Aetna-CIGNA Billing Dispute Guide

    Settlement Step-By-Step External Billing Dispute Procedure

    Listed below are the steps to take to challenge a payment by Aetna or CIGNA which you believe violates your contract or that Settlement Agreement in connection with health plan's application of coding and payment rules or methodologies to patient-specific factual situations.  This process does not apply to disputes over medical records submission requirements or Medical Necessity Denials.  For these types of disputes, obtain the relevant dispute form and follow the instructions.  Also, if your dispute involves a violation of Section 7.19 or 7.20 or other systemic issue, you may pursue your complaint as a Compliance Dispute .

    How do I file a billing dispute?
    •  You must complete an External Billing Dispute Resolution Form ("Form") and submit the Form to the Billing Dispute External Review Board (BDERB): 

      HAYES Plus, Inc.
      157 S. Broad Street, Suite 400
      Lansdale, PA  19446
      Phone:  (215) 855-0615, Fax: (215) 855-5318
      www.hayesplus.com
        
    •  Copies of the forms applicable to each Settlement and each dispute resolution process are also available at www.hmosettlements.com
    What are the prerequisites to filing?
    • Completion of Internal Appeals Process.   Physicians or physician groups must either complete the health plan's internal appeals process or have waited at least 45 calendar days from the health plan's receipt of all documentation necessary to complete the internal appeal ("implied exhaustion").  To the extent that there is a disagreement about whether the internal appeals process has been exhausted, the matter will be decided by the BDERB. 
    • Filing Deadline.   Billing disputes, with all supporting documentation, must be submitted no more than 90 calendar days after the internal appeals process is exhausted.
    • Filing Fee.   If the difference between the amount that the physician received and the amount the physician believes that the health plan should have paid ("amount in dispute") is $1,000 dollars or less, the filing fee is $50.  If the amount in dispute exceeds $1,000, the filing fee is $50 plus 5% of the amount in dispute.  The filing fee will never exceed 50% of the cost of the review.  In the event that a dispute is withdrawn, the fee will be refunded. 
        
    • Minimum $500 in Dispute.   The amount in dispute must be greater than $500 before it will be resolved.  If the amount in dispute is less than $500, you should still submit the External Billing Dispute Resolution Request Form and request the BDERB to defer consideration of the dispute until the physician or physician group accumulates documentation of similar disputed claims totaling an amount greater than $500.  The physician or physician group will have 1 year from the date of deferment to supply additional disputes.  In the event that the physician or physician group does not reach the $500 threshold during that year, the filing fee will be refunded. 

      

    When will the decision be made?

    Dispute decisions must be rendered by the BDERB within 30 calendar days of receipt of all necessary documentation, which should generally be no later than 60 calendar days from the physician's original submission of claims satisfying the $500 threshold.

    What happens when the BDERB issues a decision?
    • The decision of the BDERB is binding upon both the health plan and the physician.
    •  If the BDERB decides against the health plan, the physician or physician group must be paid within 15 calendar days of the decision. 
        
    • The health plan will record, in writing, a summary of the results of the proceedings conducted by the BDERB.
    • If the same issue is the subject of 20 proceedings or more, and the health plan's position is overturned 50% of the time, the issue will be brought to the attention of the Physician Advisory Committee. (NOTE: The purpose of the Physician Advisory Committee is to provide input to the health plan on issues of common concern to physicians nationwide.  The Committee includes nine (9) physician members who have authority to recommend changes to the health plan's business practices.  A listing of the Physician Advisory Committee members for each Settlement is available at www.hmosettlements.com .)
    Why should I consider using this process?
    •  The dispute will be decided by certified coders and, as necessary, professionals in the clinical specialty or area at issue. 
        
    • The BDERB will apply the Settlement terms, applicable contract terms that are consistent with the Settlement and "generally accepted medical billing standards" where these are silent.  The Settlement incorporates state laws that are more protective of physicians' rights, so physicians retain the benefits of those laws.  
        
    • The process is cheaper and faster than arbitration or litigation.
    Do I have to use this process?
    • This process is optional.

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