Claims, Authorizations, and Explanations of Benefits

Claims, Authorizations, and Explanations of Benefits (EOBs)

How to submit a claim and read your claim statements

Health care can be confusing. The good news is we’re here to help. Below are a few important terms that will help you to better understand your medical bills and health plan coverage.

What is a claim?

In many ways, a claim is similar to a bill. It is a request to be paid for care. Sometimes people say "filing" or "submitting a claim." These phrases mean the same thing.

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 or service pre-approved by Cigna before you receive care, otherwise the claim may be denied. 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 pay the health care provider or you, 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. See more details on how to file a claim

What is Prior Authorization?

Under your plan, certain services and equipment may need approval from your health plan first before they’re covered. The services and equipment requiring prior authorization are described in your plan documents.

Prior Authorization for medication

Under your plan, certain medications need approval from your health plan first before they’re covered. Medications requiring prior authorization have a (PA) next to them on your drug list. These medications will only be covered by your plan if your doctor requests and receives approval from your health plan.

The types of medications that typically need approval are:

  • Those that may be unsafe when combined with other medications
  • Have lower-cost, equally effective alternatives available
  • Should only be used for certain health conditions
  • Are often misused or abused

How does the Prior Authorization process work?

For health care services and equipment, 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.

Prior Authorization process for medication

For medications, prior authorizations are typically handled by your doctor’s office which will work directly with your health plan. Your health plan will then contact you with the results to let you know if your drug coverage has been approved or denied, or if they need more information.

Results of your Prior Authorization

If you are unhappy with the results of your prior authorization, you or your health care provider can ask for another review of the decision. Or, your health care provider may prescribe a different treatment or medication. In some instances, your health plan will recommend an alternative treatment or medication before coverage is available for your doctor’s original prescription.

What is an explanation of benefits (EOB), and how does it relate to claims?

An explanation of benefits, or EOB, is a document that Cigna sends you after a doctor's visit or procedure to show the costs and coverage related to your care. 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 doctor 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.

Cigna offers a guide to understanding your EOBs [PDF].

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

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 when you receive services. Make sure your provider has your current ID card information.
  • Stay in-network, if required by the plan
  • Get prior authorization, if required by the 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) Cigna24 (1 (800) 244-6224).

Learn more about appeals and grievances.

How do I know if I need to file 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.

If you have a plan through your employer, please check your benefits package to learn more about the details associated with your coverage. If you purchased coverage on your own through a state or federal marketplace, please review your plan documents to learn more about your coverage.

HMO, Network, or EPO Plans

In-network

For most covered services, 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 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 Plans

In-network

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.

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 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 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.

Get help on filing a claim