What is a health insurance claim?
A claim is a request to be paid, similar to a bill. If you recently went to the doctor and received care, you or your doctor will submit or “file” a claim. In most cases, if you received in-network care, your provider will file a claim for you. When Cigna HealthcareSM receives a claim, it’s checked against your plan to make sure the services are covered. Once approved, we pay the health care provider or reimburse you, depending on who submitted the claim. Any remaining charges that weren’t covered by your plan are billed directly to you by your provider.
What is our claims process?
When we receive a claim, we check it against your plan to make sure the services are covered. In some cases, you need to have a procedure, medication, or location pre-approved by Cigna Healthcare before you receive care, otherwise the claim may be denied. This is known as prior authorization.
If you purchased coverage on your own through a state or federal marketplace, the plan may require that you see providers in the plan’s network; the claim may be denied for out-of-network services.
When a claim is approved, we either pay the health care provider directly or you do, depending on who submitted the claim. In most cases for in-network care, providers will submit claims for you and you’ll receive an explanation of benefits, or EOB.
Your EOB is not a bill but an explanation of how your claim was paid.The provider will bill you directly for any amounts you owe to them under your plan.
