A look behind the scenes of Cigna Healthcare’s five steps to reviewing a claim.
Navigating the world of health insurance can sometimes feel confusing, especially when it comes to understanding the medical claims process and what that entails. After you receive medical care from your doctor or a hospital, that provider will send Cigna Healthcare a claim, or a request for payment for services covered by your health plan. The claim includes information about what care you received (using medical codes), when you received it, and how much the provider is billing for it. We use that information to check your plan coverage and determine the appropriate payment to your care provider.
Care providers usually send claims to us within 15 days after you received your care, though they have almost six months (up to 180 days) to send it. Most are sent electronically, while some arrive by mail. Once we receive the claim, it goes through a five-step process for review and payment.
The 5 steps of the claims process
- Check claim details: We check the file to make sure all required fields are filled in. We also confirm your coverage, check the provider’s information, and read the medical codes.
- Determine coverage and pricing: We look to see if the services your provider billed are covered by your plan and if any special approval is needed. If the services are covered by your benefit plan, we apply the correct price for the care based on our contract with the care provider. Then we determine what amount the plan pays and how much you may owe (depending on your deductible, copay, or coinsurance). At this step, we also check for any billing errors, discrepancies, or unusual charges. These checks help protect you by making sure the billing is accurate.
- Determine approval: Based on the previous steps, the claim will either be paid according to your plan coverage, or “pended” if we need more information from the provider.
- Send the payment: If the claim is approved, we send the payment to the provider within three business days.
- Send the explanation of benefits (EOB): We also send you an explanation of benefits that explains, in plain language, what we covered and the amount you may owe the provider. The EOB is not a bill; your provider would bill you the amount you owe. Your provider also receives a copy of the EOB.
Who reviews the claim?
Most Cigna Healthcare medical claims are automatically processed and approved. However, there will be times when a claim needs a closer look, like when there is missing information or if services for complex care are being billed.
When this happens, a Cigna Healthcare claims specialist steps in. These specialists are trained in claims processing, plan rules and policies, and medical coding and documentation standards. Their job is to finish the claims processing by addressing any issues the initial screening in steps 2 and 3 above identified. For example, the specialist would reach out to your care provider for any missing information.
Claims for services like a transplant or other complex treatments may also require a clinical check under your health plan policies. In these cases, the claims specialist will route the claim to a Cigna Healthcare registered nurse and/or a medical director (a licensed doctor) to review the medical details before the claim moves forward.
Most Cigna Healthcare claims are fully processed in about 7–10 business days, with 95% completed within 14 calendar days and more than 99% completed within 30 calendar days after we receive them.
Checking your claim status
You can check the status of your claim by logging on to myCigna.com and selecting the “Claims” option under the “Claims” tab. Your claim will appear on myCigna once we finish checking the claim details (step 1 above), which usually happens within 1-2 days after we receive it from your care provider.
What the status labels on myCigna mean:
- Claim received – We received the claim, checked the details, and loaded it into our system.
- Claim processing – We’re checking the coverage and pricing. Claims with no issues tend to move through these checks quickly. We may also be taking a closer look to confirm details or are waiting on additional information from your care provider. When that happens, the claim will continue to be “processing” until our review is done.
- Claim processed – We’ve finished our review and sent the payment. Your EOB will be available to view and download.
If you have any questions about a specific claim, contact Cigna Healthcare or your care provider for help.
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