Tag: Reimbursement Policies

Cigna Healthcare^® will implement a new reimbursement policy, Evaluation and Management Coding Accuracy (R49), to review professional claims billed with Current Procedural Terminology (CPT^®) evaluation and management (E/M) codes 99204-99205, 99214-99215, and 99244-99245 for billing and coding accuracy in alignment with American Medical Association (AMA) E/M services guidelines.

Effective for dates of service on or after October 1, 2025, services may be adjusted by one level to reflect the appropriate reimbursement when the AMA guidelines are not met.

What this means to you

Cigna Healthcare will conduct periodic claim reviews to verify compliance. Based on that review, providers may be eligible to be removed from the program. Supporting documentation will be requested should we determine the established guidelines were not followed.

Reconsideration requests

Providers who believe their medical record documentation supports reimbursement for the originally submitted level for the E/M service should follow the reconsideration and appeals processes.

To request a reconsideration, please submit the customer’s full record of the encounter to the secure Cigna Healthcarefax number 833.392.2092. Should the original determination be overturned, claims will be adjusted, and an updated explanation of payment will be issued.

Administrative appeal rights are available if the original determination is upheld.