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HOSPITAL CARE CLAIM FORM INSTRUCTIONS
Please complete the claim form in its entirety, including supporting medical documentation.
Have your Physician complete Section 7: Physician Statement.
Provide ALL of the below:
o
Documentation outlining room and board charges or observation stay (with hospital
arrival and discharge times)
File this claim form using one of these methods:
Mail Cigna Supplemental Health Solutions
P. O. Box 188028
Chattanooga, TN 37422
Email
OR
o
Medical documentation with procedure and diagnosis codes associated with the date(s)
of treatment
Note: the claim review process will start once we receive all documentation supporting your claim.
Additional documentation is required if you qualify for one of these special situations:
• If the claimant was a driver in a motor vehicle accident, also provide the police report.
• If claimant is a child dependent who is 26 or more years old and has a mental or physical handicap that
requires employee support, also include the SSDI Award letter.
• If you are filing a claim on behalf of an insured claimant who is deceased, also provide the death
certificate AND a disclosure authorization for the deceased, which can be obtained from the employee's
Human Resources department.
UB-04 Form – Can be requested from hospital billing department. This is the preferred
option for the fastest claim processing time.
OR
Note: The Claimant must complete Sections 1-6.
Proof of hospitalization is required for this claim. Include the UB-04 form with the submission for fastest claim
processing. Otherwise, have your Attending Physician complete Section 7.
We will contact you if we need additional information to process the claim.
Cigna Healthcare Supplemental Health Solutions
Hospital Care Claim Form
This document is confidential and proprietary to Cigna Healthcare
Note: * = Required field
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SECTION 1: EMPLOYEE INFORMATION
Was the employee considered actively at work on the date of the
incident?*
If no, what was the reason the employee was not actively at work?*
Group Policy Number:
Date of Birth (mm/dd/yyyy):*
Name of Employer (at time of claim):*
If adult child is disabled, please provide
the SSDI Award Letter.*
If Child is not a full-time student, is he/she
totally disabled?*
Relationship to Insured:*
Name (First & Last):*
SECTION 4: CHILD'S ADDITIONAL INFORMATION: (Complete for Child claim only)
SECTION 3: CLAIMANT DEMOGRAPHIC INFORMATION (Complete for Spouse or Child claim only)
Unpaid Leave of Absence
Paid Leave of Absence
Family Leave (FMLA)
Other:
Name (First & Last):*
Yes
No
Is the Child a full-time student?*
SECTION 5: DESCRIPTION OF YOUR HOSPITALIZATION
Does the employee have health care coverage with Cigna?
Email Address:*
Daytime Phone Number:*
Date of Birth (mm/dd/yyyy):*
Social Security Number:*
SECTION 2: EMPLOYER INFORMATION
SSN:
Does not have SSN
Yes
No
Yes
No
Yes
No
Does the claimant have health care coverage with Cigna?
Yes
No
City:* State:* Zip Code:*
City:* State:* Zip Code:*
Address:*
Address:*
CLEAR FORM
SECTION 6: LIST OF HOSPITALS, CLINICS OR PHYSICIANS
Address:
Treatment Period:
Phone Number:
Physician/Facility Name:
Specialty: Fax Number:
Fax Number:Specialty:
Physician/Facility Name:
Phone Number:
Treatment Period:
Address:
Address:
Treatment Period:
Phone Number:
Physician/Facility Name:
Specialty: Fax Number:
Fax Number:Specialty:
Physician/Facility Name:*
Phone Number:*
Treatment Period:
Address:*
Diagnosis*
Present Condition
History
When did the current symptoms first appear?*
Confirmed Diagnosis Date*
Has the patient ever had the same or a similar condition? (If “yes,” provide date and description below.)*
Yes
No
Treatment Details
Admission Date and Time* Discharge Date and Time*
Number of days newborn was hospitalized* Was newborn in NICU?*
Yes
No
SECTION 7: HOSPITAL CARE PHYSICIAN'S STATEMENT
Childbirth
Newborn Discharge Date*
Newborn Birth Date*
If so, how many days?*
Observation Unit
Number of Hours in Observation Unit*
Admission Date* Discharge Date*
Standard Inpatient Hospital Bed
Number of Days in Standard Hospital Bed*
Admission Date* Discharge Date*
Intensive Care Unit (Critical Care Unit and includes ICU Step Down Facility)
Number of Days in ICU
Admission Date* Discharge Date*
Inpatient Substance Abuse Rehabilitation Facility
Number of Days in Rehabilitation Facility
Admission Date* Discharge Date*
Inpatient Skilled Nursing Facility
Number of Days in Skilled Nursing Facility
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CAUTION: Any person who, knowingly and with intent to defraud any insurance company or other person: (1)
files an application for insurance or statement of claim containing any materially false information; (2) conceals
for the purpose of misleading, information concerning any material fact thereto, commits a fraudulent
insurance act. For residents of the following states, please see the last page of this form: Alaska, Alabama,
Arizona, Arkansas, California, Colorado, District of Columbia, Florida, Kansas, Kentucky, Louisiana, Maine,
Maryland, Minnesota, New Hampshire, New Jersey, New Mexico, Ohio, Oklahoma, Pennsylvania, Puerto
Rico, Rhode Island, Tennessee, Texas, Virginia, Washington, West Virginia.
New York Residents: FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance
company or other person files an application for insurance or statement of claim containing any materially false
information, or conceals for the purpose of misleading, information concerning any fact material thereto,
commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed
$5000 and the stated value of the claim for each such violation.
Proof of hospitalization is required for this claim.
•
Include the UB-04 form with the submission for fastest claim processing.
Otherwise, have your Attending Physician complete Section 7.
We will contact you if we need additional information to process the claim.
Date Signed*
Claimant’s Signature*
(or Parent/Guardian if Claimant is under 18 years old)
The issuance of this form is not the admission of the existence of any insurance nor does it recognize the
validity of any claim and is without prejudice to the company’s legal rights.
SECTION 7: HOSPITAL CARE PHYSICIAN'S STATEMENT (cont'd)
Physician Information / Signature
Attending Physician Name (First & Last):*
Degree:*
Fax Number:*
Phone Number:*Street Address:*
City:*
State:*
Zip Code:*
Date Signed*
Attending Physician Signature*
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Disclosure Authorization
AUTHORIZATION
NOTE: This authorization is designed to comply with HIPAA and relates to information necessary to administer coverage and services
under your employer’s employee health and welfare plan(s) ("the Plan") and similar or coordinating governmental benefits. You are
not required to sign the authorization, but if you do not, the Plan, insurers or other providers of services or coverage under the Plan
may not be able to process your request for Plan benefits, coverage or services.
Company Names: Cigna Health and Life Insurance Company, Life Insurance Company of North America (LINA), and New York Life Group
Insurance Company of NY (NYLGICNY) (formerly Cigna Life Insurance Company of New York).
Guardian, or Conservator, please attach a copy of the document granting authority.
(indicate relationship). If Power of Attorney Designee,I signed on behalf of the claimant as
Claimant’s Name (can be Employee, Spouse, or Child):*
I authorize any physician, medical professional or other health care provider, hospital or other medical facility; pharmacy; health plan;
other medically related entity; rehabilitation professional; vocational evaluator; employee assistance plan; insurance company,
reinsurer, health maintenance organization, third party administrator, broker or other insurance service provider, or similar entity; the
Medical Information Bureau; the Association of Life Insurance Companies, which operates the Health Claims Index and the Disability
Income Record System; government organization or agency, including the Social Security Administration; any of your social security
disability advocates or representatives; financial institution, accountant or tax preparer; consumer reporting agency; and employer or
group policyholder that has information about my health, prescriptions, financial, earnings or employment history, or other insurance
claims and benefits to provide access to or copies of this information to the Plan and to any individual or entity who provides services
to or insurance benefits on behalf of the Plan, including but not limited to the requesting company(ies) named below ("Company"). To
the extent I may be eligible for governmental benefits similar to or that coordinate with those available to me under the Plan, I also
authorize disclosure of information necessary to apply for or determine my eligibility for such benefits to the relevant government
agency and/or vendor providing application assistance.
For any claim for insurance benefits, this authorization is valid for the shorter of 24 months or the duration of my claim. For all other
permitted disclosures, this authorization is valid for one (1) year from the date below. I am entitled to a copy of this authorization and a
photographic or electronic copy of it is as valid as the original.
I understand that any information obtained with this authorization will be used for evaluating and administering my coverage,
including any claim for benefits, or otherwise providing services related to or on behalf of the Plan, which may include, but is not
limited to assisting me in returning to work and Plan administration. With respect to governmental benefits similar to or that
coordinate with benefits available to me under the Plan, I understand that the information will be used to help determine my eligibility
for any such benefits and may include assisting me in applying for the benefits. I understand that the information disclosed under this
authorization is subject to redisclosure and may no longer be protected by certain federal regulations governing the privacy of health
information, although it will continue to be protected by other applicable privacy laws and regulations.
Information about my health may relate to any disorder of the immune system including but not limited to HIV and AIDS; use of drugs
or alcohol; and mental and physical history, condition, advice or treatment, but does not include psychotherapy notes.
If my employer, union, and/or group association sponsors any other plans, whether or not underwritten or administered by a Cigna
company, the information and/or records obtained may also be shared with the underwriting company (insurer) or administrators of
those other plans, including their internal or external health management, disease management, wellness, employee/member
assistance program or other similar programs, for the purpose of administering any service, benefit or feature described in those plans.
Date Signed*
Claimant’s Signature*
(or Parent/Guardian if Claimant is under 18 years old)
Print Name*
Date of Birth (mm/dd/yyyy):*
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IMPORTANT CLAIM NOTICES
Alaska Residents: A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim
containing false, incomplete, or misleading information may be prosecuted under state law.
Alabama Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who
knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or
confinement in prison, or any combination thereof.
Arizona Residents: For your protection Arizona law requires the following statement to appear on this form: Any person who
knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.
Arkansas Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly
presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
California Residents: For your protection California law requires the following statement appear on this form: Any person who
knowingly presents false or fraudulent information to obtain or amend insurance coverage or to make a claim for the payment of a
loss is guilty of a crime and may be subject to fines and confinement in state prison.
Colorado Residents: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance
company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of
insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete
or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the
policyholder or claimant with regard to settlement or award payable from insurance proceeds shall be reported to the Colorado
division of insurance within the department of regulatory agencies.
District of Columbia Residents: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of
defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance
benefits if false information materially related to a claim was provided by the applicant.
Florida Residents: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or
an application containing any false, incomplete or misleading information is guilty of a felony of the third degree.
Kansas Residents: Any person who knowingly and with intent to defraud any insurance company or other person (1) files an
application for insurance or statement of claim containing any materially false information; or (2) conceals for the purpose of
misleading, information concerning any material fact thereto, may be guilty of insurance fraud determined by a court of law.
Kentucky Residents: Any person who knowingly and with intent to defraud any insurance company or other person files an
application for insurance containing any materially false information or conceals, for the purpose of misleading, information
concerning any fact material thereto commits a fraudulent insurance act, which is a crime.
Louisiana Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly
presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
Maine Residents: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the
purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.
Maryland Residents: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or
who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines
and confinement in prison.
Minnesota Residents: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.
New Hampshire Residents: Any person who, with a purpose to injure, defraud, or deceive any insurance company, files a statement
of claim containing any false, incomplete, or misleading information is subject to prosecution and punishment for insurance fraud, as
provided in RSA 638:20.
New Jersey Residents: Any person who knowingly files a statement of claim containing any false or misleading information is
subject to criminal and civil penalties.
New Mexico Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly
presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.
Ohio Residents: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an
application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
Oklahoma Residents: Warning: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any
claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
Pennsylvania Residents: Any person who, knowingly and with intent to defraud any insurance company or other person, files an
application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading,
information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects such person to
criminal and civil penalties.
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Puerto Rico Residents: Caution: Any person who knowingly and with the intention of defrauding presents false information in an
insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other
benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned
for each violation by a fine of not less than five thousand dollars ($5,000) and not more than ten thousand dollars ($10,000), or a fixed
term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances be present, the penalty thus
established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may be reduced to a
minimum of two (2) years.
Rhode Island Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or
knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement
in prison.
Tennessee Residents: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for
the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
Texas Residents: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and
may be subject to fines and confinement in state prison.
Virginia Residents: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the
purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.
Washington Residents: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for
the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.
West Virginia Residents: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or
knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement
in prison.
THESE POLICIES PAY LIMITED BENEFITS ONLY. THEY ARE NOT COMPREHENSIVE HEALTH INSURANCE COVERAGE AND DO NOT COVER ALL
MEDICAL EXPENSES. THIS COVERAGE DOES NOT SATISFY THE “MINIMUM ESSENTIAL COVERAGE” OR INDIVIDUAL MANDATE
REQUIREMENTS OF THE AFFORDABLE CARE ACT (ACA). THIS COVERAGE IS NOT MEDICAID OR MEDICARE SUPPLEMENT INSURANCE.
Product availability may vary by location and plan type and is subject to change. All group insurance policies may contain exclusions, limitations,
reduction in benefits, and terms under which the policy may be continued in force or discontinued. For costs and details of coverage, review your
plan documents or contact a Cigna representative.
All Cigna Healthcare products and services are provided exclusively by or through operating subsidiaries of The Cigna Group. The Cigna Healthcare
name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. LINA and NYLGICNY are not affiliates of The Cigna Group.
© 2023 Cigna. Some content provided under license
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