Filing A Healthcare Claim Requirements For Cigna Vendors
Filing A Healthcare Claim should be done as soon as possible. If you’re unable to file a claim right away, please make sure the claim is submitted accordingly.
- If you are a participating health care provider, submit by 90 days after the date of service
- If you are an out-of-network provide, submit by 180 days after the date of service
There are some exceptions to these deadlines. These include:
- 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 for Seniors): In accordance with Medicare processing rules, non-participating health care providers have 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 payer, 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 one year from the date of that determination. After one year and prior to 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.
- Extraordinary circumstances
To learn more about Healthcare EDI and become a certified EDI Professional please visit our course schedule page