How to File a Claim for Benefits Sample Clauses

How to File a Claim for Benefits. Below is an example of what Your cost could be for an In-Network or Out-of-Network medical claim. For the purpose of this example the Deductible has been met. Your actual out-of-pocket responsibility may be different due to Your specific plan and benefits. Costs with In Network Doctors* Costs with Out of Network Doctors* Billed Charges $1,000 Billed Charges $1,000 Cigna's negotiated rate $650 Amount Cigna Considers Reasonable $650 You Get a Discount Of $350 Cigna pays (60% of $650) $390 Cigna Pays (80% of $650) $520 You Pay (60% of $650) $260 You Pay (20% of $650) $130 Plus Billed Charges Balance ($1000-$650) $350 Total Amount You Pay $130 You Pay a Total of $610 *Assuming any applicable Deductible(s) have been met and any applicable Out-Of-Pocket Maximum has not been met. Cigna has contracted with Participating Providers to charge only agreed upon Coinsurance, Copayments, or Deductibles for Covered Services. You may not be billed for additional amounts which exceed the amounts agreed upon by Cigna and the Participating Providers. You will be responsible for the difference between the Participating Providers contracted amount with Cigna and amounts that exceed any maximum benefit amounts which are described in the Benefit Schedule of this Policy. Notice Regarding Provider/Pharmacy Directories and Provider/Pharmacy Networks If Your Plan utilizes a network of Providers, a separate listing of Participating Providers who participate in the network is available to you without charge by visiting xxx.xxxxx.xxx; xxxxxxx.xxx xxx.xxXXXXXxxxxxxxxx.xxx or by calling the toll-free telephone number on Your ID card. Your Participating Provider/Pharmacy networks consist of a group of local medical practitioners, and Hospitals, of varied specialties as well as general practice or a group of local Pharmacies who are employed by or contracted with Cigna HealthCare. NOTICE: Your actual expenses for Covered Services may exceed the stated Coinsurance percentage because actual provider charges may not be used to determine plan and Insured payment obligations. Notice of Claim: There is no paperwork for claims for services from Participating Providers. You will need to show Your ID card and pay any applicable Copayment; Your Participating Provider will submit a claim to Us for reimbursement. Claims for services from Non-Participating Providers can be submitted by the provider if the provider is able and willing to file on Your behalf. If a Non-Participating Provider is not submitt...
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How to File a Claim for Benefits. Obtain a claim form from the Policyholder and have the Dentist complete the required information or include a copy of an approved American Dental Association (ADA) xxxx suitable for insurance submission that the claimant received from the Dentist. Payment of the amount provided by the Policy will be sent directly to the Covered Person or to the Dentist, if the benefit payment has been assigned to him.
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Related to How to File a Claim for Benefits

  • Application for Benefits Requests for short-term leaves shall be in writing, upon the appropriate form prescribed and provided by the District, and shall be filed with the unit member's supervisor and the appropriate manager five (5) days in advance of the intended leave (except in emergency situations), unless otherwise stated by the provisions of the specific leave.

  • Eligibility for Benefits A member will not be eligible to receive Long Term Disability benefits until their Income Protection benefits have expired.

  • City Benefits The Contractor shall not be entitled to any of the benefits established for the employees of the City nor be covered by the Worker's Compensation Program of the City.

  • Disability Benefits Technology Errors and Omissions Not less than $1,000,000 each claim Not less than $2,000,000 in aggregate At the time of the first transaction with an Authorized User and updated in accordance with Contract Crime Insurance Not less than $50,000 Lot 3 Insurance Type Proof of Coverage is Due Commercial General Liability Not less than $5,000,000 each occurrence Updated in accordance with Contract General Aggregate $2,000,000 Products – Completed Operations Aggregate $2,000,000 Personal and Advertising Injury $1,000,000 Business Automobile Liability Insurance Not less than $5,000,000 each occurrence Workers’ Compensation

  • ELHT Benefits The Parties agree that since all active eligible employees have now transitioned to the OSSTF ELHT all references to existing life, health and dental benefits plans in the applicable local collective agreement for active eligible employees shall be removed from that local agreement. Post Participation Date, the following shall apply:

  • Program Benefits Under the Probation Status, the Participating Contractor will be eligible for all contractor incentives, its customers will have access to financing offered through the Program, and income- eligible households will be eligible to receive Program incentives.

  • Claim Form i. Within 15 days after receiving a notice of a claim, you or your Dental Provider will be provided with a Claim Form to make claim for Benefits. To make a claim, the form should be completed and signed by the Provider who performed the services, and by the patient (or the parent or guardian if the patient is a minor), and submitted to the address above.

  • How to File an Appeal of a Prescription Drug Denial For denials of a prescription drug claim based on our determination that the service was not medically necessary or appropriate, or that the service was experimental or investigational, you may request an appeal without first submitting a request for reconsideration. You or your physician may file a written or verbal prescription drug appeal with our pharmacy benefits manager (PBM). The prescription drug appeal must be submitted to us within one hundred and eighty (180) calendar days of the initial determination letter. You will receive written notification of our determination within thirty (30) calendar days from the receipt of your appeal. How to File an Expedited Appeal Your appeal may require immediate action if a delay in treatment could seriously jeopardize your health or your ability to regain maximum function, or would cause you severe pain. To request an expedited appeal of a denial related to services that have not yet been rendered (a preauthorization review) or for on-going services (a concurrent review), you or your healthcare provider should call: • our Grievance and Appeals Unit; or • our pharmacy benefits manager for a prescription drug appeal. Please see Section 9 for contact information. You will be notified of our decision no later than seventy-two (72) hours after our receipt of the request. You may not request an expedited review of covered healthcare services already received.

  • Claims Submission We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company; we are not party to that contract.

  • Maternity Benefits (i) Subject to the provisions of this part of the Agreement a female contributor who-

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