893368 THN-2016-474 09/16
Cigna SureFitTM is a new plan offering that builds networks around local physician and hospital groups and provides our customers with access to personal, patient-centered care. Patients get to choose the primary care physician (PCP) that works best for their individual needs. And they can receive all of their care within the community of care network.
CIGNA SUREFIT
Denver and Boulder, Colorado
Important plan information
Hospital networkBoulder Community Hospital (BCH), HealthONE, Sisters of Charity of Leavenworth (SCL)
Emergencies In-network and out-of-network coverage for emergency care*
PCP selection PCP selection is required
Specialist referralsReferrals required. Select from health care professionals participating in the network aligned to the Cigna SureFit plan
Out-of-network coverage Visits to providers outside of the network aligned to the Cigna SureFit plan are not covered
National ancillary providersAll Cigna-contracted national ancillary providers currently in the market participate
Participating health care professionals search
Access the online directory at Cigna.com/hcpdirectory/
*For emergency medical conditions as defined in the plan documents.
Look in the top right corner of the ID card to identify the network aligned to the patient’s plan
Images for illustrative purposes only.
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Group: 00699999Issuer (80840)ID: 911111102Name: Christianna Q Johnson-SmythePCP: Bartholomew Johannsen MD
GCigna Health and Life Insurance Comapny
No Referral RequiredSureFit CO FI
RxBIN 017010 RxPCN 05180000RxGrp 00699999 RxID 911111102 00
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Mask 703 Issue Date: 11/25/15
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•PresentthisID
cardeach
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visitahealthcare
professional.•
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questionsortoelectorchangeyourPCP,please
visitourwebsite
orcallthetoll-free
customerservicenumberlocated
onyourID
card.
Group: 00699999Issuer (80840)ID: 911111102Name: Christianna Q Johnson-SmythePCP: Bartholomew Johannsen MD
GCigna Health and Life Insurance Comapny
Referral RequiredSureFit CO FI
RxBIN 017010 RxPCN 05180000RxGrp 00699999 RxID 911111102 00
ABCDEFGHIJKLMNOPQRSTUVWXYZabcdefghijkl 123456789012345678921234567893123456
Primary CareSpecialistUrgent CareERHospital Stay
$25/0%$50/0%$50/10%$150/10%$500/20%
030409440935
00000000002
0000002329
5116
>0000029440935
003040
RUN_DATE 20151125 16:48:22DATA_SEQ_NO 0000002CLIENT_NUMBER 003040UHG_TYPE DIG1CARDDOC_ID 9440935/000002-00DOC_ID 9440935/000002-01DOC_ID 9440935/000002-02DOC_SEQ_ID 0000002NAME Johnson-Smythe ,ChristiannaMAILSET_NUMBER 0000002CUST_KEY1 00699999CUST_KEY2 911111102CUST_KEY3 00CUST_KEY4 ChristiannCUST_KEY5 QCUST_KEY6 Johnson-Smythe
Wha
tdo
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mean
?De
d/Coin
-Sub
jectt
othe
plan
dedu
ctible
and/o
rcoin
sura
nce
Ded
-Sub
jectt
othe
plan
dedu
ctible
amou
ntCo
in-S
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tto
thepla
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insur
ance
amou
ntCo
pay-
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ctto
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paym
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rs/ur
gent
care
ER-E
merg
ency
Room
Hosp
italo
rHos
pital
Stay
-Inp
atien
thos
pital
Rx-P
harm
acy
The
follow
ingno
tice
appli
esto
custo
mers
cove
red
unde
rLo
uisian
apla
ns:
Your
shar
eof
thepa
ymen
tfor
healt
hca
rese
rvice
smay
beba
sed
upon
oura
gree
ment
with
your
prov
ider.
Your
prov
iderm
aybil
lyou
foram
ounts
upto
thepr
ovide
r'sre
gular
billed
char
ges.
'Cign
a'an
dthe
'Tree
ofLif
e'log
oar
ere
gister
edse
rvice
marks
ofCi
gna
Intell
ectua
lPro
perty
,Inc
.,lic
ense
dfor
use
byCi
gna
Corp
orati
onan
dits
oper
ating
subs
idiar
ies.
Allp
rodu
ctsan
dse
rvice
sare
prov
ided
byor
throu
ghsu
chop
erati
ngsu
bsidi
aries
and
notb
yCign
aCo
rpor
ation
.Suc
hop
erati
ngsu
bsidi
aries
includ
eCo
nnec
ticut
Gene
ralL
ifeIns
uran
ceCo
mpan
y(CG
LIC)
Cign
aHe
alth
andL
ifeIns
uran
ce(C
HLIC
),Ci
gna
Healt
hMa
nage
ment,
Inc.
and
Cign
aDe
ntalH
ealth
,Inc
.The
Cign
aDe
ntalP
POis
unde
rwritt
enor
admi
nister
edby
CGLIC
orCH
LICwi
thne
twor
kman
agem
ents
ervic
espr
ovide
dby
Cign
aDe
ntalH
ealth
,Inc
.,an
dce
rtain
ofits
oper
ating
subs
idiar
ies.I
nAriz
ona
and
Louis
iana,
theins
ured
Denta
lPPO
prod
uctis
refer
red
toas
the'C
GDe
ntalP
PO'
(CGL
IC)o
r'CH
Denta
lPPO
'(CHL
IC).
InTe
xas,
theins
ured
denta
lpro
duct
offer
edby
CGLIC
and
CHLIC
isre
ferre
dto
asthe
'Cign
aDe
ntalC
hoice
Plan
'.Th
eCign
aDe
ntalP
PONe
twor
k(s)i
sana
tiona
lrefe
renc
eto
ourn
etwor
k;in
Texa
sthi
snetw
ork(s
)will
beuti
lized
with
theCi
gna
Denta
lCho
icePl
an
Medical Claims PO Box 188061 Chattanooga, TN 37422-8061 Payer ID #62308Dental Claims Cigna Dental PO Box 188037 Chattanooga, TN 37422-8037 Payer ID #62308Rx Claims: Pharmacy Service Center, PO Box 188053 Chattanooga TN 37422-8053Customers & Medical & MHSA Health Care Professionals: call 1-866-494-2111Routine Vision Health Care Professionals call 1-877-478-7557For Pharmacists Only 800-351-9170
Mask 703 Issue Date: 11/25/15
*116*
00000000DIRECT
USPS
Christianna Johnson-Smythe124 Purple PlaceDenver, CO 80999
20151125Wed Nov 25, 2015 @ 16:48:22N
703
BCH HealthONE SCL Health In Network Only
Cigna Dental PPO Cigna Vision
Total Cigna DPPO
CO-DOI
You may have to show this card when you receive care. This doesn’t guarantee coverage. Not using this card correctly is fraud. For emergencies, call 911 or get immediate care. Contact your doctor after you get emergency services. If you don’t know if your situation is an emergency, call your doctor or our 24/7 Health Information Line. Customers: Check your plan documents for out-of-network (OON) precertification requirements. This may affect your OON benefits. Health Care Professionals: Check your provider contract for precertification requirements. Customers: myCigna.com Health Care Professionals: CignaforHCP.com
Boulder and Denver, CO
Cigna SureFit service area for Boulder and Denver, Colorado
Adams, Arapahoe, Broomfield, Boulder, Denver, Douglas, and Jefferson counties
The network aligned to the Cigna SureFit plan includes access to many hospital and physician groups, including:
Hospital systems
› Boulder Community Hospital (BCH)
› HCA/HealthONE
› Sisters of Charity of Leavenworth (SCL) (formerly Exempla)
Cigna Collaborative Care (CCC) large physician groups
› Community Medical Associates
› New West Physicians
› PHPprime
› Rose Integrated Health Network
This listing is not all inclusive. For a complete listing of physicians and facilities, please refer to the online health care professional directory at Cigna.com/hcpdirectory/.
Cigna SureFit service areaHHospital locations
● Physician groups
JEFFERSONARAPAHOE
DOUGLAS
ADAMSBROOMFIELD
BOULDER
HH
HHHH
H
H
H
H
DENVER
Referrals and precertification
To support coordination of care, PCPs must request referrals to specialists for their patients with a Cigna SureFit plan. Precertification may be required for some services.
If you need to submit a referral or obtain precertification for a patient, please use one of the following options.
› Health care request and response (ANSI 278): Contact your electronic data interchange (EDI) or practice management system vendor.
› Phone: 1.866.494.2111, choose the prompt for specialist referral or precertification.
› Fax: 1.866.873.8279. You can obtain referral and precertification forms on the Cigna for Health Care Professionals website (CignaforHCP.com > Resources > Form Center > Medical Forms).
› Mail: Cigna Attn: Precertification and Referral Department 2nd Floor, 1640 Dallas Parkway, Plano, Texas 75093
Specialists can confirm referrals by using one of the following options.
› The PCP’s written referral presented by the patient
› Calling Cigna Customer Service at 1.866.494.2111. Choose the prompt for specialist referral
When making referrals, access the online directory at
Cigna.com/hcpdirectory/ to find participating physicians, hospitals, and other health care professionals.
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, and Cigna Behavioral Health, Inc. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. All pictures are used for illustrative purposes only.
893368 THN-2016-474 09/16 © 2016 Cigna. Some content provided under license.
Questions? We’re here to help. Visit CignaforHCP.com or call 1.866.494.2111.
To avoid delays in processing your referral or precertification, please confirm your EDI vendor is using “SC” for specialty care review in the Request Category Code field (UM01 segment) for referrals, and “AR” for admission review or “HS” for health services review in the Request Category Code field (UM01 segment) for precertification.