How to Appeal a Claim

You have the opportunity to appeal a claim if you believe the claim was not processed appropriately based on your understanding of the benefit plan. There may be additional rules that apply to you, so refer to your Summary Plan Description (SPD). Your SPD is located:

Blue Cross Blue Shield Appeal Instructions

See the BCBS Benefits Booklet for information and instructions regarding appeal.

 

UNITEDHEALTHCARE CLAIM APPEAL INSTRUCTIONS

(does not apply to Cigna Dental claims)

FIRST LEVEL APPEAL
If you don't agree with the UHC explanation of benefits (EOB), you can contact UHC at 1-866-228-4215 and request a first level appeal of your claim, or you can submit a written appeal. Your first appeal request should be submitted within 180 days after you receive the claim denial. UHC will respond in writing. Go to myuhc.com for an appeal form > "Claim Center" tab > download claim issue and appeal form.

Send it to:

Healthcare Appeal
UnitedHealthcare
Attn: Caterpillar Appeals
P.O. Box 30432
Salt Lake City, UT 84130-0432

SECOND LEVEL APPEAL
If you don't agree with the outcome of the first level appeal, you may submit a request in writing to UHC for a second level review. This request must be received by UHC within 60 days after you receive the first level appeal denial. Document your concern in writing including copies of EOB, claim and pages from your SPD showing benefit coverage, along with your appeal letter. Label the letter “APPEAL” at the top. UHC will respond in writing.

CIGNA DENTAL CLAIM APPEAL INSTRUCTIONS


FIRST LEVEL APPEAL
Cigna Dental has a two-step appeals process for coverage decisions. The member or dentist, on behalf of a member, can submit a verbal or written appeal request within one year of the initial denial. Verbal appeals can be filed by calling Cigna Dental at 1-800-244-6224.

Please provide the date of services being appealed and the reason for the appeal. Cigna may send written requests for additional information, if it is required to perform the Explanation of Benefits, a copy of x-ray(s) if available, a narrative from the provider, and a cover letter explaining the intent of the Appeal.

Send it to:

Cigna Dental
P.O. Box 188044
Chattanooga, TN 37422-8044

First level appeal decisions are made within 30 calendar days by a dental expert not involved in the initial review. A dental professional will review all appeals involving dental neccessity or clinical appropriateness. If more time or information to make the decision is required, Cigna will contact you to request an extension and specify any additional information needed to complete the review. Notification will be sent to the party whom filled the appeal.

SECOND LEVEL APPEAL
If you don't agree with the first level appeal decision, you may request a level two appeal. Appeals may be conducted by an Appeal Committe or reviewed by a dental reviewer not involved in the first level appeal decision. If dental necessity or clinical appropriateness is in dispute, a dentist in the same or similiar specialty will be involved. The review will be completed within 30 calendar days unless more time or information is needed to complete the review. Cigna will send written notification of the decision and include the specific contractual or clinical reasons, as applicable.

If you disagree with the final outcome of the second level appeal, you may be able to request an external review of your claim by an independent third party who will review the denial and issue a final decision. External review is only for claims involving medical judgment or a rescission (retroactive cancellation) of coverage. For information on how to request an external review, contact UHC or review instructions included in the written second level appeal determination. Your request must be filed within 4 months after the date of receipt of the final adverse benefit determination.

Please remember: If the issue deals directly with an interpretation of the benefits plan and level of payment for the provider, UHC has the responsibility of administering the Caterpillar Healthcare Plan (UHC PPO) and the UnitedHealthcare Choice Plan. Cigna Dental has the responsibility of administering the dental portion of the Caterpillar Healthcare Plan. In most cases you and/or your provider will have to accept their decision.