% Paid: The part of the Amount Billed that your health plan paid
Allowed Amount: The amount that Cigna determines is reasonable reimbursement for covered services provided to you. This may be
established in accordance with an agreement between a health care provider and Cigna.
Amount Billed: The amount a health care provider can bill for covered services
Amount Not Covered: The part of the Amount Billed that is not covered by, or eligible for payment under, your plan
Coinsurance: A shared cost between you and your health plan that equals the Allowed Amount for a covered service. This shared cost starts
once you have met your deductible.
Copay: A dollar amount you pay for an eligible health care or related service, typically due at the time the service is provided. When present,
a copay is usually applied on a per occurrence, per admission, per day, or annual basis.
Deductible: A set amount you pay out of pocket in one plan or contract year for covered services before your health plan will start covering
part of the cost
Discount: The amount you save by using a network health care provider. Cigna negotiates lower rates with network health care providers to
help you save money. Using out-of-network providers will cost you more. If you go out-of-network for services, Cigna may be able to get you
discounts through third-party vendor contracts.
In-Network: A group of health care providers that have a contract with Cigna to provide you with health care coverage. Using in-network
providers will save you money.
Out-of-Network: Any health care provider that does not have a contract with Cigna to provide you with health care coverage. Using
out-of-network providers will cost you more money.
Out-of-Pocket Maximum: The total dollar amount a customer will pay toward the coverage of a health plan's benefits/services within a
calendar or contract year.
What My Plan Paid: The part of the Amount Billed that your health plan paid
What I Owe: The part of the Amount Billed you are responsible for. This amount might include your deductible, coinsurance, any amount
over the maximum reimbursable charge, or products or services not covered by your plan.

If you have any questions about this explanation of benefits, please call Customer Service at the toll-free number on the front of this form.
If you're not satisfied with this decision, you can start the Appeal process by sending a written request to the address listed in
your plan materials within 180 days of receipt of this explanation of benefits (unless a longer time frame is provided by applicable state law
or permitted by your plan).
Please follow the steps below to make sure that your appeal is processed in a timely manner.
·

Send a copy of this explanation of benefits along with any relevant additional information (e.g. benefit documents, medical records) that
helps to determine if your claim is covered under the plan. Contact Customer Service if you need help or have further questions.

·

Be sure to include: 1) Your name 2) Account number from the front of this form 3) ID number from the front of this form
4) Name of the patient and relationship and 5) "Attention: Appeals Unit" on all supporting documents.

·

Contact Customer Service at the number on the front of this form to request access to and copies of all documents, records and other
information about your claim, free of charge.

·

You will be notified of the final decision in a timely manner, as described in your plan materials. If your plan is governed by ERISA, you
may also bring legal action under section 502(a) of ERISA following our review and decision.

Page 2 of 4

 Claim received for MICHAEL SANTOS
7682005610518
Claim #
U65874867
ID

THIS IS NOT A BILL

CIGNA received this claim on February 25, 2020 and processed it on February 26, 2020.
Service
dates

Amount
billed

METHODIST HSP, Claim # 7682005610518
02/15/20 LABORATORY
1,418.00
02/15/20 X-RAY
410.00
02/15/20 EMERGENCY ROOM
1,310.00
Total

Type of service

$3,138.00

Discount

Amount
not
covered

Allowed
amount

Copay

Deductible

What your
plan paid

616.83
360.63
569.85

0.00
0.00
0.00

801.17
49.37
740.15

0.00
0.00
0.00

801.17
49.37
740.15

0.00
0.00
0.00

$1,547.31

$0.00

$1,590.69

$0.00

$1,590.69

$0.00

%
paid Coinsurance*

0
0
0

0.00
0.00
0.00

See
notes

A0
A0
A0

$0.00

* After you have met your deductible, the costs of covered expenses are shared by you and your health plan.
The percentage of covered expenses you are responsible for is called coinsurance.

You've
You've
You've
You've
You've

paid a total of $0.00 toward your $3,800 out of network family deductible for 2020
paid a total of $1,615.28 toward your $1,900 in network family deductible for 2020
paid a total of $0.00 toward your $12,000 out of network family out of pocket expenses for 2020
paid a total of $1,615.28 toward your $3,800 in network family out of pocket expenses for 2020
paid a total of $1,071.26 toward your Unlimited all medical benefits individual lifetime maximum

IF YOU ARE COVERED BY MORE THAN ONE HEALTH BENEFIT PLAN, YOU SHOULD FILE ALL YOUR CLAIMS WITH EACH PLAN.
A0 - CUSTOMER:THANK YOU FOR USING CIGNA'S OPEN ACCESS PLUS NETWORK. THE DISCOUNT SHOWN IS HOW MUCH YOU SAVED. YOU DON'T NEED TO PAY THAT AMOUNT. IF YOU
ALREADY PAID YOUR HEALTH CARE PROFESSIONAL MORE THAN THE "WHAT I OWE" AMOUNT, PLEASE ASK FOR A REFUND. HEALTH CARE PROFESSIONAL: YOUR CIGNA AGREEMENT
DOES NOT ALLOW YOU TO BILL THE PATIENT FOR THE DIFFERENCE. IF YOU ARE IN INDIANA, CALIFORNIA OR TENNESSEE, PLEASE CONTACT CIGNA CUSTOMER SERVICE AT
1.800.88CIGNA (882.4462) FOR INFORMATION ON YOUR DISCOUNTED RATE.

H701A 08/18

RETAIN THIS FOR YOUR RECORDS.

Page 3 of 4