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Retiree Medical, Prescription Drug and Mental Health and Substance Abuse Programs - Moore Wallace   
How to File a Claim
Retiree Group Health Program Claims
CIGNA is the claims administrator and network manager for Medical Program claims, and CBH is the claims administrator and network manager for Mental Health and Substance Abuse Program claims.
In situations when you or your spouse/domestic partner needs to file a claim, you or your spouse/domestic partner should follow these general instructions:
 | Participating providers in the CIGNA network have agreed to submit claims on your behalf. Show the provider your ID card or have him or her confirm your eligibility.
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| If you or your spouse/domestic partner receives care from a non-participating provider, you or your spouse/domestic partner needs to submit a claim. You or your spouse/domestic partner needs to submit a claim form each time you or your spouse/domestic partner receives treatment. Processing is faster when you or your spouse/domestic partner includes a claim form with your bill.
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| Fill out the applicable sections of the form completely. If your provider’s bill includes the services provided and the diagnosis, the back page of the form does not require completion.
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| Make sure that all bills and receipts are original and include the following information:
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 | The patient’s name, age, and relationship to the retiree;
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| The retiree’s name, address, and member number;
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| The name, address, telephone number, and tax identification number of the provider, hospital, laboratory, or pharmacy that provided the service or supply;
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| The date the service or supply was received;
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| A description of the service or a CPT (Current Procedural Terminology) code;
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| The patient’s diagnosis; and
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| The amount charged.
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| If you or your spouse/domestic partner wants the claims administrator to pay the provider of services directly, sign your name to the payment authorization box on the claim form. The check will be sent to the provider instead of to you or your spouse/domestic partner.
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| Mail the completed claim form and any attachments to the address on the form.
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| Keep a copy of the claim for your records. |
If you or your spouse/domestic partner has coverage under the Program and another group plan or program or Medicare, you or your spouse/domestic partner should submit a claim to the primary plan or program first. When the primary plan or program pays your claim, it will provide you or your spouse/domestic partner with an Explanation of Benefits (EOB) statement. Send the EOB statement, together with a copy of the bill, to the secondary plan or program to claim benefits from that plan or program.
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