Yuzu has noticed a high number of provider disputes related to Cigna contracts:
My claim was paid OON but I am INN with Cigna.
My claim was paid at $0 but marked as INN with Cigna.
My claim was paid with the wrong discount per my Cigna contract.
My claim was paid INN but I am OON with Cigna.
Various codes were not paid, but I believe they should be paid and want an explanation of the code editing / bundling logic applied that I believe was not part of my Cigna contract.
I have tried to submit my claim but it is not received.
This document is written to help providers understand best steps to resolving these errors.
Yuzu’s Role in Processing Your Cigna Claims
Yuzu is a Third-Party Administrator (TPA) completely independent from Cigna. Please check out this post for more detail including a helpful diagram.
Yuzu does NOT do contracting for Cigna. We do not have the ability to know if you are in the Cigna network or the terms of your contract with Cigna. Our role is to pay claims according to the data Cigna sends us about your claims and our record of member eligibility and benefits.
(1) My claim was paid OON but I am INN with Cigna.
This is the most common issue we see with Cigna claim appeals. You are not alone in having this problem. The most common remedies are:
(A) Check if the TIN/NPI in the claim match what is on record with Cigna
Cigna determines network status based on both the TIN of the billing provider and the NPI of the rendering provider. These values need to match exactly what is in the Cigna provider directory in order to repriced as in-network.
The majority of network status disputes are resolved through this process and requires no involvement from Yuzu. We will not review your dispute unless you have completed this and/or the following step.
Once you have corrected the TIN/NPI, please resubmit your claim. Yuzu will automatically re-process these claims once they are re-submitted.
(B) Check that the service date on the claim matches with your Cigna contract.
If the claim occurred before you were in-network with Cigna, the claim will be processed according to your contract status at that time.
(C) I checked the above, and am still convinced there is an error on Cigna’s end.
If you have a dispute related to status once NPI/TIN has been confirmed, Cigna must be contacted directly. Please go to https://cignaforhcp.cigna.com/app/login or 1 800-882-4462 for clarification or to dispute directly with Cigna.
Helpful tip: If you know who your Cigna contracting rep is, you should loop them into this process. This will give them visibility into your experience with Cigna.
(2) My claim was paid at $0 but marked as INN with Cigna.
Sadly, this type of dispute happens frequently as well, and unfortunately also must be remedied through Cigna.
(A) Check that this was actually allowed at zero and not just processed as $0 plan paid.
Occasionally, the EOP indicates that the reason for non-payment was that the entirety of the claim was member responsibility, but providers think the claim indicates that Cigna priced the claim incorrectly. If the EOP indicates the full amount is attributable to deductible, coinsurance, or copay then the claim was likely processed correctly.
(B) Review that the TIN / NPI were correct
See instructions above.
(C) I checked the above, and am still convinced there is an error on Cigna’s end.
If you have a dispute related to status once NPI/TIN has been confirmed, Cigna must be contacted directly. Please go to https://cignaforhcp.cigna.com/app/login or 1 800-882-4462 for clarification or to dispute directly with Cigna.
(3) My claim was paid with the wrong discount per my Cigna contract.
This may be related to the contract Cigna had on file during the date of service. If that is not the issue, then Cigna must be contacted directly. Please go to https://cignaforhcp.cigna.com/app/login or 1 800-882-4462 for clarification or to dispute directly with Cigna.
(4) My claim was paid INN but I am OON with Cigna.
This is an uncommon issue that has comes up typically in the context of emergency services covered under the No Surprises Act (NSA) where it may be financially advantageous to providers to be OON and able to pursue payment according to the independent dispute resolution (IDR) process laid out by the NSA.
Once again, Yuzu is not able to verify network status with Cigna and recommends providers double-check their NPI / TIN is not in network with Cigna by following instructions above or contacting Cigna through instructions above. We will not approve an appeal on this basis without evidence from Cigna that the claim was actually OON.
(5) Various codes were not paid, but I believe they should be paid and want an explanation of the code editing / bundling logic applied that I believe was not part of my Cigna contract.
Cigna has policies related to claim-editing that are standard in their contracts. You can see their own description of these policies here. When one of these is applied, you will see a description on the EOP attached to the line item reduced with a description tying to Cigna’s claim-edit policy.
These edits need to be appealed with Cigna directly. Please go to https://cignaforhcp.cigna.com/app/login or 1 800-882-4462 for clarification or to dispute directly with Cigna.
Below is a table of common edits:
Code | Description | |
|---|---|---|
G94 | The quantity of units billed exceeds the Medically Unlikely Edit limit. Patient not responsible. | |
F18 | The submitted code is disallowed because reimbursement is included in the primary service on this claim or a previously submitted claim. Patient not responsible. |
(6) I have tried to submit my claim but it is not received.
Please review the description of claims ingestion here which includes a diagram of how claims are sent through Cigna to Yuzu for processing and instructions to see if your claim is processing.
Also consider reviewing this blog post from our partner Stedi that explains why claims go missing and what can be done.
(A) Submit Your Claim Electronically.
Most issues with claims submissions happen when providers are unable to submit claims electronically and have to “fall back” to using paper. The issue with how your claim is being submitted may be related to which EMR or RCM vendor you are using to help file claims.
The Cigna electronic Payer ID is 62308 (the same as all non-Medicare Cigna). See instructions here from Cigna on how to electronically submit claims to Cigna.
(B) If Mailing Your Claim, Use Standard Claims Forms
If you are sending claims with snail mail, please ensure that they are sent on standard CMS 1500 or UB04 forms. Other forms will not be considered and scanned by Cigna.
Everything else failed. Please help.
Email support@yuzu.health. This is the slowest way to get your issue resolved but we will serve you.
Please also fill out this questionnaire related to your experience trying to get the issue resolved with Cigna.