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Cigna Global GOP Provider

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Royer Hyacinthe
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351 views2 pages

Cigna Global GOP Provider

Uploaded by

Royer Hyacinthe
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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GUARANTEE OF PAYMENT

Date: 01-Jun-21 Patient Name: ROLLAND RABESON


Attn: Clinique Médico-chirurgicale Patient Identification 509/09689/01
Andrindra. Number:
Country: Madagascar Date of Birth: March 14, 1959
Provider ID: Reference number: 0004755634
Group / Employer WORLD BANK
Type of Services: In Patient Number: GROUP - SHORT
Date(s) of Service: 01-Apr-2021 TERM CONSULTANTS
Note: This Guarantee
of Payment is valid for Cost Estimate
30 days before or after If no cost estimate has been provided before
proposed date of service the patient’s treatment, the costs are subject to
or until policy expiration. limitation, in accordance with reasonable and
Diagnosis(es): COVID-19, virus identified customary charges in the country of care.
Procedure(s): Multiple procedures/
treatments
Room Coverage: 100% of a private room
Date of Admission: 01-Apr-2021
Date of Discharge: 10-May-2021
Approved Length of Stay:

This Guarantee of Payment is issued by Cigna for the above named patient for the Diagnosis(es) and
Procedure(s) indicated above. Cigna guarantees payment of medically necessary, reasonable and
customary medical expenses for services covered by the benefits plan related to treatment for the above
diagnosis.

In the event of a change in diagnosis(es) or Procedure(s), you must inform us as soon as possible
so we can review the guarantee and extend it if appropriate. We may ask you for additional medical
information.
COVERAGE:
Cigna is responsible for the payment of: theroom charges as indicated above, 100% of the other hospital
expenses, 100% ofthe professional fees.

The patient is responsible for the following: 0%.

The patient’s medical plan has an overall maximum limit. Currently, the remaining balance is 50.000
USD.

EXCLUSIONS:
Patient convenience items (e.g., television, telephone, extras, etc.); Cosmetic treatments; expenses for
Robot surgery (unless authorized prior to surgery); optical and dental care; Rehabilitation/convalesce;
Spa Cures; (in)fertility treatment; maternity and delivery expenses; preventive care.

To obtain a settlement, please submit the final itemized invoice(s) within 6 months after the service(s) to
bills@cigna.com

Contacts for questions regarding:


Payment: providerquestions@cigna.com
Eligibility & Benefits: authorization@cigna.com

Or call us at the number on the customer’s ID card.

Best regards,
Alejandro Sanchez Santos

Cigna is a registered service mark and refers to Cigna Corporation and/or its subsidiaries and affiliates. Cigna Global Health
Benefits is a trading name that refers to these subsidiaries and affiliates. Cigna products and services are provided by or
through operating subsidiaries of Cigna Corporation. Cigna Global Health Benefits products and services are provided, between
others, by Cigna Health and Life Insurance Company, Cigna Life Insurance Company of Canada, Cigna Global Insurance
Company Ltd., Cigna International Health Services BVBA, Cigna Life Insurance Company of Europe SA/NV, Cigna Europe
Insurance Company SA/NV, Cigna European Services Limited, Cigna Worldwide General Insurance Company Limited, Cigna &
CMB Life Insurance Company Ltd., Cigna Insurance Middle East S.A.L., or contracted companies. Products and services may
not be available in all jurisdictions and are excluded where prohibited by applicable law. The Cigna name, logo, and other Cigna
marks are owned by Cigna Intellectual Property, Inc.
© 2021 Cigna. Some content provided under license.

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