Fillable Member Claim Form Not to be used for (Cigna Medicare Providers)

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Member Claim Form Not to be used for (Cigna Medicare Providers)

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Member Claim Form
803392e Rev. 01/2017
FAMILY/OTHER COVERAGE INFORMATION:
Complete only if claim is for a dependent and/or other coverage is in effect
NOTE:
X
NAME OF HEALTH INSURANCE COMPANY EFFECTIVE DATE OF COVERAGE
EMPLOYEE INFORMATION: Employee complete this section
If yes, provide:
X
POLICY NUMBER TYPE OF PLAN (HMO OR PPO) IF KNOWN
C. DESCRIPTION OF HOW ACCIDENT OR WORK RELATED ILLNESS/INJURY OCCURRED
PATIENT INFORMATION: Complete only if patient is other than employee
ACCIDENT/OCCUPATIONAL CLAIM INFORMATION:
Complete only if claim is a result of an accident or occupational (work related) illness/injury
YES NO
NOYES
NOYES
NO
YES
NO If yes, Name of Third Party:
F. EMPLOYER NAME
TELEPHONE #
A1. EMPLOYEE’S NAME (Last Name)
E. ACCOUNT NO.
(on the front of your Cigna ID card)
YES
OtherChild
NO
D. CIGNA ID NUMBER OR EMPLOYEE SOCIAL SECURITY NUMBER
(on the front of your Cigna ID card)
YES
A. PATIENT’S NAME (Last Name)
E. PATIENT’S ADDRESS - IF DIFFERENT THAN EMPLOYEE ADDRESS
(No., Street)
SPOUSE’S DATE OF BIRTH
IF NO, HAS SPOUSE BEEN EMPLOYED
DURING LAST 12 MONTHS?
B. INJURY DUE TO
AUTO ACCIDENT?
IS THIS A CHANGE OF ADDRESS?
(Note: address must also be changed with Employer)
A. ACCIDENT OR ILLNESS
DUE TO EMPLOYMENT?
B. RELATIONSHIP TO EMPLOYEE
STUDENT FULL-TIME
*
EFFECTIVE DATE
G. EMPLOYEE STATUS
Please be aware that if the provider of service holds a contract with Cigna, and its affiliates, payment will always be made to the
provider at the contracted rate even if this section is not signed. If the provider is contracted with Cigna, the provider will be paid
by Cigna at the contracted rate. If you have already paid for services, you should seek reimbursement directly from the provider.
D2. IS THE PATIENT COVERED UNDER MEDICARE?
(City)
B. NAME OF SPOUSE (Last Name)
E. ARE YOU OR YOUR DEPENDENTS FILING A CLAIM OR LAWSUIT AGAINST A THIRD PARTY INCLUDING AN INSURANCE COMPANY
EMPLOYEE’S SIGNATURE
N/A
B. DATE OF BIRTH
EMPLOYED FULL-TIME
F. AT THE TIME SERVICE WAS PROVIDED WAS THE PATIENT:
C. DATE OF BIRTH
IF YES TO D1. OR D2. AND THE OTHER INSURANCE IS PRIMARY, ENCLOSE A COPY OF THE EXPLANATION OF BENEFITS (EOB) WITH THIS FORM AND THE ITEMIZED BILL(S).
M
F
Insured and/or Administered by
Cigna Behavioral Health, Inc.
A2. GENDER
A. SPOUSE EMPLOYED?
D. GENDER
D. DATE OF ACCIDENT OR BEGINNING OF ILLNESS
IN ORDER TO RECOVER THE COST OF EXPENSES INCURRED AS A RESULT OF THIS ACCIDENT OR ILLNESS?
NOYES
Spouse
DATE EMPLOYEE’S SIGNATURE
PAYMENT INSTRUCTIONS
The information provided on this form may be disclosed to other persons or entities, including my Plan Sponsor, for the purpose of
processing this claim and performing health plan administration.
I certify that the information supplied is true and correct.
NOYES
YYYYMM DD
( )
C. NAME OF SPOUSE’S EMPLOYER
C. EMPLOYEE’S MAILING ADDRESS (No., Street)
(City)
(State) (Zip Code) ADDRESS OF SPOUSE’S EMPLOYER (No., Street)
DAYTIME TELEPHONE #
YYYYMM DD
YYYYMM DD
YYYY
(City)
(Zip Code)
MM DD
YYYYMM DD
( )
(State) (Zip Code)
YYYYMM DD
D1. IS THE PATIENT COVERED UNDER ANOTHER EMPLOYER GROUP HEALTH INSURANCE PLAN?
YYYY
MM DD
DATE
YYYYMM DD
Not to be used for Medical, Pharmacy or Dental claims
I authorize payment to be made directly to the healthcare provider(s) indicated on the enclosed bill(s)
CERTIFICATION
Please refer to instructions attached.
This form can be used for all behavioral plans.
This form only needs to be completed if the provider is not submitting the claim on your behalf.
Out-of-network claims can be submitted by the provider if the provider is able and willing to file on your behalf.
Any person who knowingly and with intent to defraud any insurance company or other person: (1) files an application for insurance or statement
of claim containing any materially false information; or (2) conceals for the purpose of misleading, information concerning any material fact
thereto, commits a fraudulent insurance act which is a crime. For residents in the following states, please see the last page of this form: Alaska,
Arizona, California, Colorado, District of Columbia, Florida, Kentucky, Maryland, Minnesota, New Jersey, New Mexico, New York, Oregon,
Pennsylvania, Rhode Island, Tennessee, Texas and Virginia.
M F
(First Name) (M.I.)
(First Name) (M.I.)
(First Name) (M.I.)
"Cigna" and the "Tree of Life" logo 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 such operating subsidiaries, including Cigna Health Management, Inc. and Cigna Behavioral Health, Inc., and not by Cigna Corporation.
(State)
EMPLOYED
COBRA*
RETIRED*
DISABLED*
Clear Fields
If you are enrolled in an HMO or POS plan, as indicated on your card, please mail in-network and out-of-network Mental
Health or Substance Abuse claims to:
If you are enrolled in Open Access Plus, send completed claim form and itemized bill(s) to the Cigna address listed on
your identification card.
If you are completing this form by hand, use a new printed form rather than a photocopy to ensure the form can
be scanned into our system. Also, be sure to print clearly and use blue or black ink when you complete the form.
2.
To consider your claim for payment, Cigna must receive it within 180 days of the date you received the service,
unless your plan or state law allows more time.
3.
Use a separate claim form for each provider and each member of the family. A new form can be obtained from
www.cignabehavioral.com. The form is found under: Are you a Member?, Visit Our Education & Resource
Center, Forms, Out-of-Network Claim Form.
4.
Your claim cannot be processed without your ID Number (Employee Section, Block D). Please reference the front
of your Cigna ID card to find this number. Your ID may be the employee’s Social Security Number.
5.
Cigna reserves the right to request additional documentation, such as medical records prior to processing your claim.
6.
10.
If the patient has coverage through another health insurance carrier which is considered primary (Cigna as
secondary), you must submit the Explanation of Benefits (EOB) from the primary insurance carrier for this service
along with this completed form and itemized bill.
You must submit an itemized bill for your claim to be processed. Receipts, balance due statements and cancelled
checks are not acceptable replacements for the itemized bill.
7.
If you have additional questions, please contact Customer Service using the toll-free number on your ID card.
EXPLANATION OF BENEFITS
MAILING INSTRUCTIONS FOR CIGNA BEHAVIORAL HEALTH CLAIMS
Provider Name/Credentials
Provider Address
Provider Tax ID Number
Date of Service (mm/dd/yyyy)
Diagnosis Code (ICD-10 format)
Charge for Service
ITEMIZED BILLS MUST INCLUDE:
INSTRUCTIONS FOR FILING A CLAIM
803392e Rev. 01/2017
8.
We suggest you make a copy of your bill(s) and your completed claim form for your records.
9.
1.
Employee Name
Patient Name
Type of Service/Procedure Code
You will receive an Explanation of Benefits (EOB) after your claim is processed explaining the charges applied to
your deductible and any charges you owe to the provider, if applicable. Please keep your EOBs for later reference.
If you are submitting one claim, please do not paper clip or staple your claim form and bill(s). If you are submitting multiple
claims in one envelope, please paper clip the appropriate claim form and itemized bill(s) together.
IMPORTANT
This form can be used for all behavioral plans. This form only needs to be completed if the provider is not
submitting the claim on your behalf. Out-of-network claims can be submitted by the provider if the provider is able
and willing to file on your behalf.
Cigna Behavioral Health, Inc.
Attn: Claims Service Dept.
P.O. Box 188022
Chattanooga, TN 37422
803392e Rev. 01/2017
New York Residents: Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact
material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed $5000 and the stated value
of the claim for each such violation.
Kentucky Residents: Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim
containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a
fraudulent insurance act, which is a crime.
Florida Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an application
containing any false, incomplete or misleading information is guilty of a felony of the third degree.
Virginia Residents: Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application
or files a claim containing a false or deceptive statement may have violated state law.
New Jersey Residents: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal
and civil penalties.
Tennessee Residents: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of
defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
Minnesota Residents: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.
District of Columbia Residents: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding
the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information
materially related to a claim was provided by the applicant.
Colorado Residents: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the
purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any
insurance company or agent of an insurance company who knowingly provides false, incomplete or misleading facts or information to a policyholder or
claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance
proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
Pennsylvania Residents: Any person who, knowingly and with intent to defraud any insurance company or other person, files an application for
insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact
material thereto, commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
Oregon Residents: Any person who knowingly and with intent to defraud any insurance company or other person: (1) files an application for
insurance or statement of claim containing any materially false information; or, (2) conceals for the purpose of misleading, information concerning any
material fact, may have committed a fraudulent insurance act.
Maryland Residents: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who
knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
Texas Residents: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to
fines and confinement in state prison.
Alaska Residents: A person who knowingly and with intent to injure, defraud or deceive an insurance company or files a claim containing false,
incomplete or misleading information may be prosecuted under state law.
IMPORTANT CLAIM NOTICE
Caution: Any person who, knowingly and with intent to defraud any insurance company or other person: (1) files an application for insurance or
statement of claim containing any materially false information; or (2) conceals for the purpose of misleading, information concerning any material fact
thereto, commits a fraudulent insurance act.
Arizona Residents: For your protection, Arizona law requires the following statement to appear on/with this form. Any person who knowingly
presents a false or fraudulent claim for payment of loss is subject to criminal and civil penalties.
California Residents: For your protection, California law requires the following to appear on/with this form. Any person who knowingly presents
a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
Rhode Island Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents
false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
New Mexico Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents
false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.
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Member Claim Form Not to be used for (Cigna Medicare Providers)

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Completed 4 November 2020

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