimburse the claim accordingly, and issue an explanation of payment. We will also send you a letter explaining any charges determined to be not payable, the supporting rationale, and appeal information. Not-Payable Reason Codes list includes descriptions and reconsideration criteria.

For more information about our clinical reimbursement policies and payment policies, visit Reimbursement and Payment Policies, or call us at 1.800.88Cigna (882.4462).

* Effective dates:
  Medical - December 1, 2009
  Behavioral - October 19, 2015