Qualified Health Plan (QHP) Transparency in Coverage

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 Healthcare at the time you receive services. These providers include doctors, hospitals, clinics, pharmacies and labs.
Also, some health 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 health plan does not cover non-emergency services from an out-of-network provider. 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 our allowed amount for the service(s).

• For example, if the out-of-network provider's charge is $100 and our 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 our negotiated rate.

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

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. Please visit the myCigna^® website to 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 Healthcare must receive the claim by a certain date.

• Medical Claims must be received by Cigna Healthcare within 15 months (18 months for North Carolina residents) of the original date of service, except in the event of a legal incapacity.
• Pediatric Vision Claims must be received by Cigna Healthcare within 12 months (15 months for Tennessee residents) 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 Healthcare. 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

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

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/service agreement 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 (10 days in Mississippi and North Carolina). 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 Healthcare may be retroactively denied.

Grace Period with Advanced Premium Tax Credit

If you bought your plan from a state or federal Marketplace/Exchange 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 Healthcare will pay claims for covered services during the first 30 days of the grace period.
  • Cigna Healthcare will not pay for covered services received during the second and third month of the grace period unless and until the premium is paid.

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 Healthcare may be retroactively denied.

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

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

You will receive an Explanation of Benefits detailing how Cigna Healthcare 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 Healthcare is not paying for the services you received.

A retroactive denial is a claim paid by Cigna Healthcare 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 Healthcare 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.

Arizona residents: learn more about appeals and grievances.

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, our 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.

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

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

• Cigna Healthcare 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.
• Cigna Healthcare will respond to your request within 10 calendar days (15 calendar days in Arizona and Indiana) if all information needed to make a decision is received. If the request is urgent, Cigna Healthcare will respond within 72 hours.
• You must get approval before your admission or treatment. If you don’t, then Cigna Healthcare 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. If you have already received the service, Cigna Healthcare will respond to your request within 30 calendar days.

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 Healthcare at the number on the back of your ID card, or
• Check www.mycigna.com, under "Coverage/Medical Authorizations"

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.

Covered prescription drugs

Your health insurance plan has its own list of covered drugs, also called the Prescription Drug List. 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 related supplies may need prior authorization from Cigna Healthcare. This means we have to approve coverage before your doctor can prescribe them.

Exceptions for prescription drugs not covered by your insurance plan

Sometimes our members need access to drugs that are not listed on our drug list. A member or a member’s prescribing doctor can request that we make an exception to cover a drug. There is a process for requesting a prescription drug exception. Information regarding the prescription drug exception process may be found below, as well as in the prescription drug benefits section of the policy/service agreement or by using the drug search tool.

The member or the member’s prescribing doctor can submit the drug exception request to us either by completing and submitting the Cigna Healthcare Prescription Drug Claim Form [PDF] online (myCigna.com) or printing and completing the form and mailing it to us.

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 completely.
• Write your ID number and the plan number on the claim form.
• Be sure that you are referencing your ID card.

Cigna Healthcare will process your request in:

• 24 hours for an expedited request
• 72 hours for a non-expedited request (2 business days for Tennessee residents)

To request an expedited review for exigent circumstance, select the “Request for Expedited Review” option in the Request Form.

Pharmacy forms

Cigna Healthcare 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.

The exception request is initially reviewed by Cigna Healthcare through the formulary exception review process. If you don't like our 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.

Learn more about appeals and grievances

If you have questions about exceptions or prior authorizations, call Cigna Healthcare customer service at the number on your ID card. If you are still not satisfied following completion of the internal appeals process, you or your representative may request independent review by an external review organization. The decision of the external reviewer is binding upon Cigna Healthcare, but not upon you. You can request more information about an independent external review by contacting Cigna Healthcare customer service at the number on your ID card.

Claims and Customer Service

Drug claim forms are available upon written request to:

For retail pharmacy claims:
Cigna Healthcare Pharmacy Service Center
P.O. Box 188053
Chattanooga TN 37422-8053

For mail-order pharmacy claims:
Express Scripts
P.O. Box 66301
St. Louis MO 63166-6301

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 Healthcare Specialty Pharmacy^SM Services at .

How do you know if Cigna Healthcare paid a claim?

Your doctor's office submits a claim for payment to Cigna Healthcare 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 Healthcare 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:

• Guide to the Cigna Healthcare EOB [PDF]
• The EOB also includes a glossary of the words and terms used.

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

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."

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 Healthcare at the time you receive services.
• Out-of-network dentists do not offer Cigna Healthcare 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 our allowed amount for the service(s).

• For example, if the out-of-network dentist charge is $100 and our 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 our negotiated rate.

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

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 Healthcare 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 Healthcare 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 Healthcare. 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 our dental claim forms

• Mail your completed claim form(s), with original itemized bill(s) attached, to Cigna Healthcare 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 Healthcare Dental
PO Box 188037
Chattanooga, TN 37422

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 Healthcare 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 Healthcare will pay claims for covered services during the first 30 days of the grace period.
  • Cigna Healthcare 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 Healthcare may be retroactively denied.

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

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

You will receive an Explanation of Benefits detailing how Cigna Healthcare 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 Healthcare will not pay for the services you received.

A retroactive denial is a claim paid by Cigna Healthcare 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 Healthcare 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 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, our 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.

What is dental necessity?

Dental necessity refers to a procedure, service, or supply that is appropriate and necessary to treat your dental condition. The service must also be consistent with broadly accepted standards of care.

For dental services:

You do not need approval before you receive outpatient care.

What if you have insurance with another company?

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