Medical Claim Glossary

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A | C | D | M | N | O | P | R | S


CIGNA Medical Claim Glossary

A

Automatic Claim Forwarding Indicator

If the value for the Automatic Claim Forwarding Indicator is "yes" this indicates that we are determining if you have dollars in an account (such as a Flexible Spending Account (FSA), Health Savings Account (HSA) or Health Reimbursement Account (HRA) that are available to pay some or all of your member responsibility. If we determine that you do have funds available in one or more of your accounts, your claim information will be updated to indicate which account(s) the funds were drawn from and the amount that was paid from the account(s).


C

Charges Not Covered/Other

The portion of submitted charges that is not covered/eligible for payment under the benefit plan. Examples of "Charges Not Covered" include amounts over Maximum Reimbursable Charges, amounts for services or products not covered by your plan or duplicate claims that are not your responsibility.

Covered Balance

Portion of submitted charges covered/eligible for payment under the benefit plan. Refer to your Benefit Summary to review expenses covered by your plan.


D

Deductible

The dollar amount that you must pay for the year before the plan begins to pay benefits for covered services.


M

Member Coinsurance

After you have met your deductible, the cost of covered expenses are shared by you and your underlying plan. The portion of covered expenses you are responsible for is referred to as coinsurance.

Member Copay

A flat per service charge that you are responsible for paying for services such as doctor visits.

Member Responsibility

Portion of submitted charges that is your responsibility. Amount may include deductible, coinsurance, amounts over Maximum Reimbursable Charges, or amounts for services or products not covered by your plan. Refer to the Benefit Summary for plan specifics.


N

Negotiated Discount

The difference between the provider's submitted charges and the rates negotiated between CIGNA and the service provider, e.g., in-network savings. For example if a particular service costs $100 and the negotiated rate between CIGNA and the service provider is $80, the Negotiated Discount is $20.

Network Indicator

Indicates whether the service was provided by a health care provider or facility that is under contract with CIGNA HealthCare.


O

Out of Pocket Maximum

The most you will pay per year for covered health expenses before the plan pays 100% of covered health expenses for the rest of the year.


P

Paid by Plan

Portion of submitted charges paid by the underlying medical benefit plan.

Paid from FSA

Portion of submitted charges paid from your Health Care Flexible Spending Account (FSA) that you established to pay for eligible expenses such as office visit copays.

Note: Use the Accounts tab on myCIGNA home page to view your most up-to-date summary of acount balances and funds used. From the Summary page, select Claim History to see full current transaction history.

Paid from Healthy Awards

Portion of submitted charges paid from the Healthy Awards Account. Healthy Awards is an account in which dollars are deposited for participation in/completion of various incentive and/or disease management programs.

Note: Use the Accounts tab on myCIGNA home page to view your most up-to-date summary of account balances and funds used. From the Accounts tab, select the appropriate View Balances & Transaction History link. From the Accounts Summary page, select Claim History to see full current transaction history.

Paid from HRA

Portion of submitted charges paid from the Health Reimbursement Account (HRA) that your employer has established for you. These funds can be used to pay for any covered health care expenses e.g., deductibles, copays, coinsurance, etc.

Note:Use the Accounts tab on myCIGNA home page to view your most up-to-date summary of account balances and funds used. From the Summary page, select Claim History to see full current transaction history

Paid from HSA

Portion of submitted charges paid from the Health Savings Account (HSA) in which you and/or your employer have set aside dollars to pay for qualified medical, pharmaceutical, dental and other health care costs.


R

Remaining Member Responsibility

Portion of submitted charges that is your responsibility after payments from the underlying benefit plan, Health Savings Account (HSA), Health Reimbursement Arrangement (HRA) or HealthCare Flexible Spending Account (FSA).

Remarks

Codes that provide further details for how a claim was processed including denials, partial denials, etc.


S

Service Date

The date the service was provided to the participant as specified on the claim.

Status

Indicates the status of the claim. Following is a list of the possible claim status values along with a definition of the status:

Submitted Charges

Total amount submitted by health care provider or facility for services rendered before any discounts are applied.