Cigna Individual and Family Medical Plans
Out-of-network liability and balance billing

This is important information. If you visit an out-of-network provider, you may pay more. Out-of-network providers do not have a contract with Cigna at the time you receive services. These providers include doctors, hospitals, clinics, pharmacies and labs.

Also, some plans do not cover services provided by an out-of-network provider, except:

  • In the event of a medical emergency, as defined by your plan
  • When medically necessary services aren’t available from an in-network provider

Refer to your plan documents for important benefit information.

Out-of-network non-emergency services

Your plan may cover non-emergency services from an out-of-network provider. If so, you will pay a larger part of the cost share for those services than you would for the same services provided by an in-network provider. This may include the deductible, coinsurance and other out-of-pocket amounts.

In addition, you may have to pay the difference between what the plan allows and the amount billed by the provider. This is called Balance Billing. Balance Billing is the difference between the out-of-network provider's charge and Cigna’s allowed amount for the service(s).

  • For example, if the out-of-network provider’s charge is $100 and Cigna's allowed amount is $70, the provider may bill you for the remaining $30.

An in-network provider may not bill you for the difference between their charge and Cigna's negotiated rate.

  • For example, if the in-network provider’s charge is $100 and Cigna's negotiated rate is $70, the provider may not bill you for the $30 difference.
Enrollee claim submission

How you get your bill paid when visiting an in-network provider

When you visit an in-network provider, show your ID card and pay any required copay. After your visit, the provider will send a bill to us. We refer to a bill as a claim. We will process the claim according to the terms of your insurance plan and any payment due will be made to the provider directly.

How you get your bill paid when visiting an out-of-network provider

When you visit an out-of-network provider, show your ID card and ask the provider if they will bill your insurance company. Out-of-network providers may agree to submit a bill on your behalf, but they are not required to. We refer to a bill as a claim. We will process the claim according to the terms of your insurance plan. If authorized by you, any payment due will be made to the provider. Otherwise, any payment due will be made to you.

If your provider does not agree to submit a bill on your behalf, you must send a completed claim form and an itemized bill to the address listed on your ID card. Request a Medical ID card.

Or, you can call the Customer Service number on your ID card for information about how to submit a claim.

This is important information. To pay a claim, Cigna must receive the claim by a certain date.

  • Medical Claims must be received by Cigna within 15 months of the original date of service, except in the event of a legal incapacity.
  • Pediatric Vision Claims must be received by Cigna within 12 months of the original date of service, except in the event of a legal incapacity.

 

Claim forms

Access the required claim forms for medical, behavioral, pharmacy, vision and dental.

  • Mail your completed claim form(s) and the original itemized bill(s) to Cigna. Send it to the Cigna HealthCare Claims Office printed on your ID card.
  • You will receive an Explanation of Benefits after your claim is processed.
  • If you are unable to find a claim form or need help, please call Customer Service. The toll-free number 1.800.Cigna24 (1.800.244.6224).

 

Claims Form mailing address

Medical Claims: Use the mailing address provided on your ID card.
Cigna Claims
PO Box 182223
Chattanooga, TN 37422
         Or
Cigna Claims
PO Box 188061
Chattanooga, TN 37422-8061

Mental Health & Substance Abuse Claims:
Cigna Behavioral Health, Inc.
Attn: Claims Service Dept.
P.O. Box 188022
Chattanooga, TN 37422

Grace periods and claims pending policies during the grace period

What is a grace period?

To keep your health insurance coverage in effect, you must pay the monthly bill. We call this the premium payment. If you do not pay the monthly bill, then there is a grace period. You still have coverage during the grace period. A grace period is a short span of time after the date your premium is due.

If your claim is not approved or denied it is referred to as pending.

Your policy provides specific grace period information for your plan.

Standard Grace Period

If you bought your plan and you DO NOT qualify for federal financial assistance:

  • The grace period is 31 days. As long as initial payment for coverage has been paid and the plan is active, you have 31 days to pay your bill or premium. Coverage will continue during the grace period.

  • If you fail to pay premium within the applicable grace period, your coverage may be rescinded (or cancelled). Rescission of your coverage will result in denial of all pending claims and, if claim payments exceed total premiums paid, then claims already paid by Cigna may be retroactively denied.

 

Grace Period with Advanced Premium Tax Credit
If you bought your plan from a state or federal marketplace AND you qualify for federal financial assistance and receive an advanced premium tax credit:

  • The grace period is 3 consecutive months. As long as initial payment for coverage has been paid and the plan is active, you have 3 months to pay your bill or premium. Coverage will continue during the grace period.

  • Services received during the grace period. If you receive services during the grace period and receive an Advanced Premium Tax Credit:
    • Cigna will pay claims for covered services during the first 30 days of the grace period.
    • Cigna will hold or pend claims for covered services received during the second and third month of the grace period.

    • If you fail to pay premium within the grace period, your coverage may be rescinded (or cancelled). Rescission of your coverage will result in denial of all pending claims and, if claim payments exceed total premiums paid, then claims already paid by Cigna may be retroactively denied.

 

Retroactive denials

Did you go to a provider and your claim was denied?
Did you go to a provider and your claim was paid by Cigna, but then later denied?

You will receive an Explanation of Benefits detailing how Cigna handled your claim. If your claim was not paid, the Explanation of Benefits will provide the reason why it was denied.

You have the right to appeal when a claim is not paid. Appeal rights and timeframes can vary from state to state. Your policy will include full information on your grievance and appeal rights.

A denied claim means Cigna is not paying for the services you received.

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 policy
  • Rescission (or cancellation) of coverage

 

Ways to avoid denied claims:

  • Pay your monthly premium on time
  • Present your ID card when you receive services. Make sure your provider has your current insurance 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.

Enrollee recoupment of overpayments

How to get a refund if you paid too much for your insurance

If you overpaid your insurance premium you may qualify for a refund. If you think you overpaid, Cigna's Billing and Enrollment department can help you. Please call the number on the back of your ID card with questions about your premium payment and possible refund.

Medical necessity, prior authorization timeframes and enrollee responsibilities

Do you need approval before a non-emergency hospital stay or having outpatient care?

You may need to get Cigna's approval before a hospital stay or outpatient care. Getting approval is also called prior authorization.

  • Cigna reviews medical guidelines and your medical condition to make sure you have a medical need for services.
  • To get approval, you or your provider must call us at least four business days (Monday through Friday) before you plan to have the procedure or service.
  • You must get approval before your admission or treatment. If you don’t, then Cigna will review the services after you receive them. If we find that the service was not medically necessary, you may have to pay for the services or it may result in a penalty.

Please note: We will review emergency admissions or care after you receive them to determine whether the services were emergent and medically necessary.

What is medical necessity?

A service is medically necessary if it is appropriate and necessary to treat your medical condition. The service must also be consistent with sound medical practice.

Get approval (or prior authorization) for:

  • Inpatient admission. Approval is required for admission and continued stay in the hospital.
  • Certain outpatient procedures and services

To verify approval or prior authorization you can:

  • Call Cigna at the number on the back of your ID card, or
  • Check www.mycigna.com, under "View Medical Benefit Details"

How to get prior approval:

  • If you have an in-network provider, the provider must obtain the approval.
  • If you have an out-of-network provider, you must get approval.
  • You can request approval for yourself or a family member. Just call the Customer Service phone number on your ID card.
Drug exception timeframes and enrollee responsibilities

Covered prescription drugs

Your health insurance plan has its own list of covered drugs, also called formulary. The amount covered for your drugs depends on your plan, the drug and the state where you live.

To find out what drugs are covered on your plan, use the drug search tool and select the state you live in.

Prior authorization for prescription drugs

Some prescription drugs and other supplies may need prior approval from Cigna. This means we have to approve coverage before your doctor can prescribe them.

Exceptions for prescription drugs not covered by your insurance plan

Your prescribing doctor can request that we make an exception to cover a drug. There is a procedure for requesting a prescription drug exception. Look for it in the prescription drug benefits section of the policy.

To request a Prescription Drug List exception or Prior Authorization, your doctor may call Cigna or fax the appropriate request form.

Pharmacy forms

Access the required claim forms for medical, behavioral, pharmacy, vision and dental. Or, you can call Customer Service using the toll-free number on your ID card.

How to complete the pharmacy form for a prior authorization or exception request:

  • For a TIMELY response to your prior authorization or exception request:
    • Fill out a Prescription Drug Claim Form, which has been designed for Cigna drug plans.
    • Write your Cigna ID number and the plan number on the claim form.
    • Be sure that you are referencing your Cigna ID card.
  • Cigna will process your request:
  • 24 hours for an expedited request
  • 72 hours for a non-expedited request

Cigna will cover a prescription if you need it during an emergency and a participating pharmacy can’t fill it in a reasonable amount of time. The prescription will be covered at same benefit level as a Participating Pharmacy.

If you don't like Cigna's decision about your drug claim you can request that we look at the claim again. Just submit a written appeal. Tell us in the appeal why the prescription drugs or related supplies should be covered.

If you have questions about exceptions or prior authorizations, call Customer Service. Just call the toll-free number on your ID card.

Claims and Customer Service

Drug claim forms are available upon written request to:

For retail pharmacy claims:

Cigna Pharmacy Service Center

P.O. Box 188053

Chattanooga TN 37422-8053

For mail-order pharmacy claims:

Cigna Home Delivery Pharmacy

P.O. Box 1019

Horsham PA 19044-1019

As part of your plan, we're at your service. If you have questions about your medications, contact us. We have information about side effects, and how some medications interact with other medications. We can let you know how to handle or store them too. Just call Cigna Specialty Pharmacy Services at 1.800.351.3606, option 1.

Information on Explanations of Benefits (EOBs)

How do you know if Cigna paid a claim?

Your doctor’s office submits a claim for payment to Cigna after you see your doctor or receive other medical care.

If your provider is not submitting a claim on your behalf, you must send a completed claim form and an itemized bill to the address listed on your ID card.

After the claim is processed, Cigna will provide an Explanation of Benefits (EOB) to you. We send this statement to explain what medical treatments and/or services were paid. It tells you how your claim was paid, including the amount that was paid and to whom it was paid. It’s simple and clear, so you can see what was submitted, what’s been paid and what you owe.

EOBs are available for you to look at online at www.mycigna.com for up to two years. You’ll also find:

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

For more information:

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

Coordination of Benefits (COB)

What if you have insurance with another company?

When two plans cover the same service they may coordinate benefits. This is so that neither plan duplicates the other plan's payment. Coordination of Benefits rules can vary from state to state. Please refer to your policy for more information on "Coordination of Benefits".

Other Insurance Coverage – when the other plan is with another insurance company

If you have other coverage with another insurance company, you must let Cigna know before you go for care. We won’t reduce your benefits payable by other coverage if you let Cigna know ahead of time. We will reduce the benefits payable by other coverage if you don’t. If we reduce your benefits due to other coverage, Cigna will return part of the last premium paid.

Other Insurance Coverage – when the other plan is also with Cigna

If you are covered by more than one Cigna plan, you will receive the benefits of only one plan. You may choose the plan under which you will be covered. Cigna will refund any premium received under the other plan. Any claims payments made by us under the plan you choose to cancel will be deducted from any such refund of premium.

Cigna Individual and Family Dental Plans
Out-of-network liability and balance billing

This is important information. If you visit an out-of-network dentist or other provider, you may pay more for services.

  • Out-of-network dentists do not have a contract with Cigna at the time you receive services.
  • Out-of-network dentists do not offer Cigna customers discounted fees.

You may have to pay the difference between what the plan allows and the amount billed by the dentist. This is called Balance Billing. Balance Billing is the difference between the out-of-network dentist's charge and Cigna's allowed amount for the service(s).

  • For example, if the out-of-network dentist charge is $100 and Cigna's allowed amount is $70, the dentist may bill you for the remaining $30.

An in-network dentist may not bill you for the difference between their charge and Cigna's negotiated rate.

  • For example, if the in-network dentist's charge is $100 and Cigna's negotiated rate is $70, the dentist may not bill you for the $30 difference.
Enrollee claims submission

Enrollee claims submission

After a visit with your dentist, they may send a bill to us. We refer to a bill as a claim.

This is important information.

For in-network dental claims, your provider will submit your claim. Cigna will process the claim according to the terms of your insurance plan and any payment due will be made to the provider directly.

For out-of-network dental claims, Cigna must receive your claim within 12 months after the date of service, except in absence of legal capacity. If your dentist is not submitting a claim on your behalf, you must send a completed claim form and itemized bill to Cigna. We will process the claim according to the terms of your insurance plan. If authorized by you, any payment due will be made to the provider. Otherwise, any payment due will be made to you.

Claim forms

View Cigna's dental claim forms

  • Mail your completed claim form(s), with original itemized bill(s) attached, to Cigna Dental. The address is printed on your ID card.
  • You will receive an Explanation of Benefits after your claim is processed.
  • If you are unable to find the claim forms or need help, please call Customer Service. The toll-free number is 1.800.Cigna24 (1.800.244.6224)

Claims Form mailing address:

Mail dental claims to:

Cigna Dental

PO Box 188037

Chattanooga, TN 37422

Grace periods and claims pending policies during the grace period

What happens if you do not pay the monthly dental insurance bill?

To keep your dental insurance coverage in effect, you must pay the monthly bill. We call this the premium payment. If you do not pay your monthly bill, then there is a grace period. You still have coverage during the grace period. A grace period is a short span of time after the date your premium is due.

If your claim is not approved or denied it is referred to as pending.

Your policy provides specific grace period information for your dental plan.

Standard Grace Period

If you bought your plan and you DO NOT qualify for federal financial assistance:

  • The grace period is 31 days. As long as initial payment for coverage has been paid and the plan is active, you have 31 days to pay your bill or premium. Coverage will continue during the grace period.
  • If you fail to pay premium within the applicable grace period, your coverage may be rescinded (or cancelled). Rescission of your coverage will result in denial of all pending claims and, if claim payments exceed total premiums paid, then claims already paid by Cigna may be retroactively denied.

Grace Period with Advanced Premium Tax Credit

If you bought your plan from a state or federal marketplace AND you qualify for federal financial assistance and receive an advanced premium tax credit:

  • The grace period is 3 consecutive months. As long as initial payment for coverage has been paid and the plan is active, you have 3 months to pay your bill or premium. Coverage will continue during the grace period.
  • Services received during the grace period. If you receive services during the grace period and receive an Advanced Premium Tax Credit:
    • Cigna will pay claims for covered services during the first 30 days of the grace period.
    • Cigna will hold or pend claims for covered services received during the second and third month of the grace period.
  • If you fail to pay premium within the grace period, your coverage may be rescinded (or cancelled). Rescission of your coverage will result in denial of all pending claims and, if claim payments exceed total premiums paid, then claims already paid by Cigna may be retroactively denied.
Retroactive denials

Did you go to a dentist and your claim was denied?

Did you go to a dentist and your claim was paid by Cigna, but then later denied?

You will receive an Explanation of Benefits detailing how Cigna handled your claim. If your claim was not paid, the Explanation of Benefits will provide the reason why it was denied.

You have the right to appeal when a claim is not paid. Appeal rights and timeframes can vary from state to state. Your policy will include full information on your grievance and appeal rights.

A denied claim means that Cigna will not pay for the services you received.

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 policy
  • Rescission (or cancellation) of coverage

Ways to avoid denied claims:

  • Pay your monthly premium on time
  • Present your ID card when you receive services. Make sure your dentist has your current insurance information.

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.

Enrollee recoupment of overpayments

How to get a refund if you paid too much for your insurance

If you overpaid your insurance premium you may qualify for a refund. If you think you overpaid, Cigna’s Billing and Enrollment department can help you. Please call the number on the back of your ID card with questions about your premium payment and possible refund.

Medical necessity, prior authorization timeframes and enrollee responsibilities

For dental services:
You do not need approval before you go to a hospital.
You do not need approval before you receive outpatient care.

Information on Explanations of Benefits (EOBs)

How do you know if Cigna paid a claim?

You or your dentist's office will submit a claim for payment to Cigna after you visit your dentist.

After the claim is processes, Cigna will provide an Explanation of Benefits (EOB) to you. We send this statement to you to explain what dental treatments and/or services were paid. It tells you how your claim was paid, including the amount that was paid and to whom it was paid. It's simple and clear, so you can see what was submitted, what's been paid and what you owe.

EOBs are available for you to look at online at myCigna.com for up to two years. You'll also find:

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

For more information:

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

Coordination of Benefits (COB)

What if you have insurance with another company?

Some insured people may have two dental plans. If you do, your Cigna dental plan will cover services according to the terms of your Cigna dental plan. Cigna does not coordinate benefits for dental coverage.