Claims, Prior Authorizations, and Explanations of Benefits

Claims, Prior Authorizations, and Explanations of Benefits (EOBs)

Get the information you need to file a claim, and find out how prior authorizations and explanations of benefits figure in the process.

Health care can be confusing, so we’re here to help you better understand your medical bills and health plan coverage.

Claims

What is a claim?

A claim is similar is a request to be paid for care. It is also referred to as “filing a claim” or “submitting a claim.”

In some cases, you may need to file a claim, depending on your plan type and whether you received in-network or out-of-network care. For more information, select your plan type below:

HMO, Network, or EPO Plans

In-Network

For most services covered under your plan, you are not responsible for filing a claim. Just show your Cigna ID card and (if applicable) pay your copayment at the time of service, or coinsurance after your claim is processed.

It is a good idea to compare your medical bill and EOB before paying a bill to make sure that you have been charged the correct amount.

Out-of-Network

Most HMO, Network, and EPO plans only include out-of-network coverage for emergency care. Some plans may also cover urgent care services, as defined in your plan documents.

In this instance, you will usually need to file a claim since out-of-network providers are not required to submit a claim on your behalf.

Point of Service (POS) Plans

In-Network

You are not responsible for filing a claim. Just show your Cigna ID card and pay any copayment at the time of service.

It is a good idea to compare your medical bill and EOB before paying a bill to make sure that you have been charged the correct amount.

Out-of-Network

You will always need to file a claim.

Indemnity Plans

You or your provider will need to file a claim.

Depending on the provider, you may have to pay for the cost of your health care services when you receive them, or you may be billed directly for any services provided.

However, your provider will often take care of filing a claim with Cigna so that you will be reimbursed. If your provider does not file a claim, you will need to file one in order to be reimbursed. In both cases, you will be reimbursed based on the amount covered by your plan and subject to your plan’s deductible, copay, or coinsurance requirements.

Claims Process

When we receive a claim, we check it against your plan to make sure the services are covered. In some cases, you need to have a procedure, medication, or location pre-approved by Cigna before you receive care, otherwise the claim may be denied. This is known as prior authorization.

If you purchased coverage on your own through a state or federal marketplace, the plan may require that you see providers in the plan’s network; the claim may be denied for out-of-network services.

You can see the status of your claims on the myCigna® website. When a claim is approved, we either pay the health care provider directly or you do, depending on who submitted the claim. In most cases for in-network care, providers will file claims for you and you’ll receive an explanation of benefits, or EOB.

Your EOB is not a bill but an explanation of how your claim was paid. The provider will bill you directly for any amounts you owe to them under your plan.

File a claim

Retroactive Claim Denials

A retroactive denial is a claim paid by Cigna and then later denied, requiring you to pay for the services.

A retroactive denial could be due to:

  • Eligibility issues
  • Service(s) determined to be not covered by your plan
  • Rescission (or cancellation) of coverage

Ways to avoid denied claims:

  • If you purchased coverage on your own through a state or federal marketplace, pay your monthly premium on time
  • Present your ID card at the time of service and be sure your provider has your current information
  • Stay in-network, if required by your plan
  • Get prior authorization, if required by your plan

What to do if your claim is retroactively denied:

  • Cigna will notify you in writing about your appeal rights
  • For additional assistance, call Customer Service at 1 (800) 244-6224

Learn more about appeals and grievances

Prior Authorizations

What is a prior authorization?

Certain services, prescriptions, locations, and medical equipment may need approval from your health plan before they’re covered and you can file a claim.

Services and prescriptions that require prior authorization include:

  • Medications that may be unsafe when combined with other medications
  • Medical treatments that have lower-cost, equally effective alternatives available
  • Medical treatments and medications that should only be used for certain health conditions
  • Medical treatments and medications that are often misused or abused

Prior Authorization Process

Your health care provider will inform you if you need prior authorization:

    • In-network providers will handle the process for you.
    • If you use an out-of-network provider, you are responsible for contacting the health plan and obtaining prior authorization.

Your health plan will then contact you with the results to let you know if your prior authorization has been approved or denied, or if they need more information.

If you are unhappy with the results of your prior authorization, there are some options:

      • You or your health care provider can ask for another review of the decision.
      • Your health care provider may prescribe a different treatment or medication.
      • Your health plan may recommend an alternative treatment or medication before coverage is available for the original treatment or prescription.

Learn more about prior authorization

EOB

What is an EOB?

An EOB (Explanation of Benefits) is a claim statement that Cigna sends to you after a health care visit or procedure to show you how your claim was paid.

An EOB is not a bill. It is a document to help you understand how much each service costs, how much your plan will cover, and how much you will have to pay when you receive a bill from your health care provider or hospital.

It includes:

      • An item-by-item breakdown of your care visit with a claim details page displayed in an easy-to-read format
      • How much you have paid toward your plan deductible (if applicable) and out-of-pocket limits
      • A summary page with the amount saved and what you owe

Remember to save your EOBs for tax purposes and as a record of care dates and services.

Find out more about EOBs