Frequently Asked Questions

Individuals are frequently asked to make informed decisions about the care they receive, and may not always understand what they have to pay or how their payment amount is determined. In addition, attempts to collect coinsurance or deductibles at the point of care can result in patients making duplicate or incorrect payments.

The Cigna Cost of Care Estimator® can help eliminate these issues by allowing you and your patients in Cigna-administered plans to see the total owed for your services, what their plan benefits will cover, and what they will have to pay out-of-pocket.

  • In 2009, we launched the Cigna Cost of Care Estimator, technology that informs you and your patients in Cigna-administered plans what they will be expected to pay for specific services, based on their plan.
  • The tool can now be used with patients in all these Cigna-administered plans:
    • Preferred Provider Organization (PPO)
    • Exclusive Provider Organization (EPO)
    • Open Access Plus (OAP) and Open Access Plus In-Network (OAPIN)
    • Managed care plans (HMO, Network-EPP, HMO Open Access, Network Open Access, HMO POS-Flex, Network POS-DPP, HMO POS Open Access, Network POS Open Access)
    • Choice Fund
    • Cigna Behavioral
  • The Cigna Cost of Care Estimator can help your patients understand their specific benefits and how much they will be expected to pay for specific services by providing itemized cost estimates and explaining the sources of payment. It can also help facilitate proactive pre-care financial discussions between you and your patients.
  • You do not need to invest in new technologies to use the Estimator – you can quickly obtain estimates using your existing desktop technology.
  • Providing the Estimator reinforces our commitment to shorten the revenue cycle by improving our payment information and processes, and providing information that enables you to reduce patient bad debt.

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  • Frequently Asked Questions

    • General

    1. What is the Cigna Cost of Care Estimator?

      2. The Estimator is an electronic tool that can enable you to create an estimate of your patient's payment responsibility specific to you and the treatment or service, based on a real-time snapshot of your patient's Cigna-administered plan.

    2. How do I access the Estimator?

      3. As a participant in the Cigna network, you can access the Estimator by logging in to Cigna for Health Care Professionals website (CignaforHCP .com) At the top of the page, select Patients > Search Patients > Select Patient > Estimate Costs.

      If you are not already registered for the website, go to the home page and select "Register Now." You will be able to use the Estimator tool once you've completed a simple registration process.

    3. How will I know what to do when I access the Estimator tool?

      4. You will be taken step by step through the estimation process once you access the tool.

      You and your office staff that have been delegated access to the Cigna for Health Care Professionals website can also take the Cigna Cost of Care Estimator eCourse by logging in at the top of this page, then select Resources > eCourses to learn what to expect when using the Estimator.

    4. How does it work?

      5. The Estimator uses technology that is already available in your office.

      • To run an estimate, log in to CignaforHCP.com > Patients > Search Patients > Select a Patient > Estimate Costs.
      • You should then enter in CPT or HCPCS codes, place of service, service type, other identifying information about the service(s), and anticipated date of service, along with identifying information about your patient (date of birth, Cigna ID number, etc.)
      • After this information is submitted, you will receive an Explanation of Estimate that details the total cost, how the patient's Cigna-administered benefits are applied, the anticipated payment from their health account (such as an HRA), and any out-of-pocket costs for which they would be responsible.

    5. Can the Estimator only be accessed through the Cigna for Health Care Professionals website?

      6. No. We have successfully worked with leading multi-payer vendors such as Availity and Navinet to allow you to access the Estimator functionality through your preferred systems.

    6. Am I required to use the Estimator?

      7. No. However, using the Cigna Cost of Care Estimator can be beneficial as it provides estimates for many types of services, interacts easily and effectively with current systems, and helps facilitate proactive pre-care financial discussions between you and your patients. It can also assist in minimizing confusion, late payments of bills, and potential bad debt issues.

      In many cases you will receive a direct payment on behalf of your patient through our automatic claim forwarding (ACF) capability. However, we understand that market dynamics may be causing you to collect deductibles and coinsurance amounts at the point of care. While we do not encourage point of care collections, if you do decide to take this approach, we are requiring that you use the Cigna Cost of Care Estimator and provide the resulting Explanation of Estimate to your patient. The Estimate will show the amount due and allow for a financial discussion between you and your patient prior to services being rendered.

    7. For what services can the Estimator be used?

      8. The Estimator can be used for all professional services in all care settings (e.g., outpatient, facility, specialty, etc.) and for outpatient and inpatient facility services and treatments. Estimates can be generated at any time prior to or during the patient's visit to the office or facility – at appointment scheduling, at check-in or registration, pre-care, or check-out.

      We do not recommend that you use the Estimator for the following care scenarios:

      • Advanced Radiology
      • Autism services
      • Chemotherapy/High cost drugs
      • Emergency room
      • Home health visits
      • Implants
      • Infertility benefits
      • Maternity (outpatient/professional estimates)
      • Physical therapy/Occupational therapy
      • Transplants
      • Vision
      For more information, contact your Health Care Professional Experience Consultant.

    8. How do I use the Estimator for inpatient procedures?

      9. To run an inpatient estimate:

      • Select "Inpatient Hospital Facility Services" as the estimate type in Step 2 (Describe Service) of the estimation process.
      • Select the appropriate service type and health care professional or facility.
      • Select the appropriate "Clinical Category" and "Code Description". The "Code Description" drop down box will display only those services related to the clinical category selected.

    9. Can the Estimator be used with all Cigna-administered plans?

      10. The Estimator can be used with patients enrolled in these Cigna-administered plans:

      • Preferred Provider Organization (PPO)
      • Exclusive Provider Organization (EPO)
      • Open Access Plus (OAP) and Open Access Plus In-Network (OAPIN)
      • Managed care plans (HMO, Network-EPP, HMO Open Access, Network Open Access, HMO POS-Flex, Network POS-DPP, HMO POS Open Access, Network POS Open Access)
      • Choice Fund
      • Cigna Behavioral
      If you or your facility participates in the HAP alliance network, you can run estimates for your patients in the above mentioned Cigna-administered plans, and will receive estimates specific to you or your facility.

      If you or your facility participates in the HealthPartners, Tufts, and MVP Health Care alliance networks, you can run estimates for patients in the above mentioned Cigna-administered plans. However, the estimates will be based on regional averages and will not reflect negotiated discounts. Estimates will not be specific to individual contract rates, therefore we recommend if you are part of these networks that you not use the Estimator.

      There is significant contractual overlap between health care professionals in Cigna direct networks and the CareLink network in Massachusetts and Rhode Island for patients who participate in the above mentioned Cigna-administered plans. This overlap does not allow the Estimator to create estimates specific to you for your patients in these markets at this time. If you are a health care professional in Massachusetts or Rhode Island and attempt to use the Estimator, the estimate generated will be based upon regional averages. This means the estimate is not specific to you and does not reflect negotiated discounts. This may also cause you to receive the error message "We are unable to generate an estimate at this time." We are working on a solution and will notify you when new information is available.

      Estimates are not currently available for your patients covered by these Cigna-administered plans or networks:

      • Shared Administration (Taft-Hartley)
      • Starbridge or Fundamental Care
      • Global Health Benefits

    10. What happens if I try to run an estimate on a patient that is not in one of the plans that can be used with the Estimator?

      11. If you try to run an estimate on a patient that is not in one of the Cigna-administered plans mentioned above, you will receive the error message, "Member is not eligible for cost of care estimation."

      You will receive this error message if the patient does not have active coverage in a Cigna-administered plan, the date of service is greater than 30 days of a service being performed, the patient is not in a plan that can be used with the Estimator, or if our records indicate the patient has other insurance [coordination of benefits (COB)].

    11. Can the Estimator be used for capitated services? (medical only)

      12. Yes. The Estimator can be used for capitated services if we receive the utilization from you or your group for those services or claims. The results shown for these capitated services are intended to be a "preview" of what is reflected on the explanation of benefits (EOB) provided to your patient.

      If you submit encounter information to us, the allowed amount for services will be the fee-for-service equivalent amount shown on your patient's EOB. This amount will be the basis for the patient liability calculations. The patient liability reflected in the estimate will be as accurate as those for non-capitated services or Open Access plans.

      If we do not have any submitted encounters from you, the estimate returned will not be specific to you.

    12. Can I use the Estimator if the patient's Cigna-administered plan is not their primary insurance?

      13. No. Since we would not know the contract rates or benefit coverage for the primary insurer, estimates are only available where the Cigna-administered plan is the primary coverage and there is no other coverage involved.

    13. Is special technology required for the Estimator?

      14. No. The Estimator is available using the Internet to access CignaforHCP.com.

    14. When should I run an estimate?

      15. The Cigna Cost of Care Estimator can be used to run an estimate up to 30 days prior to a service being performed. We encourage having the financial discussion as early in the care encounter process as possible, for example at time of scheduling. However, if an estimate is run early, it should be re-run just prior to care being rendered to ensure the most up-to-date information, such as deductible status.

    15. How accurate is the Estimator? Does it differ from the final paid claim amount?

      16. The Estimator accurately predicts the actual cost to the patient in a Cigna-administered plan within +/- 10% nearly 90% of the time at the time the estimate is generated. Accuracy at the time of the estimate's creation is important because that is the moment at which you and your patient are having a financial discussion and need accurate information.

      While in most cases the estimate will be very close to the final billed amount, there are factors that can change the estimated amount vs. the claim paid amount, including changes in deductible status (i.e., the deductible or out-of-pocket maximum is reached between the time of the estimate and the claim submission), and changes in the services that are estimated and the services that are billed, which can cause the patient's responsibility to be different from the estimated responsibility. These instances are outside of our control, and can occur with any cost estimation tool.

    16. What does an Explanation of Estimate look like?

      17. Here is a link to a sample of a printed Explanation of Estimate.

    17. How does the Cigna Cost of Care Estimator differ from other estimation tools?

      18. The Estimator is unique in that it combines an estimated total cost based on your contracted rate with a real-time snapshot of your patient's Cigna-administered benefits. This means the estimate is personalized and is very accurate based on that patient's benefits at the time the estimate is created.

      The itemized cost estimate is generated by the proprietary Truven Health Analytics treatment cost calculation tool and backed by its analytic and predictive modeling expertise. Compared to other vendor solutions, the Cigna Cost of Care Estimator has the following advantages:

      • It provides an opportunity for a financial discussion between you and your patient – before care is rendered – and provides a consumer-friendly Explanation of Estimate that serves as educational material for your patient.
      • It is available for all care settings, including those where high-cost services are used most, having significant financial impact on the patient.
      • It is easy to use and requires no new systems or technology.

      The Cigna Cost of Care Estimator aligns with current industry initiatives, such as CORE and AHIP, by aiding in the quest for administrative simplification between payers and health care professionals.

    18. Do primary administrators on CignaforHCP.com have to delegate access for other staff to access the Estimator?

      19. No. Primary administrators do not have to delegate access for other staff to access the Estimator. Every user that has access to Eligibility and Benefits on CignaforHCP.com has access to the Estimator. All users automatically receive access to the Eligibility and Benefits transaction when they either register or are delegated access to the website.

      To become familiar with the Estimator, you and your office staff can take the Cigna Cost of Care Estimator eCourse by logging in to this site and selecting Resources > eCourses.

    19. Have my patients been educated about the Cigna Cost of Care Estimator?

      20. Your patients who participate in a Cigna-administered plan that can be used with the Estimator have been sent targeted communications. Materials have also been provided to employers for distribution to their employees with these plans.

    20. Can my patients use the tool themselves if the Estimator can be used with their Cigna-administered plan?

      21. No. A separate estimation tool is available to these patients through the "Find a Doctor" link on myCigna.com . These patients have the ability to:

      • Find detailed cost estimates for over 200 common procedures
      • Compare costs by health care professional or facility
      • See quality distinctions of health care professionals in our network, including physicians with Cigna Care designations
      The estimates produced are specific to your patient, and use real-time calculations of their potential liability including deductible, coinsurance, and out-of-pocket maximums. This is the same functionality used by the Cigna Cost of Care Estimator.

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    Contract/Network

    1. Can I use the Estimator if my patient has Tiered Benefits or I am in a Client Specific Network (CSN)? (medical only)

      2. If you are a Tier 1 health care professional, or if you and your facility participate in a CSN, you have access to run estimates for patients in applicate plans. However, the estimate transaction is not able to determine the Tiered Benefits or appropriate CSN benefit. This results in the estimate showing a higher liability for your patient. Contact your Health Care Professional Experience Consultant for more information.

    2. Is the Estimator available through prnLink?

      3. No. The Cigna Cost of Care Estimator is not available on prnLink. For more information, contact your Health Care Professional Experience Consultant.

    3. If I am part of a third party vendor (TPV), can I use the Estimator?

      4. Yes. If you are part of a TPV, you are considered contracted with Cigna and are able to use the Estimator if you are a registered user of CignaforHCP.com.

    4. How does the Estimator work for me if I have discounts on billed charges in my contract?

      5. The Estimator looks into past claims history to determine the appropriate payment amount which should allow an accurate estimate to be generated.

    5. Can I use the Estimator if my hospital bills with revenue codes?

      6. You and your facility are required to enter CPT or HCPCS codes to run an estimate for outpatient services. All facilities bill CPT/HCPCS codes in conjunction with the revenue codes, specifically for outpatient, surgery, radiology, and laboratory. The appropriate CPT or HCPCS codes are needed to generate the estimate. The tool does not recognize revenue codes for this functionality.

      For inpatient services, you must select a clinical category and code description to describe the purpose of the stay.

    6. Can I use the Estimator if I am not part of the Cigna network?

      7. No. You must be directly contracted and part of the Cigna network in order to use the Estimator, even if you see patients covered by Cigna-administered plans, or have received claim payments from us.

    7. I am a new physician to the Cigna network. Can I use the Estimator?

      8. If you have recently contracted with us, estimates specific to you may not be available until you have current claims data in our systems that reflect your new contract rates. The Estimator generates estimates based on historical claims data. Until your claims data is in our system, the tool may provide estimates based on regional averages that may or may not reflect your contract rates.

    8. Did Cigna change its policy regarding point of care (POC) collections?

      9. We understand that market dynamics may have caused you to implement a collections policy at the point of care for deductible and coinsurance amounts, regardless of carrier policies. In acknowledgement of the shift in behavior and its impact to our customers, we are providing tools and capabilities that enable you to have a more complete picture of your patient's Cigna-administered benefits and helps ensure appropriate patient billing.

      If you decide to collect deductibles or coinsurance prior to receiving the explanation of payment (EOP) or direct deposit activity report (DDAR), we are requiring that you use the Cigna Cost of Care Estimator and provide the resulting Explanation of Estimate to your patient. The Estimate will show the amount due and allow for a financial discussion between you and your patient prior to services being rendered.

      As a reminder, patients participating in Cigna-administered Choice Fund plans can choose to have their out-of-pocket costs paid directly out of their health account(s). After claim processing, if funds are available, we will automatically sends payment to you on behalf of your patient in the Choice Fund plan, usually along with our portion of the payment. This process, called automatic claim forwarding (ACF), is highly encouraged by us and is currently active on over 95% of our customers covered by Choice Fund plans.

      ACF offers significant bad debt mitigation through automatic and direct payments, and helps alleviate the need for your office to pursue the patient for any applicable coinsurance or deductible payments. ACF can help shorten your revenue cycle by improving our payment information and processes, and providing information that enables you to reduce patient bad debt.

    9. How is my contracted rate used when generating an estimate?

      10. The Estimator tool uses a rolling 12 months of claims history as a proxy to the contract rates. The actual contract rates are not utilized to build the estimates. Your patient's specific Cigna-administered benefits are then applied to the estimated cost of the service(s) for which you are requesting the estimate. Market trials validated this approach to be highly accurate in simulating claims payment rules, which may not be apparent in contract language.

    10. What if I receive an estimate that does not match my current contract rate with Cigna?

      11. The estimation process builds estimates based on a rolling 12 months of claims history, specific to Cigna and the plan types with which the Estimator can be used. There will be instances where we do not have enough paid claims data to produce an estimate specific to your rate and will therefore provide an estimate based on a broader base of our paid claims, or in rare instances, provide an estimate based on Truven Health Analyitics' paid claims database.

      In these instances, the estimate generated is still a reasonable number to share with the patient for setting a financial expectation.

    11. What happens when a contract rate is renegotiated between the last claim encounter and when I request the estimate?

      12. The Cigna Cost of Care Estimator will use the most current rate based on the claims history available. The changes to the contract will not be reflected until the next system update, which is every 30 days, provided that you have submitted claims within the last 30 days and we have finalized those claims within that same time period. After that time, an estimate would be generated using the new rate.

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    Fund Account

    1. How do I receive the payment indicated from the patient's health account?

      2. Your patients who participate in Cigna Choice Fund plans can choose to have their out-of-pocket costs paid directly out of their health account(s) through automatic claim forwarding (ACF). After claim processing, if funds are available, we automatically send payment to you on behalf of the patient in the Choice Fund plan, usually along with our portion of the payment. ACF is highly encouraged and is currently active for over 95% of customers covered by our Choice Fund plans.

      The goal of ACF is to reduce collection time and expense for you while allowing your patients greater control over their health care fund.

    2. Will the amount that is to be paid from my patient's health account (HRA/HSA/FSA) be "held" once the estimate is generated?

      3. No "holds" will be put on the funds available in a patient's health spending account when an estimate is generated.

    3. Is flexible spending account (FSA) and health savings account (HSA) fund information available through the Estimator?

      4. A section on the Explanation of Estimate indicates the "Anticipated payment from my health account (for account based plans only)." Depending on the type of coverage or health financial accounts your patient has, different information will be displayed in that section.

    4. Are the fund balances of patients with HSAs or FSAs being shown on the estimate?

      5. HSA and FSA account fund balances (i.e., the total amount in the account) are not shown on the estimate. Here is how that information is shared:

      • For HSA and FSA, the Estimator will only indicate whether there are sufficient funds in the account to cover the estimated amount (e.g., if the estimated out-of-pocket cost is $50 and there is $200 in the HSA, the Estimator will only indicate there is $50 available to cover the estimated amount.)
      • Only patients with HSAs and FSAs who have health care professional-assigned ACF turned on will have available balance information included on the estimate.
      • You will not see total balance information.

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    Estimate

    1. Can I request an estimate for a facility charge if a treatment will involve both my and a facility's services?

      2. No. You can only request an estimate for the services or treatment you provide. The facility would have to run its own estimate to determine their charges. However, if the entity is responsible for billing both your and a facility's services, separate estimates can be run for each component.

    2. I am now part of the Cigna network, but I used to see patients in Cigna-administered plans and submitted claims while I was not participating in your network. Will my "non-par" claims data be used for generating estimates?

      3. No. We do not use out-of-network claim history for in-network estimates. If you do not have current in-network claims data with us, the tool will be unable to generate an estimate based on your specific in-network rates.

    3. What if my claims have been paid incorrectly or there was a contract renewal with new rates?

      4. The Estimator looks into past claims history, including adjustments, which should allow an accurate estimate to be generated. Information is updated every 30 days.

    4. How does the Estimator determine if precertification should be a factor in the estimate?

      5. The Estimator does not determine whether or not the service being estimated requires precertification. The estimate is based on the eligibility and benefits information, which does not include precertification requirements.

    5. Does the Estimator take into consideration pre-existing conditions when running an estimate?

      6. No. An estimate is based on the eligibility and benefits information, which does not include pre-existing information.

    6. Is the estimate a guarantee of coverage or payment? (medical only)

      7. No. It is only an estimate of the amount the patient will owe if the billed services are covered; it is not a guarantee of coverage for the charges made. The final amount the patient may owe may change from the estimate for several reasons:

      • The patient's benefits have changed from the time the estimate was run.
      • The patient's coverage with Cigna has ended.
      • Other claims have processed before the services were received and submitted for payment.
      • Fewer, more, or different services were received.
      • The patient's out-of-pocket plan maximum (when the plan starts to pay 100% for covered services) has been met.
      • The patient has more than one medical plan and coverage is coordinated with that plan.
      • The patient's copayment or coinsurance may vary based upon their benefit plan.
      • The chosen health care professional is out-of-network (non-participating) for the patient's Cigna plan.
      • The amount in the patient's health account (HSA, HRA, FSA) has changed.

    7. How does the Estimator determine anesthesia costs?

      8. The Estimator does not look at your specific anesthesia claims when determining an estimate. Instead, the tool looks at a broader level to determine what a service is generally reimbursed at in a market or regional area. The tool also verifies if the procedure chosen typically has anesthesia charges linked to it. If the procedure code entered is for a service that typically does not include anesthesia charges, the tool will not calculate anesthesia costs into the estimate, even if you have selected "include anesthesia" on the request.

    8. Are all CPT/HCPCS codes loaded into the Estimator and available for estimates?

      9. Since estimates are based on paid claims history, we're able to estimate the majority of services you have rendered to your patients covered by a Cigna-administered plan.

    9. The Estimator allows up to 10 CPT/HCPCS codes to be entered when running an estimate. Is the cost for each individual code shown on the Explanation of Estimate?

      10. The Explanation of Estimate will display the individual procedure codes for which the estimate was run. It does not list each cost separately but will display a combined estimated amount for all procedure codes entered.

    10. What happens if I don't know the complete CPT/HCPCS code and/or description?

      11. You should use the "Lookup Code" feature to search for the appropriate CPT/HCPCS code. You may perform a CPT/HCPCS code search either numerically or alphabetically.

    11. What happens if an old or invalid CPT/HCPCS code is entered?

      12. You will receive an error message indicating an estimate cannot be generated using the code entered. The tool will automatically validate whether the procedure code(s) entered is a valid code once you hit the "Submit Estimate" button. The validation process will look at the code sets from the previous calendar year as well as the current calendar year.

      Remember that the CPT/HCPCS procedure code field requires five characters in order to return an estimate. If you have not entered the required five characters for the desired procedure code, the Estimator will return an error message indicating this.

    12. What happens if a CPT/HCPCS code is new and not yet in your system?

      13. You will receive an error message indicating an estimate cannot be generated using the code entered.

      Remember that the CPT/HCPCS procedure code field requires five characters in order to return an estimate. If you have not entered the required five characters for the desired procedure code, the Estimator will return an error message indicating this.

    13. Does the Estimator consider multiple procedure payment guidelines when determining an estimate?

      14. Yes. The Estimator is able to calculate an estimate using multiple procedure payment guidelines.

    14. Can I still run an estimate if I can't find certain modifiers in the drop down list?

      15. Yes. Only those modifiers that have an impact on the cost of the service are listed in the drop down list.

    15. What if the provider drop down box does not display individual physicians associated with my group?

      16. If your group has more than 50 health care professionals linked to a particular identification number, you have the option of searching for an individual health care professional using the "Associated Providers" search option. If the health care professional still cannot be found, you should contact us at 1.800.261.6232 to have your user profile reviewed.

    16. What should I do if I receive a message indicating the number of health care professionals associated with my profile exceeds 15,000?

      17. You should contact us at 1.800.261.6232 to have your user profile reviewed.

    17. Why is the Estimator indicating that there is a deductible due when the Eligibility and Benefits page indicates it does not apply for this benefit?

      18. The Estimator is indicating that the plan level deductible still applies, even though the benefit itself does not carry a separate deductible.

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    Additional Information

    • For technical assistance with the Estimator or CignaforHCP.com, call 1.800.261.6232.
    • For assistance with site navigation and registration for CignaforHCP.com, call 1.800.853.2713.
    • For general assistance, call 1.800.88Cigna (882.4462).
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