Medical Claim Form Instructions

To file a claim:

1. Print these medical claim form instructions. They'll guide you through the steps required to help ensure your claim is processed correctly.
   
2. Download and print a ready-to-use claim form(PDF).
3. Mail your completed claim form(s), with original itemized bill(s) attached, to the CIGNA HealthCare Claims Office printed on your CIGNA HealthCare ID card.

Allow approximately three weeks from the time you mail your claim form to the time you receive your Explanation Of Benefits.

Important Filing Tips

1. Type or print in black ink.
2. Use a separate form for each participating family member each time you submit a claim. For example, don't include your spouse's medical receipts on the same claim form with yours.
3. You can submit two or more health care bills together on the same claim form if they're for treatment of the same illness. For example, if you have bills from a specialist, an X-ray lab, and a pharmacy that are all for the treatment of an injury, you can submit one claim form.
4. Please don't submit canceled checks or cash receipts as proof of payment. They don't contain the information we need to properly process your claim.
5. Always use original claim forms because they scan better than photocopied versions.

Questions 1 through 13 are to be completed by the patient and/or the insured.

Note: The PATIENT is the person who received health care service from a provider, and the INSURED is the person who carries the health care insurance.

1. Medicare/Medicaid/CHAMPUS/CHAMPVA/Group Health Plan/FECA BLK LUNG/Other
   This field is optional. Place a check mark in the box that indicates the insured's health care plan or program.
   
   

   1a. Insured's I.D. Number (For Program in Item 1)
   This field is required. The insured's I.D. number can be found on his/her health care I.D. card.
   
   

2. Patient's Name
   This field is required.
   
   
3. Patient's Birth Date and Sex
   This field is required.
   
   
4. Insured's Name
   This field is required.
   
   
5. Patient's Address
   This field is required. Provide the patient's address (number, street, city, state, and ZIP code) and telephone number (including area code).
   
   
6. Patient's Relationship to Insured
   This field is required. Indicate whether the patient is also the insured (Self), or is the insured's spouse, child, or other relation.
   
   
7. Insured's Address
   This field is required. Provide the insured's address (number, street, city, state, and ZIP code) and telephone number (including area code).
   
   
8. Patient Status
   This field is required. Indicate the patient's marital status (Single, Married or Other), and the patient's employment status (Employed, Full-time Student, or Part-time Student).
   
   
9. Other Insured's Name
   Provide the name of the person who carries the other health benefit plan (if applicable). Note: Fields 9 and 9a through 9d are required only if the patient is also covered under another health benefit plan.
   
   
   1. Other Insured's Policy or Group Number
      This number can be found on the other insured's health benefit plan ID card or other documentation.
      
      
   2. Other Insured's Date of Birth and Sex
      Provide if applicable.
      
      
   3. Employers Name or School Name
      Provide the name of the employer or school that provides the other insured's health benefit plan (if applicable).
      
      
   4. Insurance Plan Name or Program Name
      Provide the name of the other insured's health benefit plan or program (if applicable).
   
   
   
10. a-c. Is Patient's Condition Related to:
    These fields are required. Indicate whether the patient's condition occurred as a result of (a.) a job-related injury at a current or present employer, (b.) an auto accident (please indicate the state in which it occurred), or (c.) another type of accident.
    
    

    10d.Reserved for Local Use
    Do not write in this field.

    
    
    
11. Insured's Policy Group or FECA Number
    This field is optional. The Group or FECA number can be found on the insured's I.D. card.
    
    
    1. Insured's Date of Birth and Sex
       This field is required.
       
       
    2. Employer's Name or School Name
       This field is optional. Provide the name of the employer or school that provides the other insured's health benefit plan.
       
       
    3. Insurance Plan Name or Program Name
       This field is optional. Provide the name of the other insured's health benefit plan or program.
       
       
    4. Is There Another Health Benefit Plan?
       This field is required. Indicate whether the patient is also covered under another health benefit plan. If "Yes", be sure to complete fields 9a-d.
    
    
    
12. Patient's or Authorized Person's Signature
    A signature is required. An authorized person is the employee, the employee's spouse, or the dependent if he/she is the patient and is 18 years or older.
    
    
13. Insured's or Authorized Person's Signature
    A signature is required only if the benefit payment should be sent to the provider. Do not sign here if the payment should be sent to the insured. An authorized person is the employee, the employee's spouse, or the dependent if he/she is the patient and is 18 years or older.
    
    
14. 14-33. These fields must be completed by the physician, or you can include the bill from the provider and leave these fields blank.

Before you submit your claim...

1. Verify that printing is legible.
2. Be sure that all required fields are completed.
3. Make photocopies of all receipts and completed claim forms. Receipts will not be returned to you.
4. Write your CIGNA HealthCare ID number from your member ID card on all paperwork or bills you submit.