Citi Benefits Handbook
Claims and Appeals for the Cigna Dental HMO
If you have a concern about your dental office or the Cigna Dental HMO, call 1 (800) Cigna24 (1 (800) 244-6224) and explain your concern to a Member Services representative. You can also express that concern to Cigna Dental in writing. Most matters can be resolved with the initial telephone call. If more time is needed to review or investigate your concern, Cigna Dental will respond to you as soon as possible, usually by the end of the next business day, but in any case within 30 days.
If you are not satisfied with the results of a coverage decision, you may start the appeals procedure.
Cigna Dental has a two-step appeals procedure for coverage decisions. To initiate an appeal, you must submit a request in writing to the Cigna Dental HMO within one year from the date of the initial Cigna Dental decision. You should state the reason why you believe your request should be approved and include any information supporting your request. If you are unable or choose not to write, you can ask Member Services to register your appeal by calling 1 (800) Cigna24 (1 (800) 244-6224).
Cigna Dental HMO First-Level Appeal
Your first-level appeal will be considered and the resolution made by someone not involved in the initial decision or occurrence. Issues involving dental necessity or clinical appropriateness will be considered by a dental professional.
If your appeal concerns a denied precertification, Cigna Dental will respond with a decision within 15 calendar days after your appeal is received. For appeals concerning all other coverage issues, Cigna Dental will respond with a decision within 30 calendar days after your request is received. If Cigna Dental needs more information to make your first-level appeal decision, it will notify you in writing to request an extension of up to 15 calendar days and to specify any additional information needed to complete the review.
- For New Jersey residents: Cigna Dental will respond in writing within 15 working days.
- For Colorado residents: Cigna Dental will respond within 20 working days.
- For Nebraska residents: Cigna Dental will respond within 15 working days if your complaint involves an adverse determination.
If you are not satisfied with the decision, you may request a level-two appeal.
Cigna Dental HMO Second-Level Appeal
To initiate a second-level appeal, follow the same process required for a first-level appeal. Your second-level appeal will be reviewed and a decision made by someone not involved in the first-level appeal. For appeals involving dental necessity or clinical appropriateness, the decision will be made by a dentist. If specialty care is in dispute, the appeal will be conducted by a dentist in the same or similar specialty as the care under review. The second-level appeal process does not apply to resolutions made solely on the basis that the Plan does not provide benefits for the service performed or requested.
The review will be completed within 30 calendar days. If Cigna Dental needs more information to complete the appeal, it will notify you in writing to request an extension of up to 15 calendar days and to specify any additional information needed to complete the review. The decision will include the specific contractual or clinical reasons for the decision, as applicable.
Cigna Dental HMO Expedited Appeal
You may request that the complaint or appeal resolution be expedited if the time frames under the above process would seriously jeopardize your life, health or ability to regain the dental functionality that existed prior to the onset of your current condition. A dental professional, in consultation with the treating dentist, will decide if an expedited review is necessary. When a review is expedited, the Plan will respond orally with a decision within 72 hours, followed up in writing.
- For Maryland residents: Cigna Dental will respond within 24 hours.
- For Texas residents: Cigna Dental will respond within one business day.
If you do not agree with the Final Internal Adverse Benefit Determination on review, you have the right to bring a civil action under Section 502(a) of ERISA, provided that you file any lawsuit or similar enforcement proceeding, commenced in any forum, within 12 consecutive months after the date of receiving a final determination on review of your claim or, if earlier, within two years from the date on which you were aware, or should have been aware, of the claim at issue in the suit.
The two-year limitation shall be increased by any time a claim or appeal on the issue is under consideration by the appropriate fiduciary. If any different period to begin suit is specified in an insurance contract forming part of the Plans or any shorter period is specified in the rules of the Claims Administrator, that period will apply to proceedings against the insurer or with regard to the ruling of that Claims Administrator, respectively.
Cigna Dental HMO Independent Review
The independent review procedure is a voluntary program arranged by Cigna Dental and is not available in all areas. Call Cigna Dental at 1 (800) Cigna24 (1 (800) 244-6224) for details.
Appeals to the State
You have the right to contact your state's Department of Insurance or Department of Health for assistance at any time.
Cigna Dental will not cancel or refuse to renew coverage because you or your dependent has filed a complaint or appealed a decision made by Cigna Dental. You have the right to file suit in a court of law for any claim involving the professional treatment performed by a dentist.