contact details
Cigna International Health Services BVBA • Plantin en Moretuslei 299 • 2140 Antwerpen • Belgium Patient name and patient ID (see Cigna membership card).
COST ESTIMATE
of my personal information (including medical data) as defined in Cigna's Privacy policy. Signature of the plan member and date.
Provider Frequently Asked Questions Regarding Cigna Members
Where do I send claims for Cigna members? 1. As of 1/1/2013 Cigna members can now access Allegiance providers at in-network rates as long as the.
CONTACT INFORMATION FOR CIGNA INTERNATIONAL HEALTH
Use the Cigna Claim Form for Reimbursement of Medical and Dental Expenses. Your personal reference number is indicated in your Cigna membership card.
A guide to your group medicAl benefits plAn
Cigna is the insurance administrator for the World Bank Group's Medical Benefits. Plan (MBP) for active staff and covered family members Retiree Medical
CIGNA WELLBEING® APP
WHAT SERVICES ARE PROVIDED? • Telehealth. • Plan helpline and member portal access. • Health and Wellbeing Assessments. • Targeted Assessments relating to sleep
Quick Reference Guide - for MVP National Alliance with Cigna
Cigna HealthCare allows MVP's upstate New York provider network to treat Cigna members. Provider contracts have been amended to allow MVP providers to see
CIGNA ENVOY
Enter your nine-digit Cigna membership number into the “Cigna Identification number” field. Then click. “Register” to proceed to next step.
APPLICATION TO REGISTER AS A CIGNA PROVIDER
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Cigna
Please be aware that if the provider of service holds a contract with Cigna and its affiliates
Benefits please complete this form.
Please note by applying to be a registered provider you agree to adhere to the Cigna Fee Schedule. All sections marked
with * are mandatory, your application will not be successful if these sections are not fully completed and signed by
the applicant at the bottom of the form. The form must be completed fully using BLOCK CAPITALS. When you have
completed the form you can return it to us either via email to provider.a?airs@cigna.com , fax to 01475 788448 or post
to Provider A?airs, Cigna HealthCare Benefits, 1 Knowe Road, Greenock, Scotland PA15 4RJ.1. PROVIDER DETAILS
Title (Mr, Mrs, Dr, etc.)*
Full name*
Gender*
FemaleMale
Correspondence address 1*
Correspondence address 2
Correspondence town/city*
Correspondence postcode*
Email address*
Telephone number*
Website address
2. SECRETARY DETAILS
Title (Mr, Mrs, Dr, etc.)
Full name
Telephone number
Email address
3. SPECIALTY
Provider specialty*
Clinical areas of interest
4. REGISTRATION
Please provide the governing body registration
number (example: HCPC)Any other details
5. BILLING
HealthcodeYes:No:
Other (if NO above)
1396 MED/PRO/PRE/0321
6. ADDITIONAL CLINICS
Please advise us of clinics the provider has privileges at*Facility nameFacility address
7. BANKING DETAILS
Please note:
Payments will ONLY be paid by Direct Credit (BACS) to your bank account and a separate remittance advice will be sent.
Bank name*
Sort code*
Account number*
IBAN number
8. REMITTANCE ADVICE
Remittances will be sent via Healthcode if you are invoicing us via that method. Otherwise they will be sent to the email address
in section 1 unless specified di?erently below.Alternative email
9. WEB CONSENT
I hereby give consent for our details to be included on Cigna's website (Please tick)10. DECLARATION
By signing this form you are agreeing to adhere to the Cigna Fee Schedule when treating a Cigna member. If you do not sign
this declaration this application will not be considered and Cigna members will be directed to an alternative provider.
Below is a link to the Cigna fee schedule web pages:Signature*
Date* *Mandatory FieldCopyright © Cigna 2021 All rights reserved. Cigna European Services (UK) Ltd (Financial Services Register No. 788765) is an appointed representative for
Cigna Life Insurance Company of Europe S.A.-N.V. UK Branch (Financial Services Register No. 202845) and Cigna Europe Insurance Company S.A.-N.V.
UK Branch (Financial Services Register No. 207198) which are authorised and regulated by the National Bank of Belgium. Deemed authorised by the
Prudential Regulation Authority. Subject to regulation by the Financial Conduct Authority and limited regulation by the Prudential Regulation Authority.
Details of the Temporary Permissions Regime, which allows EEA-based firms to operate in the UK for a limited period while seeking full authorisation,
are available on the Financial Conduct Authority's website. Cigna Europe Insurance Company SA-NV, UK branch, is a foreign branch of Cigna Europe
Insurance Company S.A.-N.V. (a company registered in Belgium in the Brussels Trade Registry with limited liability, authorised under licence 2176 and with
Registration Number 0474.624.562 and registered address at Plantin en Moretuslei 309, 2140 Antwerp, Belgium), registered in England and Wales with
registered number BR017168 and registered address at 13th Floor 5 Aldermanbury Square, London, EC2V 7HR. Cigna Life Insurance Company of Europe
SA-NV, UK branch, is a foreign branch of Cigna Life Insurance Company of Europe S.A.-N.V. (a company registered in Belgium in the Brussels Trade
Registry with limited liability, authorised under licence 0938 and with registration number 00421.437.284 and registered address at Plantin en Moretuslei
309, 2140 Antwerp, Belgium), registered in England and Wales with registered number BR000754 and registered address at 13th Floor 5 Aldermanbury
Square, London, EC2V 7HR. Cigna European Services (UK) Limited is a limited company having its registered address at 13th Floor, 5 Aldermanbury
Square, London EC2V 7HR and registered number 00199739quotesdbs_dbs7.pdfusesText_13[PDF] cigna payer id
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