Claims and Explanation of Benefits (EOB)

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.

In-Network

For most services covered under your plan, you are not responsible for submitting a claim. Just show your ID card and (if applicable) pay your copayment at the time of service, or coinsurance after your claim is processed.

It is a good idea to compare your medical bill and EOB before paying a bill to make sure that you have been charged the correct amount.

Out-of-network

Most HMO, Network, and EPO plans only include out-of-network coverage for emergency care. Some plans may also cover urgent care services, as defined in your plan documents.

In this instance, you will usually need to submit a claim since out-of-network providers are not required to submit a claim on your behalf.

In-network

You are not responsible for submitting a claim. Just show your ID card and pay your copayment at the time of service.

It is a good idea to compare your medical bill and EOB before paying a bill to make sure that you have been charged the correct amount.

Out-of-network

You will always need to submit a claim.

You or your provider will need to submit a claim.

Depending on the provider, you may have to pay for the cost of your health care services when you receive them, or you may be billed directly for any services provided.

However, your provider will often take care of submitting a claim with Cigna Healthcare so that you will be reimbursed. If your provider does not submit a claim, you will need to submit one in order to be reimbursed. In both cases, you will be reimbursed based on the amount covered by your plan and subject to your plan’s deductible, copay, or coinsurance requirements.