Cigna denied your claim — here's how to appeal
National employer-focused insurer; many Cigna cards sit on top of self-funded employer plans governed by ERISA.
Plans this covers
Deadlines and how the process runs
- If your employer self-funds, Cigna administers the plan but your employer sets the benefit terms — ERISA gives you the right to request the full plan document and the claim file, free of charge.
- CO-97 bundling denials often come from Cigna's claim-editing software rather than a human reviewer; a short letter citing the correct modifier usually resolves them.
- Cigna behavioral health claims run through Evernorth — appeals for those go to a different address than medical claims.
Rights that apply to every plan
- You generally have at least 180 days from the date on your denial notice (EOB) to file an internal appeal with your insurer.
- The insurer must decide standard internal appeals within 30 days for pre-service claims and 60 days for care you already received.
- Urgent cases get an expedited review — typically within 72 hours.
- If the internal appeal fails, you can request an independent external review, usually within 4 months of the final internal denial. The external reviewer's decision is binding on the plan.
- Self-funded employer plans follow ERISA rules; fully insured plans also fall under your state insurance department, which can be a second place to complain.
Denial codes you'll most likely see from Cigna
A real example
- The situation
- Two same-day office procedures where the second line came back CO-97 (bundled).
- What went wrong
- The provider omitted modifier 59, so the editing software treated a distinct procedure as part of the first one.
- What worked
- The provider resubmitted with the correct modifier — no patient appeal was needed, but the patient had to be the one to spot it and call.
Appealing a Cigna denial, step by step
- 1Get the itemized bill from the provider and the EOB from the insurer, and line them up against each other.
- 2Find the denial code on the EOB and read what it actually means — it tells you whether the fix belongs to the insurer or the billing office.
- 3Note the appeal deadline printed on the denial notice and calendar it the same day.
- 4Request the clinical records or authorization number that answer the stated reason for denial.
- 5Send a written internal appeal that names the claim number, quotes the denial code, and states the specific correction you want.
- 6If it is upheld, request an independent external review before that window closes.
Cigna appeal FAQs
How long does a Cigna appeal take?
Standard internal appeals are decided within 30 days for pre-service claims and 60 days for post-service claims. Urgent appeals are decided within 72 hours. If Cigna misses the deadline, you can typically move straight to external review.
Can I get the documents Cigna used to deny my claim?
Yes. Under ERISA you can request the complete claim file, the internal clinical guidelines applied, and the plan document at no cost. Ask for these in writing at the same time you file the appeal — the guidelines often contradict the denial.
What if my Cigna plan is self-funded by my employer?
Cigna processes the claim but your employer funds it. You still have full ERISA appeal rights, and your employer's HR or benefits team can sometimes override an administrative denial faster than a formal appeal.
Let BillCheck write the Cigna appeal for you
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BillCheck provides informational analysis only and is not legal, medical, or financial advice. Verify all details before submitting any correspondence to insurers or providers. Deadlines and processes vary by plan — the notice you received governs.