When the patient has authorized the insurance company to make the payment directly to the provider

In addition to consumers, we also hear from medical providers with questions about health insurance. As a medical provider, learn more about your rights and responsibilities for the health plans we regulate.

Access to care

Under Washington state law, some health plans must allow patients to access every type of licensed medical provider.

Health plans must also have an adequate provider network (leg.wa.gov) that ensures patients have timely access to covered services.

Note: The Office of the Insurance Commissioner doesn't have the authority to require insurance companies to contract with a specific medical provider or facility. These contracts and reimbursement rates are privately negotiated agreements between insurance companies and medical providers.

Billing and reimbursement

As a contracted medical provider, your agreement with the insurance company requires the health plan to meet the following minimum standards (leg.wa.gov) when paying claims; 95% of the monthly volume of:

• Clean claims must be paid within 30 days (a claim that isn't missing information or documentation that prevents the health plan from paying on time).
• All claims must be paid or denied within 60 days.

Under Washington state law (leg.wa.gov), an insurance company has 24 months to request a refund from a medical provider after it pays a claim. The company must request this refund in writing (an electronic notification is considered acceptable) and specify why it believes you owe a refund. You have 30 days from the date of the notice to contest the request in writing to the company.

If you're a contracted medical provider, you cannot bill your patient more than their cost share. If you're a non-contracted medical provider or facility, there are situations in which you cannot bill a patient more than their cost share. Learn more about balance billing.

How to resolve disputes with insurance companies

Your medical provider contract with an insurance company requires the health plan to have a formal dispute resolution process (leg.wa.gov). For billing disputes, the company must make a decision within 60 days of receiving your complaint. Please contact the company or review your contract for further information on this process.

You can also file a complaint with our office, and we can review your concerns with the company. If you provide any personal information about your patient in the complaint, you must include their signed consent.

For claim denials, your patient will also have the opportunity to appeal a claim denial with their health plan.

Not all coverage is subject to these requirements

State health insurance laws don't apply to all insurance policies or medical programs we don't regulate (Medicare, Apple Health, TRICARE). The following insurance policies aren't recognized as health plans under Washington state law (app.leg.wa.gov):

• Accident-only coverage
• Fixed payment indemnity insurance
• Critical illness coverage
• Limited health care services
• Coverage through an auto or homeowner personal injury claim
• Long-term care insurance
• Dental-only and vision-only coverage
• Medicare Supplement (Medigap) plans
• Disability-income insurance
• Short-term limited purpose insurance
• Employer-sponsored self-funded health plans
• Workers compensation coverage

What is a 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 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.

Cigna's 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 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.

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What is an EOB?

An EOB (Explanation of Benefits) is a claim statement that Cigna sends to you after a health care visit or procedure to show you how your claim was paid.

An EOB is not a bill. It is a document to help you understand how much each service costs, what your plan will cover, and how much you will have to pay when you receive a bill from your health care provider or hospital.

Remember to save your EOBs for tax purposes and for your records.

Find out more about EOBs [PDF]

How do I submit a claim?

• Download and print the appropriate claim form (depending on the type of claim)
• Follow the instructions included on the form to complete it
• Mail your completed claim to the address shown on the form

Have a supplemental plan? (Hospital Indemnity, Cancer Treatment, Lump Sum Heart Attack and Stroke, or Whole Life Insurance.) Submit an online claim

Or, if you prefer to fill out a paper form, visit SuppHealthClaims.com to download a claim form.

Submit completed paper supplemental claims using one of these options:

• Email: 
• Fax: 1 (860) 730-6460
• Mail:
  Cigna Phoenix Claim Services
  PO Box 55290
  Phoenix, AZ  85078

What if my claim is denied?

In some cases, you need to have a procedure or service pre-approved by Cigna before you receive care, otherwise the claim may be denied.

Ways to avoid denied claims:

• Pay your monthly premium on time
• Present your current ID card when you receive services.
• Stay in-network, if required by the plan
• Get prior authorization, if required by the plan

A retroactive denial is a claim paid by Cigna and then later denied, requiring you to pay for the services. Denial could be due to eligibility issues, service(s) determined to be not covered by your plan, or cancellation of coverage.

If your claim is retroactively denied, Cigna will notify you in writing about your appeal rights. Learn more about appeals and grievances.

For help, call customer service at .

How do I know if I need to submit a claim?

In some cases you may need to submit a claim, depending on your plan type and whether you received in-network or out-of-network care. Use the following general plan information to help decide if you need to submit a claim.

HMO, Network, or EPO Plans

In-Network

For most services covered under your plan, you are not responsible for submitting a claim. Just show your Cigna 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 Cigna 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 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.

Which means that the insured has authorized the payer to reimburse the provider directly?

What is a payment to an insurance company called?

What is remittance processing in healthcare?

What is the process of verifying a patient's insurance?