QUICK GUIDE TO CIGNA ID CARDS 2014-2015
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2014-2015
QUICK GUIDE TO
CIGNA ID CARDS
591795 r 06/14 THN-2014-256
WE PACK A LOT OF IMPORTANT INFORMATION ON OUR ID CARDS. This brochure can help define and clarify information that appears on Cigna’s most common customer ID cards. It can also help you understand the requirements associated with our various plans, allowing you to quickly and efficiently serve your patients. We may occasionally update this brochure during the year. Download the most current version at Cigna.com > Health Care Professionals > Resources > Doing Business with Cigna. PLEASE NOTE: There are various standard Cigna ID cards shown in this brochure that are subject to regulatory oversight. As a result, the actual ID card content may vary in order to conform to legislative and regulatory requirements. The ID cards shown are samples and may vary from the actual cards.
KEY Refer to this key for explanations of the information found on the sample Cigna ID cards featured in this brochure. 1 Use this ID number for all claims and inquiries. 2 Indicates a seamless network where a patient can receive in-network care on a regional or statewide basis. 3 For patients with coinsurance, submit claims to Cigna or its designee, and receive an Explanation of Payment (EOP), which will show any remaining amount due from patient. 4 Collect any copayment at the time of service. 5 May read as “Connecticut General Life Insurance Co.,” “Cigna Health and Life Insurance Company” or “Cigna HealthCare of XXXX, Inc.” 6 ID cards with the Cigna Care Network® logo indicate the patient’s liability varies based on the health care professional’s Cigna Care designation status. Refer to the online health care professional directory to determine a physician’s Cigna Care designation status. 7 Effective date of coverage. 8 Name of patient‘s primary care physician (PCP). 9 Network Savings Program (NSP) logo indicates that out-of-network discounts may be available to the customer. 10 Client name. 11 If a third party administers services in conjunction with Cigna, the ID card may include multiple logos and may show a different claim address or telephone number on the back of the card. 12 Precertification requirements may be shown as either “Inpatient Admission” or “Inpatient Admission and Outpatient Procedures.’’ 13 Submit claims to the claim submission address shown on the card. 14 Call the Customer Service number(s) indicated on the card. Some plans have dedicated numbers for accessing information – be sure to check the card for the correct number. 15 “Away From Home Care” indicates the patient has access to the Cigna national network. 16 Indicates Shared Administration. 17 Union identifier. 18 Client-specific network (CSN) logo.
THE MYCIGNA MOBILE APP:
APP-SOLUTELY CONVENIENT
The myCigna Mobile App gives customers a simple way to personalize, organize and
access their important health and benefits information – on the go. Cigna customers
may present their ID card information, claims information and coverage eligibility to
you via the app with their cell phone or tablet.
FEATURES:
ID cards
• Quickly view ID card information (front and back) for the entire family
• Easily print, email or scan right from smartphone Health care professional directory
• Locate doctors and health care facilities
• Access maps for instant driving directions
Health wallet
• Store and organize all contact info for doctors, hospitals and pharmacies
• Add health care professionals to contact list right from a claim or directory search
Claims
• View and search recent and past claims
• Bookmark and organize claims for easy reference
Trackers
• View in-network and out-of-network medical and dental year-to-date deductibles,
as well as out-of-pocket and annual maximums
Coverage
• See plan coverage and benefit information for medical, dental, pharmacy
• Access and view health fund balances
• Review plan deductibles and coinsurance
Drug search
• Compare prescription drug costs at more than 60,000 pharmacies nationwide
• Find closest pharmacy location using GPS
Customers can get the free myCigna Mobile App
from the App StoreSMor Google Play
iOS Apple version 5.1 or higher
Android OS version 2.3 or higher
The Apple logo is a trademark of Apple Inc., registered in the U.S. and other countries. App Store is a service
mark of Apple Inc. | Android and Google Play are trademarks of Google Inc.
*The myCigna Mobile App is only available to Cigna health plan customers. Actual features may vary depending
on your plan. The downloading and use of the App is subject to the terms and conditions of the App and the
online stores from which it is downloaded. Standard mobile phone carrier and data usage charges apply.
1
Primary Care $30 Specialist $40
Urgent Care $65 Preventive Care $20 Members and Providers Call
PCP: None Selected 1-866-494-2111
No Referral Required
RUN_DATE
DATA_SEQ_NO
CLIENT_NUMBER
UHG_TYPE
DOC_ID
DOC_SEQ_ID
NAME
MAILSET_NUMBER
CUST_KEY1
CUST_KEY2
CUST_KEY3
CUST_KEY4
CUST_KEY6
CUST_KEY5
Doe
9116687/000001-00
9116687/000001-01
9116687/000001-02
20130314
DIG1CARD
00699998
100000008
00
John
Doe
0000001
0000001
003040
0000001
05:58:28
,John For plan & benefit details, please visit myCIGNAforhealth.com
CUST_KEY5
RUN_DATE
DATA_SEQ_NO
CLIENT_NUMBER
UHG_TYPE
DOC_ID
DOC_SEQ_ID
NAME
MAILSET_NUMBER
CUST_KEY1
CUST_KEY2
CUST_KEY3
CUST_KEY4
CUST_KEY6
Doe
9116687/000001-00
9116687/000001-01
9116687/000001-02
20130314
DIG1CARD
00699998
100000008
00
John
Doe
0000001
0000001
003040
0000001
05:58:28
,John Plan Contractor: Connecticut General Life Insurance Company
11 Members: Carry this card at all times. Pretreatment authorization must be obtained for hospital
*117**117*
GWH-Cigna
Plan Type admissions, outpatient surgeries performed outside a physician’s office and for the other services
GWH-CIGNA
PlanAccess
Open Type specified in the benefit plan. Member is responsible for obtaining authorization for non-network
Plus services. Failure to follow pretreatment authorization procedures may result in a reduction of
benefits. In an emergency, seek care immediately, then call your primary care doctor as soon as
Health Management, Inc. and Cigna Dental Health, Inc. The Cigna Dental
XYZ Company possible for further assistance. We encourage you to use a primary care physician as a valuable
management services provided by Cigna Dental Health, Inc., and certain
its operating subsidiaries. All products and services are
10
Inc. The Cigna Dental
Life Insurance Company, Cigna Health and Life Insurance Company, Cigna
>000001
PPO is underwritten or administered by Connecticut General LIfe Insurance
RXBIN 600428 resource and personal health advocate.
certain
Corporation and its operating subsidiaries. All products and services are
Life Insurance Company, Cigna Health and Life Insurance Company, Cigna
>000001
Corporation. Such operating subsidiaries include Connecticut General
PPO is underwritten or administered by Connecticut General LIfe Insurance
Company or Cigna Health and Life Insurance Company with network
a service
RXPCN 05180000
provided by or through such operating subsidiaries and not by Cigna
Corporation. Such operating subsidiaries include Connecticut General
is network
upon our agreement with your provider. Your provider may bill you
CIGNA has multiple networks. Your plan is paired with the GWH-CIGNA network. To find a
Cigna
'Cigna' is a registered service mark, and the 'Tree of Life' is a service
provided by or through such operating subsidiaries and not by Cigna
Issuer 80840
Your share of the payment for health care services may be based
upon our agreement with your provider. Your provider may bill you
mark, of Cigna Intellectual Property, Inc., licensed for use by Cigna
GWH-CIGNA provider, please visit your member website at myCIGNAforhealth.com.
Inc.,byand
Your share of the payment for health care services may be based
Group Plan 123456789 Providers: Pretreatment authorization must be received for all services listed above and as
John Public
13 12
with
Submit All Claims To specified in the member’s benefit plan by calling the number on the front of this card or online
for use
Company or Cigna Health and Life Insurance CompanyLife'
PO Box 188061 at CignaforHCP.com. Emergency hospital admissions must be reported within 48 hours.
ID 123456789 01 1
Health,
9116687
charges.
9116687 Chattanooga, TN 37422 - 8061
for amounts up to the provider's regular billed charges.
of
COPAY: Notice: Possession of this card does not guarantee coverage or payment for the service or
Payer ID #62308
Primary Care $30 4 Specialist $40 procedure reviewed. Please call the Member and Providers number on the front of this card for
Health,
licensed
'Tree
Urgent Care $65 ER $200 14 eligibility information.
Inc., Dental
Members and Providers Call
billed
PCP: None Selected
8
the
1-866-494-2111
9 For providers not in your primary
Dental
No Referral Required network, visit multiplan.com
What does it mean?
and
by Cigna
What does it mean?
regular
For plan & benefit details, please visit myCIGNAforhealth.com For Pharmacists Only 1-800-XXX-XXXX
001
001
Property,
mark,
R318 (5/10) Mask 401 Issue Date: 01/01/12
and Cigna
provider's
provided
service
003040
• PCP selection encouraged
003040
Intellectual
subsidiaries.
up to theInc.
• No referrals required
registered
mark, of Cignaservices
Management,
GWH-Cigna Plans
• GWH-Cigna ID cards represent all products
and
its operating
management
for amounts
Corporation
'Cigna' is a
Health
of
11
03040 9116687 0000 0000001 0000001 072 7 117
03040 9116687 0000 0000001 0000001 072 7 117
Cigna Health and Health
Cigna Life Insurance
and LifeCompany
Insurance Company
12
5
Group 00699998
Group 00699998
Issuer (80840)
Issuer (80840)
ID 100000008
ID 100000008 Copays Copays 41
Name JohnName
Doe John Doe Primary Care Primary
$25 Care $25
PCP NonePCP Selected
None Selected 8 Specialist $25Specialist $25
No ReferralNo
Required
Referral Required Urgent Care $100
Urgent Care $100
ER $200 ER $200
XYZ SampleXYZ CompanyHoldings Co.
Sample CompanyHoldings Co. 10 PO All
13 Send All Claims ToSend BoxClaims
188061To
Chattanooga, TN 37422Drive
- 8061 Payer ID #62308
1000 Great-West Kennett, MO 63857-3749 Payer ID #62308
Customers & Customers
Health Care Professionals call 1-866-494-2111
RxBIN 600428 RxPCN 05180000 14 Rx Claims: Pharmacy Service Center,&PO
Health Care
Box 3598, Professionals
Scranton PA 18505-0598call 1-866-494-2111
RxBIN 600428
RxGrp 00688888 RxPCN 05180000 Rx Claims:ForPharmacy Service
Pharmacists OnlyCenter, PO Box 3598, Scranton PA 18505-0598
800-351-9170
RxGrp 00688888 For Pharmacists Only 800-351-9170
RxID 100000008 00
RxID 100000008 00 9
Mask 601 Issue Date: 03/14/13
Mask 601 Issue Date: 03/14/13
• PCP selection encouraged
• No referrals required
• GWH-Cigna
00000000ID cards represent all products
00000000
DIRECT
USPS DIRECT
USPS
John Doe
John
888 N Main St Doe
Olympia, 888
WA N98502
Main St
Olympia, WA 98502
20130313
20130313
Thu Mar 14, 2013 @ 05:58:28
N Thu Mar 14, 2013 @ 05:58:28
12 N
Global Health Benefits
1 601
601
10
14
13
9 15
• PCP selection encouraged
• Patients in these Cigna-administered plans use Cigna PPO or Cigna OAP networks in the U.S., as indicated on the back of the card
• Network Savings Program logo on back of card indicates out-of-network discounts may apply
2
Cigna Choice Fund Open Access Plus WWW.CIGNA.COM
TPV logo
CSN logo 18
11 Client You may be asked to present this card when you receive care. The card does not guarantee coverage.
Cigna
Care Network 6 logo You must comply with all terms and conditions of the plan. Willful misuse of this card is considered fraud.
Legal entity name 5
12 INPATIENT ADMISSION:
Your provider must call the toll-free number listed below to pre-certify the above services. Refer to your plan documents for your
Coverage effective date: MM/DD/CCYY 7 Choice Fund OA Plus pre-certification requirements. Failure to do so may affect benefits. In an emergency, seek care immediately, then call your primary
Group: 1234567 No referral required care doctor as soon as possible for further assistance and directions on follow-up care within ### hours.
PCP Visit 15%/20%
Specialist 3 15%/20%
Issuer (80840) Coinsurance/deductible is paid directly to the doctor/facility by Cigna using individual’s available health funds.
ID: U23456789 01 1 Hospital ER 20% For Pharmacy, call ABC Company 1.800.XXX.XXXX (Not a Cigna Company)
Name: John Public Vision Yes For Vision, call ABC Company 1.800.XXX.XXXX (Not a Cigna Company)
Rx 30%/40%/50%
PCP: John Smith
PCP Name Ln2 8 Network Coinsurance: 13 Send claims to:
In 90%/10% CAD Name, PO Box XXXX, Anytown, USA 12345-6789
®
PCP Phone: XXX.XXX.XXXX Out 70%/30% TPV Name, PO Box XXXX, Anytown, USA 12345-6789
ID card acct name 10 Med/Rx deductible applies All Others: PO Box XXXX, Anytown, USA 12345-6789
RxBIN XXXXXX RxPCN XXXXXXXX logo 9
NSP
Customer Service: 1.800.XXX.XXXX 14 MH/SA: 1.800.XXX.XXXX
16
DOI Network Savings Program Cat# We encourage you to use a PCP as a valuable resource and personal health advocate. AWAY FROM HOME CARE
• PCP selection encouraged • Coinsurance/deductible should not be collected at the time of service unless
• Cigna Choice Fund® and medical plan type indicated you have accessed the Cigna Cost of Care Estimator®on the Cigna for Heath Care
• Most coinsurance information shown Professionals website (CignaforHCP.com) to obtain an estimate of the patient’s
• Coinsurance/deductible is paid directly to the doctor/facility by Cigna using costs, and provide a copy of the estimate to the patient
patient’s available health funds. Explanation of Payment (EOP) will show any • Collecting at the time of service without accessing the Cigna Cost of Care Estimator
remaining amount due from patient may result in overpayment and require a refund to the patient
You may be asked to present this card when you receive care. The card does not guarantee coverage.
TPV logo 11 Client You must comply with all terms and conditions of the plan. Willful misuse of this card is considered fraud.
logo 12 INPATIENT ADMISSION:
Your provider must call the toll-free number listed below to pre-certify your medical services or benefits may be affected. Refer to your
Legal entity name 5
Shared Administration PPO
plan documents for your plan’s precertification requirements. In an emergency, seek care immediately, then notify Cigna within 48 hours.
Coverage effective date: MM/DD/CCYY 7 Provider network: Mail all non-medical claims and correspondence to: ID card name back
Group: 1234567 Cigna HealthCare PPO SAR fund name
Issuer (80840) Doctor visit $10 4 13 Submit/mail claims to: Cigna Payor 62308, PO Box 188004, Chattanooga, TN 37422-8004
All other:
ID: U23456789 01 1 Specialist $20
Coinsurance 3 TPV N&A print line
Name: John Public
In-network 90% / 10% Pre-certification: Member Srvc Nu Pharmacy Questions: 1.800.244.6224
S 16
This plan is self-funded by:
Out-of-network 70% / 30% Eligibility, Benefit and Claim questions please call: SAR TPA phone 14
Rx 30% / 40% / 50%
ID card account name To access the online provider directory go to www.CignaSharedAdministration.com
Fund #: SAR F To access member pharmacy tools go to www.myCigna.com
RxBIN Rx Bin RxPCN XXXXXXXX Deductible applies
DOI
Cat#
15 AWAY FROM HOME CARE Benefits are not insured by Cigna HealthCare 17
Shared Administration (SAR)
• Cigna Care Network is available
You may be asked to present this card when you receive care. The card does not guarantee coverage.
TPV logo 11 Client You must comply with all terms and conditions of the plan. Willful misuse of this card is considered fraud.
logo 12 INPATIENT ADMISSION:
Legal entity name 5 Your network provider must call the toll-free number listed below to pre-certify the above services. Refer to your plan documents
Coverage effective date: MM/DD/CCYY 7
Shared Administration OAP
for your pre-certification requirements. Failure to do so may affect benefits. In an emergency, seek care immediately, then call your
Group: 1234567 Open Access Plus primary care doctor as soon as possible for further assistance and directions on follow-up care within ### hours.
Issuer (80840) No referral required Mail all non-medical claims and correspondence to:
ID: U23456789 01 1 PCP visit $15 4 Fund name
Name: John Public Specialist $20 Fund address
S 16 Rx 30% / 40% / 50% Send claims to: Claims address 13
PCP: James Smith Network coinsurance: All others: PO Box XXXX, Anytown, USA 12345-6789
PCP name Ln2 In 90% / 10% 3 Pre-certification: Member Srvc Nu Pharmacy Questions: Pharm Num
PCP phone: 860-555-1212 Out 70% / 30% Eligibility, Benefit and Claim Questions: Please call Payor Num 14
Fund Name Deductible applies To access the online provider directory go to www.cignasharedadministration.com
Fund #: Fund number To access member pharmacy tools go to www.mycigna.com
RxBIN XXXXXX RxPCN XXXXXXXX We encourage you to use a PCP as a valuable resource and personal health advocate.
DOI Cat# AWAY FROM HOME CARE 15 17
• PCP selection encouraged
• No referrals required
• Cigna Care Network is available
3CSN logo 18 WWW.CIGNA.COM
TPV logo 11 Client
logo You may be asked to present this card when you receive care. The card does not guarantee coverage. You must comply with all
Cigna
Care Network 6 terms and conditions of the plan. Willful misuse of this card is considered fraud.
Legal entity name 5 5 12 INPATIENT ADMISSION:
Your provider must call the toll-free number listed below to pre-certify the above services. Refer to your plan documents for your
Coverage effective date: MM/DD/CCYY Network Open Access
Group: 1234567
7 No referral required
pre-certification requirements. Failure to do so may affect benefits. In an emergency, seek care immediately, then call your primary
Network Open Access
care doctor as soon as possible for further assistance and directions on follow-up care within ### hours.
Issuer (80840) PCP Visit $10/$25
For information about mental health services and coverage, call MHSA Stmt Tel
ID: U23456789 01 1
Specialist $10/$25
Name: John Public Hospital ER 4 $50 Med Group: Sunset Med Group
PCP: James Smith 8
Urgent Care $25 Send claims to: 123 Main Street, Suite 999, Anytown, USA 12345-6789 13
Vision Yes For Pharmacy, call ABC Company 1.800.XXX.XXXX (Not a Cigna Company)
PCP Name Ln2
Rx $10/20%/40%/100% For Vision, call ABC Company 1.800.XXX.XXXX (Not a Cigna Company)
PCP Phone: XXX.XXX.XXXX Rx Indiv Deduct $50 Cigna Claims: PO Box XXXX, Anytown, USA 12345-6789
ID card acct name 10
NSP 3 TPV Name, PO Box XXXX, Anytown, USA 12345-6789
RxBIN XXXXXX RxPCN XXXXXXXX logo 9 Coinsurance applies CSN Name, PO Box XXXX, Anytown, USA 12345-6789
DOI Network Savings Program SAR Customer Service: 1.800.XXX.XXXX 14 MH/SA: 1.800.XXX.XXXX
• PCP selection encouraged
• No referrals required
• In-network coverage only, except emergency care
WWW.CIGNA.COM
Managed Care Plans: Open Access
CSN logo 18
TPV logo 11 Client You may be asked to present this card when you receive care. The card does not guarantee coverage.
Cigna
6 logo You must comply with all terms and conditions of the plan. Willful misuse of this card is considered fraud.
Care Network
Legal entity name 5
12 INPATIENT ADMISSION AND OUTPATIENT PROCEDURES:
Your network provider must call the toll-free number listed below to pre-certify the above services. Refer to your plan documents
Coverage effective date: MM/DD/CCYY 7 Open Access Plus for your pre-certification requirements. Failure to do so may affect benefits. In an emergency, seek care immediately, then call your
Group: 1234567 No referral required primary care doctor as soon as possible for further assistance and directions on follow-up care within ### hours.
Issuer (80840) PCP visit $10/$25
Open Access Plus
Specialist $10/$25 For pharmacy, call ABC Company 1.800.XXX.XXXX (Not a Cigna Company)
ID: U23456789 01 1 Hospital ER $50 4 For vision, call ABC Company 1.800.XXX.XXXX (Not a Cigna Company)
Name: John Public Urgent care $25
PCP: James Smith 8 Vision Yes Send claims to:
PCP Name Ln2 Rx $10/20/30 CAD name, PO Box XXXX, Anytown, USA 12345-6789
Network Coinsurance: TPV name, PO Box XXXX, Anytown, USA 12345-6789
13
PCP phone: XXX.XXX.XXXX In 90%/10%
ID card acct name 10 Out 3 70%/30% All others: PO Box XXXX, Anytown, USA 12345-6789
NSP
RxBIN XXXXXX RxPCN XXXXXXXX logo 9 Med/Rx deductible applies Customer service: 1.800.XXX.XXXX 14 MH/SA: 1.800.XXX.XXXX
DOI Network Savings Program Cat# We encourage you to use a PCP as a valuable resource and personal health advocate. 15 AWAY FROM HOME CARE
• PCP selection encouraged
• No referrals required
• Open Access Plus: In-network and out-of-network coverage
• Open Access Plus In-network: In-network coverage only, except emergency care
CSN logo
WWW.CIGNA.COM
TPV logo Client
You may be asked to present this card when you receive care. The card does not guarantee coverage.
Cigna 2 logo You must comply with all terms and conditions of the plan. Willful misuse of this card is considered fraud.
Care Network
Legal entity name
5 12 INPATIENT ADMISSION:
HMO or POS Open Access
Your network provider must call the toll-free number listed below to pre-certify the above services. Refer to your plan documents
Coverage effective date: MM/DD/CCYY 7 POS (or HMO) Open Access
for your pre-certification requirements. Failure to do so may affect benefits. In an emergency, seek care immediately, then call your
Group: 1234567 No referral required
primary care doctor as soon as possible for further assistance and directions on follow-up care within ### hours.
Issuer (80840) PCP Visit $15/$25
Specialist 4 $15/$25 For information about mental health services and coverage, call MHSA Stmt Tel
ID: U23456789 01 1
Name: John Public Hospital ER $50 Med Group: Sunset Med Group 13
Urgent Care $25 Send claims to:
PCP: James Smith 8 Vision Yes
PCP Name Ln2 For pharmacy, call ABC Company 1.800.XXX.XXXX (Not a Cigna Company)
Rx $10/20%/40%/100% For vision, call ABC Company 1.800.XXX.XXXX (Not a Cigna Company)
PCP Phone: XXX.XXX.XXXX Rx Indiv Deduct $50 Cigna claims: PO Box XXXX, Anytown, USA 12345-6789
ID card acct name 10 TPV name, PO Box XXXX, Anytown, USA 12345-6789
RxBIN XXXXXX RxPCN XXXXXXXX logo NSP 9 Coinsurance applies 3 CSN name, PO Box XXXX, Anytown, USA 12345-6789
DOI Network Savings Program SAR Customer service: 1.800.XXX.XXXX 14 MH/SA: 1.800.XXX.XXXX
• PCP selection encouraged
• No referrals required
• HMO Open Access: In-network coverage only, except emergency care
• POS Open Access: Offered as an HMO or Network plan; in-network and out-of-network coverage
4CSN logo WWW.CIGNA.COM
TPV logo 11 18 Client
Managed Care Plans: LocalPlus®
You may be asked to present this card when you receive care. The card does not guarantee coverage.
logo You must comply with all terms and conditions of the plan. Willful misuse of this card is considered fraud.
INPATIENT ADMISSION AND OUTPATIENT PRECEDURES: 12
Legal entity name
Your provider must call the toll-free number listed below to pre-certify the above services. Refer to your plan documents for your
Coverage effective date: MM/DD/CCYY
LocalPlus pre-certification requirements. Failure to do so may affect benefits. In an emergency, seek care immediately, then call your primary
Group: 1234567 No referral required care doctor as soon as possible for further assistance and directions on follow-up care within EF hours.
Issuer (80840) PCP Visit $10 Coinsurance/deductible is paid directly to the doctor/facility by Cigna using individual’s available health funds.
ID: U23456789 01 1 Specialist $15 4
Carve out 1 Prt Line
Carve out 2 Prt Line 13
Name: John Public Hospital ER $50
Urgent Care $25
PCP: James Smith Vision Yes Send claims to:
Jane Smith Rx $10/20/30 CAD Name, PO Box XXXX, Anytown, USA 12345-6789
PCP Phone: 860.123.4567 Network coinsurance: TPV Name, PO Box XXXX, Anytown, USA 12345-6789
ABC12 & Sons Company In 90%/10%
Out 70%/30% All Other: PO Box XXXX, Anytown, USA 12345-6789
NSP
RxBIN XXXXXX RxPCN XXXXXXXX logo 9 Med/Rx deductible applies Customer Service: 1.800.XXX.XXXX 14 MH/SA: 1.800.XXX.XXXX Open Access Plus 15
DOI Network Savings Program Cat # We encourage you to use a PCP as a valuable resource and personal health advocate. AWAY FROM HOME CARE
•• PCP
PCPselection
selectionencouraged
encouraged • Coinsurance/deductible should not be collected at the time of service unless
•• Cigna Choice Fund® and medical plan type indicated
No referral required you have accessed the Cigna Cost of Care Estimator®on the Cigna for Heath Care
•• Most coinsurance
LocalPlus: information
In-network shown
and out-of-network coverage Professionals website (CignaforHCP.com) to obtain an estimate of the patient’s
•• Coinsurance/deductible is paid directly to except
the doctor/facility costs, and provide a copy of the estimate to the patient
LocalPlus IN: In-network coverage only, emergencyby careCigna using
patient’s available health funds. Explanation of Payment (EOP) will show any • Collecting at the time of service without accessing the Cigna Cost of Care Estimator
remaining amount due from patient may result in overpayment and require a refund to the patient
WWW.CIGNA.COM
2 Client
logo You may be asked to present this card when you receive care. The card does not guarantee coverage.
You must comply with all terms and conditions of the plan. Willful misuse of this card is considered fraud.
Legal entity name 5 12 INPATIENT ADMISSION:
Your network provider must call the toll-free number listed below to pre-certify the above services. Refer to your plan documents
Coverage effective date: MM/DD/CCYY 7 HMO (or POS)
for your pre-certification requirements. Failure to do so may affect benefits. In an emergency, seek care immediately, then call your
Group: 1234567 PCP visit $15
primary care doctor as soon as possible for further assistance and directions on follow-up care within ### hours.
Issuer (80840) Specialist $15
Hospital ER 4 $50 Med group: Sunset Med Group
ID: U23456789 01 1 Send claims to: 123 Main Street, Suite 999, Anytown, USA 12345-678 13
Urgent care $25
HMO or POS
Name: John Public Vision Yes For pharmacy: Call ABC Company 1.800.XXX.XXXX (Not a Cigna Company)
PCP: John Smith 8 Rx 41/$20/$40 For vision: Call ABC Company 1.800.XXX.XXXX (Not a Cigna Company) bn
PCP phone: XXX-XXX-XXXX Rx indiv deduct $50
ID card acct name 10 Cigna: PO Box XXXXX, Anytown, USA 12345-6789
Coinsurance applies 3
RxBIN Rx Bin RxPCN Rx Contr
Managed Care Plans: Primary Care Physicians
NSP
DOI logo 9
C
Network Savings Program Cat#
Member services: 1.800.XXX.XXXX
bo
MH/SA: 1.800.XXX.XXXX
• PCP selection required
• Referrals required
• HMO: In-network coverage only, except emergency care
• POS: Offered as an HMO or Network plan; in-network and out-of-network coverage
18 WWW.CIGNA.COM
TPV logo
bl
11 CSN logo
2 Client You may be asked to present this card when you receive care. The card does not guarantee coverage. You must comply with all
Cigna
Care Network
6 logo terms and conditions of the plan. Willful misuse of this card is considered fraud.
Legal entity name 5 12INPATIENT ADMISSION:
Your provider must call the toll-free number listed below to pre-certify the above services. Refer to your plan documents for your
Coverage effective date: MM/DD/CCYY
7 Network
pre-certification requirements. Failure to do so may affect benefits. In an emergency, seek care immediately, then call your primary
Group: 1234567 care doctor as soon as possible for further assistance and directions on follow-up care within ### hours.
Issuer (80840) PCP Visit $15/$20
ID: U23456789 01
Specialist 4 $15/$20 For information about mental health services and coverage, call MHSA Stmt Tel
Name: John Public 1 Hospital ER $50 Med Group: Sunset Med Group
PCP: James Smith
Urgent Care $25 Send claims to: 123 Main Street, Suite 999, Anytown, USA 12345-6789 13
Network
PCP Name Ln2 8 Vision Yes For Pharmacy, call ABC Company 1.800.XXX.XXXX (Not a Cigna Company)
Rx $10/20%/40%/100% For Vision, call ABC Company 1.800.XXX.XXXX (Not a Cigna Company)
PCP Phone: XXX.XXX.XXXX Rx Indiv Deduct $50 Cigna Claims: PO Box XXXX, Anytown, USA 12345-6789
ID card acct name 10 TPV Name, PO Box XXXX, Anytown, USA 12345-6789
RxBIN XXXXXX RxPCN XXXXXXXX logo NSP 9 Coinsurance applies 3 CSN Name, PO Box XXXX, Anytown, USA 12345-6789
DOI Network Savings Program OAP# Customer Service: 1.800.XXX.XXXX 14 bo MH/SA: 1.800.XXX.XXXX
• PCP selection required
• Referrals required
• In-network coverage only, except emergency care
65CSN logo 18 WWW.CIGNA.COM
TPV logo 11 Client You may be asked to present this card when you receive care. The card does not guarantee coverage.
Cigna
Care Network 6 logo You must comply with all terms and conditions of the plan. Willful misuse of this card is considered fraud.
Legal entity name 5 12 INPATIENT ADMISSION AND OUTPATIENT PROCEDURES:
Your network provider must call the toll-free number listed below to pre-certify the above services. Refer to your plan documents
Coverage effective date: MM/DD/CCYY 7 PPO for your pre-certification requirements. Failure to do so may affect benefits. In an emergency, seek care immediately, then call your
Group: 1234567 Dr. visit $10/$25 primary care doctor as soon as possible for further assistance and directions on follow-up care within ### hours.
PPO or EPO Plans
Issuer (80840) Specialist $10/$25
Hospital ER $50
ID: U23456789 01 1
Urgent care
4 $25 For pharmacy, call ABC Company 1.800.XXX.XXXX (Not a Cigna Company)
Name: John Public Vision Yes For vision, call ABC Company 1.800.XXX.XXXX (Not a Cigna Company)
Rx $10/20/30 Send claims to:
ID card acct name 10 Network coinsurance: CAD name, PO Box XXXX, Anytown, USA 12345-6789 13
In
RxBIN XXXXXX RxPCN XXXXXXXX Out
3 90%/10%
70%/30%
TPV name, PO Box XXXX, Anytown, USA 12345-6789
NSP All others: PO Box XXXX, Anytown, USA 12345-6789
DOI 9 Med/Rx deductible applies
logo
Cat#
Customer service: 1.800.XXX.XXXX 14MH/SA: 1.800.XXX.XXXX 15 AWAY FROM HOME CARE
Network Savings Program
• No PCP selection required
• No referrals required
• PPO: In-network and out-of-network coverage
• EPO: In-network coverage only, except emergency care
WWW.CIGNA.COM
TPV / Alliance
logo 11 CareLink Client You may be asked to present this card when you receive care. The card does not guarantee coverage.
logo logo You must comply with all terms and conditions of the plan. Willful misuse of this card is considered fraud.
Legal entity name 5
12 INPATIENT ADMISSION:
Your network provider must call the toll-free number listed below to pre-certify the above services. Refer to your plan documents
Coverage effective date: MM/DD/CCYY Open Access Plus for your pre-certification requirements. Failure to do so may affect benefits. In an emergency, seek care immediately, then call your
No referral required
Strategic Alliances
Group: 1234567 primary care doctor as soon as possible for further assistance and directions on follow-up care within 48 hours.
Issuer (80840)
7 PCP visit $15
ID: U23456789 01 1 Specialist 4 $30 Coinsurance/deductible is paid directly to the doctor/facility by Cigna using individual’s available health funds.
Name: John Public Hospital ER $50 13 For pharmacy: Call ABC Company 1.800.XXX.XXXX (Not a Cigna Company)
Urgent care $25 For vision: Call ABC Company 1.800.XXX.XXXX (Not a Cigna Company)
PCP: John Smith
Vision Yes Send claims to: CSN name, PO Box XXXXX, Anytown, USA 12345-6789
PCP name Ln2
Rx $10/$20/$40/90%
PCP phone: 860.555.1212 All other: PO Box XXXXX, Anytown, USA 12345-6789
Rx indiv deduct $50
ID card acct name 10 Network coinsurance: 3 Customer service: 1.800.XXX.XXXX 14MH/SA: 1.800.XXX.XXXX
NSP 9
RxBIN XXXXXX RxPCN XXXXXXXX logo In 90%/10%
DOI Network Savings Program Cat# We encourage you to use a PCP as a valuable resource and personal health advocate. 15 AWAY FROM HOME CARE
• PCP selection encouraged
WWW.CIGNA.COM
Client You may be asked to present this card when you receive care. The card does not guarantee coverage. You must comply with all
logo terms and conditions of the plan. Willful misuse of this card is considered fraud.
12 INPATIENT ADMISSION:
Legal entity name 5 Your provider must call the toll-free number listed below to pre-certify the above services. Refer to your plan documents for your
5
Coverage effective date: MM/DD/CCYY 7 Indemnity pre-certification requirements. Failure to do so may affect benefits. In an emergency, seek care immediately, then call your primary
Group: 1234567 Rx $10/20%/40%/100% care doctor as soon as possible for further assistance and directions on follow-up care within ### hours.
Issuer (80840) Rx indiv deduct $50
Indemnity Plans
Indiv deduct $300 Coinsurance/deductible is paid directly to the doctor/facility by Cigna using individual’s available health funds.
ID: U23456789 01 1 Family deduct $500
3
Note: You can reduce your out-of-pocket expenses if you use a Network Savings Program provider. Use of a Network Savings
Name: John Public 1 Hospital deduct $200 Program provider does not affect your benefit coverage. For help finding a participating provider, please visit our website, or call
ER deduct $50 the toll-free number listed on this card.
Coinsurance:
ID card acct name 10 Medical 80%/20% 13 For Pharmacy, call ABC Company 1.800.XXX.XXXX (Not a Cigna Company)
For Vision, call ABC Company 1.800.XXX.XXXX (Not a Cigna Company)
bk
RxBIN XXXXXX RxPCN XXXXXXXX NSP Med/Rx deductible applies Send Claims to: PO Box XXXX, Anytown, USA 12345-6789
logo 9
DOI
Network Savings Program Cat# Customer Service: 1.800.XXX.XXXX 14MH/SA: 1.800.XXX.XXXX
• No PCP selection required
• No referrals required
• Patient files claims
67MORE WAYS TO ACCESS PATIENT INFORMATION WHEN YOU NEED IT USE OUR ELECTRONIC TOOLS • Log in to the Cigna for Health Care Professionals website (CignaforHCP.com) • Connect to us through electronic data interchange (EDI): visit Cigna.com/EDIVendors to learn more • Call our automated phone system 1.800.88Cigna (882.4462) CONDUCT ADMINISTRATIVE TRANSACTIONS ELECTRONICALLY Cigna’s convenient eServices tools help you manage the administrative details of health care. • Access patient eligibility and benefits • Estimate patient out-of-pocket costs • View and submit precertification requests • Check claim status • Enroll online for electronic funds transfer (EFT), then view, print, and share online remittance reports the same day you receive electronic payments • Receive electronic remittance advice and automatically load it to your accounts receivable system • Submit questions about fee schedules and specific patient benefits LEARN MORE To access our educational resources, log in to CignaforHCP.com > Resources > eCourses for courses about EDI, eligibility & benefits, estimating patient out of pocket costs, precertification, electronic claim submission, claim status inquiry, enrolling in and managing EFT, online remittance reports, and more. Cigna,” the “Tree of Life” logo and “GO YOU” are registered service marks of Cigna Intellectual Property, Inc., licensed for use by Cigna Corporation and its operating subsidiaries. All products and services are provided by or through such operating subsidiaries and not by Cigna Corporation. Such operating subsidiaries include Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, and HMO or service company subsidiaries of Cigna Health Corporation. 591795 r 2014-256 06/14 © 2014 Cigna. Some content provided under license.
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