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Cigna Downcoding Policy: Suggestions for Claims Management*
Cigna down coding policy is in effect as of 10/1/25. Recent communications from Cigna indicate that this downcoding policy will only apply to 1% of the provider (those who have greater utilization of the higher CPT codes). Kids Health First has contacted Cigna to see if we can obtain a list of network providers who may be impacted.
The following is advice from Shannon Fox-Levine, MD, of the Payor Advocacy Adivsory Committee (PAAC).
PAAC from the AAP has been communicating our concerns of a generalized policy to Cigna; however, we are hopeful that this policy should NOT affect anyone who properly documents to support the code submitted for payment. PAAC is committed to having ongoing discussions with Cigna to ensure this policy does not negatively impact pediatricians, understanding the administrative burden for us to file appeals.
What can you do?
- Be sure to provide documentation to support your E&M code.
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Check your EOBs for downcoding by ANY plan (Be sure you are paid the contracted rates for your CPT codes since some plans may downcode by paying you less without changing the code).
- File an appeal with your documentation to the plan.
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If the plan does not resolve the issue in a timely manner, contact your plan rep to see if you can work with them directly first. If they cannot resolve the issue:
- Notify the state AAP Chapter
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Notify the AAP Coding Hotline
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If the plan changes the code, file a HIPPA Simplification Rule violation with the asset tool. Asset complaints are filed based on the changing of the code and not the payment amount so if they are sneaky and just pay less for the same code, you cannot use it.
From SOAPM Daily Digest 10/6/25
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