Here are two ways to file an appeal.
1. Call Customer Service at (866) 487-4331. If you file an appeal over the phone, you must follow it with a written signed appeal request. Mail or fax your written appeal request to:
2. Mail or fax your written appeal request to:
Attn: Appeals Resolution Center
PO Box 24087
Nashville, TN 37202
Fax: (855) 320-4409
If you need assistance in a different language, we can provide an interpreter at no cost to you. Please include this request when you file your appeal. If you are hearing impaired, call the TTY line at 711.
Can someone help you with the appeal process?
You have several options for assistance. You may:
- Ask someone you know to assist in representing you. This could be your Primary Care Physician or a family member, for example.
- Choose to be represented by a legal professional.
If you are in the Disabilities Waiver, Traumatic Brain Injury Waiver, or HIV/AIDS Waiver, you may also contact CAP (Client Assistance Program) to request their assistance at 1-800-641-3929 (Voice) or 1-888-460-5111 (TTY).
To appoint someone to represent you, either: 1) send us a letter informing us that you want someone else to represent you and include in the letter his or her contact information or, 2) fill out the Authorized Representative Appeals form.
- We will send you an acknowledgement letter within three (3) business days saying we received your appeal.
- We will tell you if we need more information and how to give us such information in person or in writing.
- A provider with the same or similar specialty as your treating provider will review your appeal. It will not be the same provider who made the original decision to deny, reduce or stop the medical service.
- Cigna-HealthSpring will send our decision in writing to you within fifteen (15) business days of the date we received your appeal request. Cigna-HealthSpring may request an extension up to fourteen (14) more calendar days to make a decision on your case if we need to get more information before we make a decision.
- You can also ask us for an extension, if you need more time to obtain additional documents to support your appeal.
- We will call you to tell you our decision and send you and your authorized representative the Decision Notice. The Decision Notice will tell you what we will do and why.
- If Cigna-HealthSpring’s decision agrees with the Notice of Action, you may have to pay for the cost of the services you got during the appeal review. If Cigna-HealthSpring’s decision does not agree with the Notice of Action, we will approve the services to start right away.
- Things to keep in mind during the appeal process:
- At any time, you can provide us with more information about your appeal, if needed.
- You have the option to see your appeal file.
- You have the option to be there when Cigna-HealthSpring reviews your appeal.
How can you expedite your Appeal?
If you or your provider believes our standard timeframe of fifteen (15) business days to make a decision on your appeal will seriously jeopardize your life or health, you can ask for an expedited appeal by writing or calling us.
If you write to us, please include your name, Cigna-HealthSpring SpecialCare of Illinois member ID number, the date of your Notice of Action letter, information about your case and why you are asking for the expedited appeal. We will let you know within twenty-four (24) hours if we need more information.
Once all information is provided, we will call you within twenty-four (24) hours to inform you of our decision and will also send you and your authorized representative the Decision Notice.
How can you withdraw an Appeal?
You have the right to withdraw your appeal for any reason, at any time, during the appeal process. However, you or your authorized representative must do so in writing, using the same address as used for filing your appeal. Withdrawing your appeal will end the appeal process and no decision will be made by us on your appeal request.
Cigna-HealthSpring will acknowledge the withdrawal of your appeal by sending a notice to you or your authorized representative. If you need further information about withdrawing your appeal, call Cigna-HealthSpring at (866) 487-4331.
What happens next?
After you receive the Cigna-HealthSpring appeal Decision Notice in writing, you do not have to take any action and your appeal file will be closed. However, if you disagree with the decision made on your appeal, you can take action by asking for a State Fair Hearing Appeal and/or asking for an External Review of your appeal within thirty (30) calendar days of the date on the Decision Notice. You can choose to ask for both a State Fair Hearing Appeal and an External Review or you may choose to ask for only one of them.