CurrentCignaPolicy N/A

Pending retrospective decisions for lack of clinical information

Governs the process for pended retrospective (post-service) medical necessity reviews when reasonably necessary clinical information is missing; applies to Cigna's review operations affecting providers and customers/members.

Policy Summary

PayerCigna

PolicyPending retrospective decisions for lack of clinical information

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateAug 20, 2009

Next Review DateNov 19, 2024

Key ActionProvider must supply the specific clinical information requested in the 'Pending Request for Additional Information' letter within the specified timeline (typically 45 calendar days plus 5 mail days).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

45initial provider response window

30decision timeframe after info

15one-time extension

48hinpatient records window

Coverage Criteria for Pended Retrospective Reviews

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Decision criteria for pended retrospective reviews

Covered when ALL of the following are met

Information received timely: Reasonably necessary clinical information is received within the timeline requirement (the provider-specified deadline: 45 calendar days from the date of the initial request plus 5 calendar days for mail), and the nurse/MD completes the medical necessity review with a decision and notification made within 30 days of receipt of all supporting information.received within timeline (45 + 5 mail days); decision within 30 days of receipt

Decision and notification are based on medical necessity, not lack of information

Limited or insufficient additional information: If additional information is received within the timeline but is limited or insufficient to make a medical necessity decision, the available clinical information is reviewed by the Medical Director (MD) and a decision and notification are made based on medical necessity.limited/insufficient within timeline

MD may outreach to treating physician to obtain needed information

No information received within timeline: If no additional clinical information is received within the timeline requirement, the MD reviews any available information and may outreach to the treating physician; decision and notification are made consistent with UM 39 Timeliness of UM Decisions for retrospective review and are based on medical necessity (may result in denial for lack of information per process).no info received (by day 51)

If requested information is received after a denial but before an appeal, peer-to-peer reconsideration may occur

State mandates and special-state rules can supersede Cigna's standard procedures for pended retrospective reviews. For example, Texas (TX) requires a medical necessity decision if any clinical information is received (including diagnoses, procedure codes, or clinical chart content), and therefore a denial for lack of information is not permitted when such information exists. Rhode Island (RI) requires that we notify the customer and provider of the specific information required to complete the review within 30 business days of receipt, and treats all lack-of-information denials as medical necessity denials. Other states (e.g., CA, NY, VT) have specific notice and timing requirements that may alter the standard timelines described in this policy. When state law differs, the state requirement controls.

If reasonably necessary clinical information requested during a pended retrospective review is not received within the specified timeline, the request may be denied as not medically necessary. The MD reviews any available information and may outreach to the treating physician, but if no adequate information is provided the decision and notification process proceeds in accordance with UM 39 Timeliness of UM Decisions for retrospective review. Denial notices must reference the clinical criteria not met due to missing information; if insufficient information exists to reference a specific guideline, the notice must explain the inability to reference specific criteria and describe, in a way a customer or authorized representative can understand, what information is needed to render a decision.

Provider Responsibilities and Operational Steps

Prior Authorization

Retrospective review — pending for additional information

Retrospective review — pending for additional information: When a retrospective (post-service) medical necessity decision cannot be made because reasonably necessary clinical information is missing, the request will be pended and the provider notified of the specific information needed. A 'Pending Request for Additional Information' letter is sent to the provider (and a copy to the customer) on the day of the request and again on calendar day 15 if no response is received.

Letter includes the specific information needed and the deadline for receipt (45 calendar days from initial request plus 5 days for mail delivery; effectively at least 50 days from the initial request).
UM documentation must record the specific information requested, the deadline, and the individual/department from which information was requested.

Documentation Required

Provider must provide the specific clinical information requested

Provider must supply the specific clinical information requested within the specified timeframe so that a medical necessity decision can be made. If clinical information arrives within the timeline requirement, the nurse follows established medical necessity review processes and timelines; cases the nurse cannot approve are referred to the Medical Director for decision.

If additional information received is limited or insufficient, available clinical information will be reviewed by the Medical Director for a determination.
Decision and notification are based on medical necessity and not on lack of information when adequate information is received.

Denial Risk

Request may be denied for lack of information

Request may be denied for lack of information if reasonably necessary information is not received within the timeline requirement. If no clinical information is received, the nurse proceeds with the established review process and the Medical Director will review available information and render a decision. Denial notice must reference the clinical criteria not met because of lack of information or, if insufficient information prevents referencing a specific guideline, must explain the inability to reference criteria and clearly describe what information is needed.

If requested information is not received by calendar day 51, the applicable LOI MD review process is followed.
Product type and provider participation may affect customer/provider liability (participating providers — customer may be held harmless; non-participating providers — customer may be responsible and billed by the provider).

Note

PROVIDER ACTIONS — Operational steps and timelines

Operational/provider actions: The provider should respond to the 'Pending Request for Additional Information' letter with the requested records by the deadline. For on-site inpatient reviews performed by IPCMs, a pending letter is not generated; if necessary medical records are not made available within 48 hours, the IPCM follows the LOI process. If information is submitted after a denial but before an appeal, a peer-to-peer reconsideration may be requested per established processes.

Providers will receive the pending letter on day 0 and a follow-up on day 15 if no response.
Allowable extension: for non-urgent cases the organization may extend one time up to 15 calendar days if determined necessary due to matters beyond the organization's control.
If additional information is received after denial but prior to an appeal, peer-to-peer reconsideration may occur.

Background

Retrospective (post-service) reviews address requests for coverage of services already delivered and are evaluated based on the clinical information available from the time care was provided. When reasonably necessary clinical information is missing, the review is pended and the provider is notified of the specific documentation required and the deadline. If requested information is received within the timeline, nursing and MD reviewers follow established medical necessity review processes and a decision is made based on medical necessity; if information is limited, the MD reviews available data and decides accordingly. If requested information is not received, the MD reviews available records and may contact the treating physician prior to making a decision; all decisions and notifications follow the UM 39 timeliness standards and are sent to the customer with a copy to the provider.

OpenPayer

Pending retrospective decisions for lack of clinical information

Coverage Criteria for Pended Retrospective Reviews

Provider Responsibilities and Operational Steps

Background

Definitions