Filing a claim as soon as possible is the best way to get prompt payment, but if you can’t, here's what you need to know:
(This policy applies to claims submitted directly to Cigna, and not to another entity.)
It's best to submit claims as soon as possible. If you're unable to file a claim right away, Cigna will consider:
- Participating provider claims submitted three (3) months [90 days] after the date of service;
- out-of-network claims submitted six (6) months [180 days] after the date of service.
If services are rendered on consecutive days, such as for a hospital confinement, the limit will be counted from the last date of service.
- Applicable law requires a longer filing period;
- Provider agreement specifically allows for additional time;
- In Coordination of Benefits situations, timely filing is determined from the processing date indicated on the primary carrier's Explanation of Benefits (EOB) or Explanation of Payment (EOP).
- Medicare (Cigna HealthCare for Seniors): In accordance with Medicare processing rules, non-participating health care professionals have from 15 to 27 months to file a new claim. Medicare patients' claims must be filed no later than the end of the calendar year following the year in which the services were provided. However, the filing limit is extended another full year if the service was provided during the last three months of the calendar year.
- If Medicare is the primary payor, timely filing is determined from the processing date indicated on the primary carrier's Explanation of Benefit (EOB).
- If Medicare is the Secondary Payer (MSP), the initial claim must be submitted to the primary payer within Cigna's timely filing period. An initial determination on a previously adjudicated claim may be reopened for any reason for 1 (one) year from the date of that determination. After 1 (one) year and prior to 4 (four) years from the date of determination, "good cause" is required for Medicare to reopen the claim. In general, Medicare does not consider a situation where (a) Medicare processed a claim in accordance with the information on the claim form and consistent with the information in the Medicare's systems of records and; (b) a third party mistakenly paid primary when it alleges that Medicare should have been primary to constitute "good cause" to reopen.
- If a claim was timely filed originally, but Cigna requested additional information. If a resubmission is not a Cigna request, and is not being submitted as an appeal, the filing limit will apply.
- Cigna may request appropriate evidence of extraordinary circumstances that prevented timely submission (e.g., natural disaster).
We encourage you to submit your bills as soon as possible to help with prompt payment. As always, you can appeal denied claims if you feel an appeal is warranted. Remember: Your contract with Cigna prohibits balance billing your patient if claims are denied because they were not submitted within the time frame outlined above.