Cigna and Evernorth behavioral health appeals: routes, deadlines and criteria

Who manages behavioral health for Cigna Healthcare plans?

Evernorth Behavioral Health, a subsidiary of The Cigna Group and formerly Cigna Behavioral Health, is the behavioral network for customers with Cigna Healthcare plans. It also sells behavioral services to employers without Cigna medical coverage. Its September 2026 administrative guidelines are the behavioral provider manual and form part of the provider contract.

Cigna sold its Medicare Advantage, Part D and related businesses to Health Care Service Corporation (HCSC) on March 19, 2025, so former Cigna Medicare members now appeal through HCSC's plans. Cigna's current provider appeals page no longer covers Medicare.

What are Cigna's appeal deadlines and decision times?

Cigna's provider page allows 180 calendar days from the initial payment or denial notice to appeal, with review completed within 60 days and notice within 75 business days. Evernorth's behavioral guidelines add that clinical coverage appeals are due within 180 days and second-level appeals within 60 days of the first decision.

Processes vary with state mandates and contract terms, and Evernorth's state addenda may not apply to self-funded plans. Arbitration is available only after internal appeals are exhausted and must be requested within one year of the final internal decision. For some medical-necessity appeals, Cigna can offer the patient external review by an independent review organization, which needs the patient's approval.

Who can appeal which Cigna behavioral health denial?

Cigna's own table assigns appeal rights by scenario. Precertification denials for services not yet provided are customer appeals. Reimbursement disputes and denials for precertification not obtained are provider appeals. Medical-necessity, level-of-care, length-of-stay and experimental denials can be appealed by either the patient or the provider.

How does peer-to-peer review work at Evernorth?

Evernorth treats peer-to-peer review as the step before a formal clinical appeal: a board-certified psychiatrist or doctoral-level psychologist discusses the case, and afterward a physician not previously involved can review the decision. Evernorth publishes no national request window and encourages sending clinical information before the conversation.

State addenda can set timing. Massachusetts, for example, requires a peer reconsideration within one business day of the request. Reach the care manager on the case or the provider services line in the guidelines, and keep the peer-to-peer prep sheet to one page.

Which clinical criteria does Evernorth say it uses?

Evernorth uses MCG Behavioral Health Guidelines for mental health level-of-care reviews unless law or contract requires otherwise. It uses LOCUS and CALOCUS-CASII for commercial plans in states that require them, and the ASAM Criteria for substance use: the fourth edition for ages 18 and older since November 2024, the third for ages 17 and under.

Cigna stopped using its own mental health medical necessity criteria on November 27, 2020; archived versions remain online for older cases. Each adverse-determination letter should name the specific guideline used and the clinical rationale.

How do you get the criteria and the claim file from Cigna?

Each Evernorth adverse-determination letter must name the guideline used and the clinical rationale, and coverage guidelines are posted on Provider.Evernorth.com. Evernorth publishes no provider claim-file procedure, so ask in writing, in the appeal, for the criteria applied and all documents relevant to the claim, citing the federal disclosure rules.

Plans must disclose mental health and substance use medical-necessity criteria on request to participants and contracting providers, and employer plans must give claimants free copies of relevant documents. Name the criteria in your letter and quote only what the plan sent you; do not paste licensed guideline text into the appeal or into AI tools. The criteria request letter drafts the request.

Where do you submit a Cigna behavioral health appeal?

Behavioral health providers use Provider.Evernorth.com, where the reconsideration tool routes each finalized claim to the adjustment team or the national appeals team. Written behavioral appeals go to Evernorth's Central Appeals Unit with the Behavioral Appeals Cover Sheet, which asks for the issue ID from the denial letter. Follow the letter's instructions.

Corrected claims cannot go through the online reconsideration tool, and an open draft must be submitted within five calendar days. Out-of-network providers may need an appointment-of-representative form signed by the patient.

Which denial codes come up on Cigna behavioral health claims?

Cigna's remittances use the standard claim adjustment reason codes. The codes that decide the route include medical necessity (50), which either party can appeal, precertification absent (197), which is a provider appeal, benefit limits (119) and non-covered charges (96), which are often customer appeals, and coding codes such as 4 and 97.