k 05/12 Offered by: Connecticut General Life Insurance Company or Cigna Health and Life Insurance Company.

Transcription

1 202 QUICK guide to Cigna ID cards 99 k 0/2 Offered by: Connecticut General Life Insurance Company or Cigna Health and Life Insurance Company.

2 We pack a lot of important information into our ID cards. This brochure will help define and clarify information that appears on Cigna s most common customer ID cards. It will 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 for Health Care Professionals > Doing Business with Cigna. You may have noticed Cigna has a new look our, our colors, even the way we write our name on our materials. In this brochure, you ll see that some of our health plans have new ID cards with the Cigna name as a watermark. Other cards have the old Cigna. Over the next several months, we will transition all cards over to our new brand. Regardless of the s that appear on the cards, please continue to use the ID card for important information aut call, claim, and service channels.

3 Key Refer to this key for explanations of the information found on the sample Cigna ID cards featured in this brochure. 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. For patients with coinsurance, suit claims to Cigna or its designee, and receive an Explanation of Payment (EOP), which will show any remaining amount due from patient. Collect any copayment at the time of service. 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 indicate the patient s liability varies based on the health care professional s Cigna Care Network designation. Refer to the online provider directory to determine Cigna Care Network designation. Effective date of coverage. 8 Name of patient s primary care physician (PCP). 9 () indicates that out-of-network discounts may apply based upon the primary customer s home state. name. If a third party administers services on behalf of Cigna, the ID card may include multiple s and may show a different claim address or telephone number on the back of the card. Precertification requirements may be shown as either Inpatient Admission or Inpatient Admission and Outpatient Procedures. Suit claims to the claim suission address shown on the card. 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. Away From Home Care indicates the patient has access to the Cigna national network. bq Indicates Shared Administration. br Union identifier. bs -specific network (CSN).

4 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. XYZ Company IIN Control Issuer 8080 Group Plan 0062 Member Five ID COPAY: Primary Care $0 Specialist $0 Urgent Care $6 Preventive Care $20 PCP: None Selected No Referral Required For plan & benefit details, please visit mycignaforhealth.com Plan Contractor: Connecticut General Life Insurance Company GWH-CIGNA Open Access Plus Suit All Claims To 000 Great-West Drive Kennett, MO 68-9 Payer ID #800 Members and Providers Call XYZ Company RXBIN RXPCN Issuer 8080 Group Plan 2689 John Puic ID COPAY: Primary Care $0 Specialist $0 Urgent Care $6 ER $200 PCP: None Selected No Referral Required 8 For plan & benefit details, please visit mycignaforhealth.com GWH-Cigna GWH-CIGNA Plan Type Open Plan Access Type Plus Suit All Claims To 000 Great-West Drive Kennett, MO 68-9 Payer ID #800 Members and Providers Call Members: Carry this card at all times. Pretreatment authorization must be obtained for hospital admissions, outpatient surgeries performed outside a physician s office and for the other services specified in the benefit plan. Member is responsie for obtaining authorization for non-network 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 possie for further assistance. We encourage you to use a primary care physician as a valuae resource and personal health advocate. CIGNA has multiple networks. Your plan is paired with the GWH-CIGNA network. To find a GWH-CIGNA provider, please visit your member website at mycignaforhealth.com. Providers: Pretreatment authorization must be received for all services listed ave and as specified in the member s benefit plan by calling the number on the front of this card or online at gwhcignaforhcp.com. Emergency hospital admissions must be reported within 8 hours. Notice: Possession of this card does not guarantee coverage or payment for the service or procedure reviewed. Please call the Member and Providers number on the front of this card for eligibility information. For providers not in your primary network, visit multiplan.com For Pharmacists Only -800-XXX-XXXX R8 (/0) Mask 0 Issue Date: 0/0/2 GWH-Cigna Plans GWH-Cigna ID cards represent all products CIGNA Health and Life Insurance Company Group ID Name John Puic PCP None Selected No Referral Required Sample Company RxBIN RxGrp RxPCN RxID Copays Primary Care $2 Specialist $2 Urgent Care $2 ER $00 GWH-Cigna Plan GWH-CIGNA Type You may be asked to present this card when you receive care. This card does not guarantee coverage. You must meet all the plan s terms and conditions for services to be covered. It is considered fraud if you KNOWINGLY PURPOSELY misuse this card. INPATIENT ADMISSION AND OUTPATIENT PROCEDURES: Your health care professional must contact CIGNA to pre-approve these services. They can call the toll-free number listed below or go to GWHCIGNAforHCP.com for pre-approval. See your plan documents for pre-approval requirements. If these services are not pre-approved, your plan may not pay for them. In an emergency, get care immediately, then call your PCP as soon as possie for further assistance and advice on follow-up care within 8 hours. 9 Send Claims to 000 Great-West Drive Kennett, MO 68-9 Payer ID #800 Customers & Health Care Professionals call Rx Claims Pharmacy Service Center, PO Box 98, Scranton, PA For Pharmacists Only For providers not in your primary network, visit multiplan.com. RCA Mask 60 Issue Date: 0/0/2 GWH-Cigna ID cards represent all products

5 Shared Administration (SAR) Cigna Choice Fund Plans Shared Administration PPO Shared Administration OAP CSN Cigna Care Network bs 6 Legal Entity Name Coverage Effective Date: MM/DD/CCYY Choice Fund Open Access Plus Group: 26 No Referral Required PCP Visit 20% Specialist 20% ID: U Hospital ER 20% PCP: John Smith Rx 0%/0%/0% 8 PCP Name Ln2 In 90%/0% PCP Phone: XXX.XXX.XXXX Out 0%/0% ID Card Acct Name Med/Rx Deductie Applies RxBIN RxPCN Cigna Choice Fund and medical plan type indicated Most coinsurance information shown Coinsurance/deductie is paid directly to the doctor/facility by Cigna using patient s availae health funds. Explanation of Payment (EOP) will show any remaining amount due from patient Group: 26 ID: U Sbq This plan is self-funded by: ID card account name Fund #: SAR F RxBIN Rx Bin RxPCNRX contr Label Group: 26 ID: U S bq PCP: James Smith PCP name Ln2 PCP phone: Fund Name Fund #: Fund number RxBIN RxPCN Provider network: Cigna HealthCare PPO Doctor visit $0 Specialist $20 Coinsurance In-network 90% / 0% Out-of-network 0% / 0% Rx 0% / 0% / 0% Deductie applies Open Access Plus No referral required PCP visit $ Specialist $20 Rx 0% / 0% / 0% Network coinsurance: In 90% / 0% Out 0% / 0% Deductie applies Your provider must call the toll-free number listed below to pre-certify the ave services. Refer to your plan documents for your pre-certification requirements. Failure to do so may affect benefits. In an emergency, seek care immediately, then call your primary care doctor as soon as possie for further assistance and directions on follow-up care within ### hours. Coinsurance/deductie is paid directly to the doctor/facility by Cigna using individual s availae health funds. For Pharmacy, call ABC Company.800.XXX.XXXX (Not a Cigna Company) For, call ABC Company.800.XXX.XXXX (Not a Cigna Company) Send claims to: CAD Name, PO Box XXXX, Anytown, USA TPV Name, PO Box XXXX, Anytown, USA All Others: PO Box XXXX, Anytown, USA Customer Service:.800.XXX.XXXX MH/SA:.800.XXX.XXXX We encourage you to use a PCP as a valuae resource and personal health advocate. Coinsurance/deductie should not be collected at the time of service unless you have accessed the Cigna Cost of Care Estimator on the Cigna for Heath Care Professionals website (CignaforHCP.com) to obtain an estimate of the patient s costs, and provide a copy of the estimate to the patient Collecting at the time of service without accessing the Cigna Cost of Care Estimator may result in overpayment and require a refund to the patient Your provider must call the toll-free number listed below to pre-certify your medical services or benefits may be affected. Refer to your plan documents for your plan s precertification requirements. In an emergency, seek care immediately, then notify Cigna within 8 hours. Mail all non-medical claims and correspondence to: ID card name back SAR fund name Suit/mail claims to: Cigna Payor 6208, PO Box 8800, Chattanooga, TN All other: TPV N&A print line Pre-certification: Member Srvc Nu Pharmacy Questions: Eligibility, Benefit and Claim questions please call: SAR TPA phone To access the online provider directory go to To access member pharmacy tools go to Benefits are not insured by Cigna HealthCare Your network provider must call the toll-free number listed below to pre-certify the ave services. Refer to your plan documents for your pre-certification requirements. Failure to do so may affect benefits. In an emergency, seek care immediately, then call your primary care doctor as soon as possie for further assistance and directions on follow-up care within ### hours. Mail all non-medical claims and correspondence to: Fund name Fund address Send claims to: Claims address All others: PO Box XXXX, Anytown, USA Pre-certification: Member Srvc Nu Pharmacy Questions: Pharm Num Eligibility, Benefit and Claim Questions: Please call Payor Num To access the online provider directory go to To access member pharmacy tools go to We encourage you to use a PCP as a valuae resource and personal health advocate. br br 2

6 Network Open Access CSN Cigna Care Network Connecticut General Life Insurance Co. Coverage Effective Date: MM/DD/CCYY Group: 26 ID: U PCP: James Smith PCP Name Ln2 PCP Phone: XXX.XXX.XXXX In-network coverage only, except emergency care 8 bs 6 2 Network Open Access No referral required PCP Visit $ Specialist $ Hospital ER $0 Urgent Care $2 Rx $0/20%/0%/00% Rx Indiv Deduct $0 ID Card Acct Name RxBIN RxPCN Coinsurance Applies 9 SAR Cigna.com You must comply with all terms and conditions of the plan. Willful misuse of this card is Your provider must call the toll-free number listed below to pre-certify the ave services. Refer to your plan documents for your pre-certification requirements. Failure to do so may affect benefits. In an emergency, seek care immediately, then call your primary care doctor as soon as possie for further assistance and directions on follow-up care within ### hours. For information aut mental health services and coverage, call MHSA Stmt Tel Med Group: Sunset Med Group Send claims to: 2 Main Street, Suite 999, Anytown, USA For Pharmacy, call ABC Company.800.XXX.XXXX (Not a Cigna Company) For, call ABC Company.800.XXX.XXXX (Not a Cigna Company) Cigna Claims: PO Box XXXX, Anytown, USA TPV Name, PO Box XXXX, Anytown, USA CSN Name, PO Box XXXX, Anytown, USA Customer Service:.800.XXX.XXXX MH/SA:.800.XXX.XXXX Managed Care Plans: Open Access Plans Open Access Plus CSN Cigna Care Network bs 6 Group: 26 ID: U PCP: James Smith PCP Name Ln2 PCP phone: XXX.XXX.XXXX ID card acct name RxBIN RxPCN Open Access Plus No referral required PCP visit $ Specialist $0/$2 Hospital ER $0 Urgent care $2 Rx $0/20/0 In 90%/0% Out 0%/0% Med/Rx Deductie Applies Open Access Plus: In-network and out-of-network coverage Open Access Plus In-network: In-network coverage only, except emergency care INPATIENT ADMISSION AND OUTPATIENT PROCEDURES: Your network provider must call the toll-free number listed below to pre-certify the ave services. Refer to your plan documents for your pre-certification requirements. Failure to do so may affect benefits. In an emergency, seek care immediately, then call your primary care doctor as soon as possie for further assistance and directions on follow-up care within ### hours. For pharmacy, call ABC Company.800.XXX.XXXX (Not a Cigna Company) For vision, call ABC Company.800.XXX.XXXX (Not a Cigna Company) Send claims to: CAD name, PO Box XXXX, Anytown, USA TPV name, PO Box XXXX, Anytown, USA All others: PO Box XXXX, Anytown, USA Customer service:.800.xxx.xxxx MH/SA:.800.XXX.XXXX We encourage you to use a PCP as a valuae resource and personal health advocate. HMO or POS Open Access Cigna Health Care of XXXXX, Inc. Group: 26 ID: U PCP: John Smith 8 PCP phone: XXX-XXX-XXXX ID card acct name RxBIN Rx Bin RxPCN Rx Contr 9 HMO (or POS) Open Access No referral required PCP visit $ Specialist $ Hospital ER $0 Urgent care $2 Rx /$20/$0 Rx indiv deduct $0 Coinsurance applies 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 2 Your network provider must call the toll-free number listed below to pre-certify the ave services. Refer to your plan documents for your pre-certification requirements. Failure to do so may affect benefits. In an emergency, seek care immediately, then call your primary care doctor as soon as possie for further assistance and directions on follow-up care within ### hours. Med group: Sunset Med Group Send claims to: 2 Main Street, Suite 999, Anytown, USA 2-68 For pharmacy: Call ABC Company.800.XXX.XXXX (Not a Cigna Company) For vision: Call ABC Company.800.XXX.XXXX (Not a Cigna Company) Cigna: PO Box XXXXX, Anytown, USA Member services:.800.xxx.xxxx MH/SA:.800.XXX.XXXX C

7 Managed Care Plans: Primary Care Physicians HMO or POS Network Cigna Health Care of XXXXX, Inc. Group: 26 ID: U PCP: John Smith 8 PCP phone: XXX-XXX-XXXX ID card acct name RxBIN Rx Bin RxPCN Rx Contr 9 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 CSN Cigna Care Network bs 6 2 HMO (or POS) PCP visit $ Specialist $ Hospital ER $0 Urgent care $2 Rx /$20/$0 Rx indiv deduct $0 Coinsurance applies Connecticut General Life Insurance Co. Coverage Effective Date: MM/DD/CCYY Group: 26 Network Open Access PCP Visit $ Specialist $ Hospital ER $0 ID: U Urgent Care $2 PCP: James Smith 8 Rx $0/20%/0%/00% PCP Name Ln2 Rx Indiv Deduct $0 PCP Phone: XXX.XXX.XXXX ID Card Acct Name Coinsurance Applies RxBIN RxPCN SAR You must comply with all terms and conditions of the plan. Willful misuse of this card is Your provider must call the toll-free number listed below to pre-certify the ave services. Refer to your plan documents for your pre-certification requirements. Failure to do so may affect benefits. In an emergency, seek care immediately, then call your primary care doctor as soon as possie for further assistance and directions on follow-up care within ### hours. For information aut mental health services and coverage, call MHSA Stmt Tel Med Group: Sunset Med Group Send claims to: 2 Main Street, Suite 999, Anytown, USA For Pharmacy, call ABC Company.800.XXX.XXXX (Not a Cigna Company) For, call ABC Company.800.XXX.XXXX (Not a Cigna Company) Cigna Claims: PO Box XXXX, Anytown, USA TPV Name, PO Box XXXX, Anytown, USA CSN Name, PO Box XXXX, Anytown, USA Customer Service:.800.XXX.XXXX MH/SA:.800.XXX.XXXX Cigna.com You must comply with all terms and conditions of the plan. Willful misuse of this card is Your provider must call the toll-free number listed below to pre-certify the ave services. Refer to your plan documents for your pre-certification requirements. Failure to do so may affect benefits. In an emergency, seek care immediately, then call your primary care doctor as soon as possie for further assistance and directions on follow-up care within ### hours. For information aut mental health services and coverage, call MHSA Stmt Tel Med Group: Sunset Med Group Send claims to: 2 Main Street, Suite 999, Anytown, USA For Pharmacy, call ABC Company.800.XXX.XXXX (Not a Cigna Company) For, call ABC Company.800.XXX.XXXX (Not a Cigna Company) Cigna Claims: PO Box XXXX, Anytown, USA TPV Name, PO Box XXXX, Anytown, USA CSN Name, PO Box XXXX, Anytown, USA Customer Service:.800.XXX.XXXX MH/SA:.800.XXX.XXXX Cigna.com PCP selection required Referrals required In-network coverage only, except emergency care Cigna International 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 on back of card indicates out-of-network discounts may apply 9

8 20 Starbridge - CIGNA HealthCare PPO Fundamental Care A V I A N T N E T W O R K Doctor Visit $2 Coverage Effective Date: 00/00/ Primary Network: Beech Street Specialist $2 Connecticut General Life Insurance Company A V I A N ID: T Use N E Primary T W O Insured s R K Social Security Number In Primary Network: Name: Beech Name Street Out Doctor 80%/20% Connecticut General Life Insurance Visit $2 Coverage Company Effective Date: 00/00/0000 Group Name: Specialist $2 Group Number: ID: Use Primary Insured s Social Security Number Doctor Visit $2 Coverage Effective Date: 00/00/0000 In 80%/20% Specialist $2 Out 80%/20% ID: Use Primary Insured s Social Security Number Group Name: In 80%/20% Name: John For Puic Benefits, Group Claim Number: Status, Eligibility or Customer Out Service, Call -8XX-XXX-XXXX 80%/20% PPO Plans Starbridge Beech Street Group Name: Group Number: TPV / Alliance Primary Network: CIGNA HealthCare PPO Primary Network: CIGNA HealthCare PPO Secondary Network: Secondary Beech Street Network: Beech Street Connecticut General Connecticut Life Insurance General Company Life Insurance Company Coverage Effective Coverage Date: 00/00/0000 Effective Date: 00/00/0000 ID: AMI ID: AMI Name: Name Account Number: Account 2668 Number: 26 Group Name: Group Name: Group Number: Group Number: No PCP selection required In-network and out-of-network coverage TPV / Alliance A V I A N T N E T W O R K Primary Network: Beech Street Connecticut General Life Insurance Company For Benefits, Claim Status, Eligibility or Customer Service, Call For Benefits, Claim Status, Eligibility or Customer Service, Call A V I A N T N E T W O A R K V I A N T N E T W O R K Doctor Visit Doctor $2 Visit $2 Specialist Specialist $2 $2 In In 80%/20% 80%/20% Out Out 80%/20% 80%/20% 20 Starbridge - Beech Street 20 Starbridge - Beech Street -8XX-XXX-XXXX -8XX-XXX-XXXX No PCP selection required 20 FundamentalCare - CIGNA HealthCare PPO In-network and out-of-network coverage 20 Starbridge - Beech Street You may be asked to present this card when you receive care. The card does not guarantee You may be asked to present this card when you receive care. The card does not guarantee This plan does not require pre-certification of coverage for inpatient or outpatient services. Claims will This plan does not require pre-certification of coverage for inpatient or outpatient services. Claims will be paid according to terms and conditions of the plan. In the case of an emergency, seek care be paid according to terms and conditions of the plan. In the case of an emergency, seek care immediately, then call your family physician for further assistance and direction regarding follow up care. immediately, then call your family physician for further assistance and direction regarding follow up care. Send Claims to: TPV / Send Alliance Claims Mailing to: Address TPV / Alliance Mailing Address All others to: CIGNA HealthCare, All others to: P.O. CIGNA Box 8800, HealthCare, Chattanooga, P.O. Box 8800, TN 22 Chattanooga, Payor 6208 TN 22 Payor 6208 Customer Service: Customer.800.XXX.XXXX Service:.800.XXX.XXXX CIGNA 2-hour CIGNA Nurseline: 2-hour.866.XXX.XXXX Nurseline:.866.XXX.XXXX Provider: Participant Provider: is enrolled in Participant a limited-benefit is enrolled plan. in For a limited-benefit hospital services, plan. collect For hospital patient services, collect patient responsibility when service responsibility is rendered when or make service financial is rendered arrangements or make with financial the patient arrangements in with the patient in accordance with your policies. accordance with your policies. You may be asked to present this card when you receive care. The card does not guarantee This plan does not require pre-certification of coverage for inpatient or outpatient services. Claims will be paid according to terms You and conditions may be asked of the to plan. present In the this case card of when an emergency, you receive seek care. The card does not guarantee immediately, then call your family coverage. physician You for must further comply assistance with all and terms direction and conditions regarding follow of the up plan. care. Willful misuse of this card is You Send may Claims be asked to: to present This this plan card does when not you require receive pre-certification care. The card of does coverage not guarantee for inpatient or outpatient services. Claims will coverage. Connecticut You General must comply Life Insurance be with paid all Company, according terms and PO to conditions Box terms 20, and Phoenix, of conditions the plan. AZ of Willful the plan. misuse Payor In the of this case 922 card of an isemergency, seek care immediately, then call your family physician for further assistance and direction regarding follow up care. This Customer plan does not require Service: pre-certification.800.xxx.xxxx of coverage for inpatient or outpatient services. Claims will be paid according to terms and Send conditions Claims to: of the plan. In the case of an emergency, seek care CIGNA 2-hour Nurseline:.866.XXX.XXXX immediately, then call your family Connecticut physician General for further Life Insurance assistance Company, and direction PO Box regarding 20, Phoenix, follow AZ up care. Payor 922 Send Claims to: Provider: Participant is enrolled Customer in a limited-benefit Service: plan. For.800.XXX.XXXX hospital services, collect patient responsibility when service is rendered or make financial arrangements with the patient in accordance with your policies. CIGNA 2-hour Nurseline:.866.XXX.XXXX Customer Service:.800.XXX.XXXX CIGNA 2-hour Nurseline:.866.XXX.XXXX Connecticut General Life Insurance Company, PO Box 20, Phoenix, AZ Payor 922 Provider: Participant is enrolled in a limited-benefit plan. For hospital services, collect patient responsibility when service is rendered or make financial arrangements with the patient in accordance with your policies. Provider: Participant is enrolled in a limited-benefit plan. For hospital services, collect patient responsibility when service is rendered or make financial arrangements with the patient in accordance with your policies TPV / Alliance Primary Network: CIGNA HealthCare PPO Secondary Network: Beech Street Connecticut General Life Insurance Company Coverage Effective Date: 00/00/0000 TPV / Alliance ID: TPV / Alliance AMI Name: Name Primary Network: CIGNA HealthCare PPO Primary Network: CIGNA HealthCare PPO Secondary Network: Beech Street Secondary Account Network: Number: Beech 2668 Street Connecticut General Life Insurance Company Connecticut General Life Insurance Company Starbridge Cigna PPO Group Name: Coverage Effective Date: 00/00/0000 Coverage Effective Date: 00/00/0000 Group Number: ID: AMI ID: AMI Name: Name A V I A N T N E T W O R K Account Number: Account 2668 Number: 268 Group Name: Group Name: Group Number: Group Number: A V I A N T N E T W O R K A V I A N T N E T W O R K No PCP selection required In-network and out-of-network coverage Doctor Visit $2 Specialist $2 In 80%/20% Out 80%/20% Doctor Visit Doctor Visit $2 $2 Specialist Specialist $2 $2 In In 80%/20% 80%/20% Out Out 80%/20% 80%/20% You may be asked to present this card when you receive care. The card does not guarantee This plan does not require pre-certification of coverage for inpatient or outpatient services. Claims will be paid according to terms and conditions of the plan. In the case of an emergency, seek care immediately, then call your family physician for further assistance and direction regarding follow up care. 20 Starbridge 20 Starbridge - CIGNA - CIGNA HealthCare HealthCare PPO PPO 20 Starbridge 20 Starbridge - Beech - Street Beech Street Send Claims to: TPV / Alliance Mailing Address All others to: CIGNA You HealthCare, may be asked P.O. to Box present 8800, this card Chattanooga, when you TN receive 22 care. Payor The card 6208 does not guarantee You may be asked to present this card when you receive care. The card does not guarantee Customer considered Service: fraud..800.xxx.xxxx This plan does not require pre-certification of coverage for inpatient or outpatient services. Claims will This CIGNA plan does 2-hour not require pre-certification be paid according Nurseline: of coverage to terms and.866.xxx.xxxx for inpatient or outpatient services. Claims will conditions of the plan. In the case of an emergency, seek care be paid according to terms and conditions of the plan. In the case of an emergency, seek care immediately, then call your family physician for further assistance and direction regarding follow up care. immediately, then call your family physician for further assistance and direction regarding follow up care. Provider: Participant Send is Claims enrolled to: in TPV a limited-benefit / Alliance Mailing plan. Address Send Claims to: TPV / Alliance Mailing Address For hospital services, collect patient responsibility when All service others to: is rendered CIGNA HealthCare, or make financial P.O. Box 8800, arrangements Chattanooga, with the TN patient 22 in Payor 6208 All accordance others to: CIGNA with your HealthCare, policies. P.O. Box 8800, Chattanooga, TN 22 Payor 6208 Customer Service: Customer.800.XXX.XXXX Service:.800.XXX.XXXX CIGNA 2-hour CIGNA Nurseline: 2-hour Nurseline:.866.XXX.XXXX.866.XXX.XXXX Provider: Participant Provider: is enrolled Participant in a limited-benefit is enrolled in plan. a limited-benefit For hospital services, plan. For collect hospital patient services, collect patient responsibility when responsibility service is rendered when service or make is financial rendered arrangements or make financial with the arrangements patient in with the patient in accordance with your accordance policies. with your policies. AWAY FROM HOME AWAY CARE FROM HOME CARE 6 A V I A N T A N EV TI WA NO T R KN E T W O R K Primary Network: Primary Beech Network: Street Beech Street Connecticut General Connecticut Life Insurance General Company Life Insurance Company You may be asked You to present may be this asked card to when present you this receive card when care. you The receive card does care. not The guarantee card does not guarantee coverage. You must coverage. comply with You must all terms comply and with conditions all terms of and the plan. conditions Willful of misuse the plan. of this Willful card misuse of this card is This plan does not require This plan pre-certification does not require of coverage pre-certification for inpatient of coverage or outpatient for inpatient services. or outpatient Claims willservices. Claims will be paid according to be terms paid according and conditions to terms of the and plan. conditions In the case of the of plan. emergency, In the case seek of an care emergency, seek care immediately, then call immediately, your family then physician call your for family further physician assistance for and further direction assistance regarding and direction follow up regarding care. follow up care.

9 PPO or EPO Plans CSN Cigna Care Network bs 6 Group: 26 ID: U ID card acct name RxBIN RxPCN No PCP selection required PPO: In-network and out-of-network coverage EPO: In-network coverage only, except emergency care PPO Dr. visit $ Specialist $0/$2 Hospital ER $0 Urgent care $2 Rx $0/20/0 Network coinsurance: In 90%/0% Out 0%/0% Med/Rx deductie applies INPATIENT ADMISSION AND OUTPATIENT PROCEDURES: Your network provider must call the toll-free number listed below to pre-certify the ave services. Refer to your plan documents for your pre-certification requirements. Failure to do so may affect benefits. In an emergency, seek care immediately, then call your primary care doctor as soon as possie for further assistance and directions on follow-up care within ### hours. For pharmacy, call ABC Company.800.XXX.XXXX (Not a Cigna Company) For vision, call ABC Company.800.XXX.XXXX (Not a Cigna Company) Send claims to: CAD name, PO Box XXXX, Anytown, USA TPV name, PO Box XXXX, Anytown, USA All others: PO Box XXXX, Anytown, USA Customer service:.800.xxx.xxxx MH/SA:.800.XXX.XXXX Strategic Alliances TPV / Alliance Group: 26 ID: U PCP: John Smith PCP name Ln2 PCP phone: ID card acct name RxBIN RxPCN Open Access Plus No referral required PCP visit $ Specialist $0 Hospital ER $0 Urgent care $2 Rx $0/$20/$0/90% Rx indiv deduct $0 Network coinsurance: In 90%/0% Your network provider must call the toll-free number listed below to pre-certify the ave services. Refer to your plan documents for your pre-certification requirements. Failure to do so may affect benefits. In an emergency, seek care immediately, then call your primary care doctor as soon as possie for further assistance and directions on follow-up care within 8 hours. Coinsurance/deductie is paid directly to the doctor/facility by Cigna using individual s availae health funds. For pharmacy: Call ABC Company.800.XXX.XXXX (Not a Cigna Company) For vision: Call ABC Company.800.XXX.XXXX (Not a Cigna Company) Send claims to: CSN name, PO Box XXXXX, Anytown, USA All other: PO Box XXXXX, Anytown, USA Customer service:.800.xxx.xxxx MH/SA:.800.XXX.XXXX We encourage you to use a PCP as a valuae resource and personal health advocate. Indemnity Plans Group: 26 ID: U ID card acct name RxBIN RxPCN No PCP selection required Patient files claims Indemnity Rx $0/20%/0%/00% Rx indiv deduct $0 Indiv deduct $00 Family deduct $00 Hospital deduct $200 ER deduct $0 Coinsurance: Medical 80%/20% Med/Rx deductie applies Cigna.com You must comply with all terms and conditions of the plan. Willful misuse of this card is Your provider must call the toll-free number listed below to pre-certify the ave services. Refer to your plan documents for your pre-certification requirements. Failure to do so may affect benefits. In an emergency, seek care immediately, then call your primary care doctor as soon as possie for further assistance and directions on follow-up care within ### hours. Coinsurance/deductie is paid directly to the doctor/facility by Cigna using individual s availae health funds. Note: You can reduce your out-of-pocket expenses if you use a provider. Use of a Network Savings Program provider does not affect your benefit coverage. For help finding a participating provider, please visit our website, or call the toll-free number listed on this card. For Pharmacy, call ABC Company.800.XXX.XXXX (Not a Cigna Company) For, call ABC Company.800.XXX.XXXX (Not a Cigna Company) Send Claims to: PO Box XXXX, Anytown, USA Customer Service:.800.XXX.XXXX MH/SA:.800.XXX.XXXX 6

10 MORE WAYS TO ACCESS PATIENT INFORMATION WHEN YOU NEED IT USE OUR ELECTRONIC TOOLS Access our secure websites: Cigna for Health Care Professionals (CignaforHCP.com) for patients with Cigna ID cards Secured Provider Portal (GWHCignaforHCP.com) for patients with GWH-Cigna ID cards Connect to us through electronic data interchange (EDI): Visit Cigna.com > Health Care Professionals > Resources for Health Care Professionals > Doing Business with Cigna > How to Suit Claims to Cigna to learn more Call our automated phone system cigna (882.62) CONDUCT ADMINISTRATIVE TRANSACTIONS ONLINE Cigna s convenient eservices tools help you handle the administrative details of health care. Access patient eligibility and benefits Estimate patient liability View and suit 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 receivae system Suit questions aut fee schedules and specific patient benefits learn more Read more aut our electronic tools at Cigna.com > Health Care Professionals > Network Benefits > Learn more aut Cigna eservices. Cigna is a registered service mark, and the Tree of Life and GO YOU are 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 and not by Cigna Corporation. Such operating subsidiaries include Connecticut General Life Insurance Company, Cigna Health and Life Insurance Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation and Cigna Dental Health, Inc. All models are used for illustrative purposes only. 99 k THN /2 202 Cigna. Some content provided under license.