Get Cigna Provider Dispute Resolution Request Form

Filling out the Cigna Provider Dispute Resolution Request Form online can streamline the process of submitting a dispute related to billing or claims. This guide will help you navigate each section of the form accurately, ensuring that all necessary information is provided to support your request.

Follow the steps to complete the form online efficiently.

1. Press the ‘Get Form’ button to access the form and open it in your preferred online editor.
2. Begin by completing the required fields marked with an asterisk (*), starting with the Provider NPI and Provider Tax ID.
3. Fill in the Provider Name and Provider Address accurately to ensure clear identification.
4. Select the Provider Type that best describes your service; options include MD, Rehab, Mental Health Professional, and others.
5. In the Claim Information section, choose whether it pertains to single or multiple 'LIKE' claims. Provide the Patient Last Name and Health Plan ID Number.
6. Enter the Patient Account Number and Date of Birth to clearly identify the patient involved.
7. For claims involving multiple service dates, use the attached spreadsheet as guided.
8. In the Dispute Type section, indicate the nature of your dispute, which may include billing determination, medical necessity appeals, or contract disputes.
9. Carefully fill in the Description of Dispute and Expected Outcome fields with specific and detailed information to support your claim.
10. Complete your contact details including your name, title, phone number, fax number, and the date.
11. Review the form for completeness; if adding extra information, check the box indicating additional information is attached.
12. Once all the fields are filled in correctly, save your changes. You can download, print, or share the completed form for submission.

Start filling out the Cigna Provider Dispute Resolution Request Form online today to expedite your dispute resolution process.