For Network General Dentists

WELCOME TO CIGNA DENTAL CARE®

D6048a Rev. 06/18 © 2018 Cigna. Some content provided under license.

Online Solutions

Patient and claim information at your fingertips

Electronic claims submission

Electronic funds transfer & electronic remittance advice (ERA)

Encounters/Claims

Specialty referral guidelines

Specialty referral form

Alternate benefit provision guidelines

Plans with alternate benefit provision

Sample: Encounter error reportSample: Supplemental and office-visit payments closing report

Table of contents

WELCOME TO CIGNA DENTAL CARE®

“Cigna Dental Care” is a brand name used to refer to product designs that may differ by state of residence of enrollee, including but not limited to, prepaid plans, managed care plans (including Dental HMO plans), and plans with open access features. The Cigna Dental Care plan may not be available in all states.All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Cigna HealthCare of Connecticut, Inc., and Cigna Dental Health, Inc. and its subsidiaries. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc. D6038 Rev. 01/19 © 2019 Cigna. Some content provided under license.

Benefits to Your Practice

Promote your practice with Brighter Profile®

Cigna Network Rewards Program®

Vision Network Savings Program

Dental office supply requisition form

Need to connect with us? We’ve got your answer

Thank you for joining the Cigna Dental network. The information in this welcome kit will help you administer the Cigna Dental Care® plan as efficiently as possible. Our goal is to reduce your administrative burden, so you can spend more time at the heart of your practice – providing dental care to your patients, and our customers.

Use the links below to go directly to any section of the welcome kit.

The Cigna for Health Care Professionals website (CignaforHCP.com) is designed with YOU in mind – to fit your needs and the way you work. The website provides secure, 24/7 access to patient and claim information, and includes features like auto-save and flagging that save you time and keystrokes.

As a dental health care provider, you have access to all of these useful features:

Patient and claim information at your fingertiPs

cigna for Health care Professionals Website

start using cignaforHcP.com today If you’re not yet registered for the Cigna for Health Care Professionals website, go to CignaforHCP.com and click “Register Now.” If someone in your office is already registered to use the website, he or she may be able to grant you immediate access. Take a self-guided tour by visiting CignaforHCP.com and clicking “Site Tour” at the bottom of the page. To learn more about CignaforHCP.com, log in to CignaforHCP.com > Resources > eCourses, or call 1.800.Cigna24 (1.800.244.6224).

Offered by: Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company or their affiliates.

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc.

869193 a Dental 2017 01/17 © 2017 Cigna. Some content provided under license.

Easily access all your tools from your personalized “home page”

See eligibility and coverage detail

• Search and view claims• Review claim details

• Access claim payment reports up to two years

• Save and share PDF reports

• Access financial and office management reports up to two years

• Save and share PDF reports

• Enroll and manage electronic funds transfer

• Update Provider Directory Information

• Assign or update website access

Access:• Dental plans and products• Reference guides• DHMO patient charge schedules • Cigna Network Rewards Program®

Use flagging to quickly and easily save patient and claim information to your dashboard

Use “Detach” to open a new window to compare coverage and claim details pages to other web pages, without having to toggle between pages

Flexible tabs work just like your favorite browser to let you easily manage all your work

Submitting dental claims electronically can help you save time and money, and improve claim processing accuracy.

Benefits of submitting claims to Cigna electronically

› Quicker claims submission, including DHMO encounters

› Receive payments faster

› Improve claims accuracy – reduces errors and missing data

› Track claims received electronically, which are automatically archived before processing

› Save time on resubmissions – incomplete or invalid claims can be reviewed and corrected online

› View, track, and monitor claim status reports

› Send primary and secondary (COB) claims quickly, reduce paperwork, and eliminate printing and mailing expenses

How to submit claims electronically

EDI vendors – For the list of EDI vendors and the transactions they support, visit Cigna.com/EDIvendors. If you have questions about the transactions submitted through your EDI vendor, contact the vendor directly.

Using Payer ID 62308, you can electronically submit all claims and encounters at the same time – indemnity, DPPO, and DHMO. This includes general dentistry and specialty encounters.

Both primary and secondary (COB) claims should be submitted to Cigna electronically.

Submit X-rays electronically at a discount

You can electronically submit X-rays and other attachments through National Electronic Attachment (NEA) FastAttach®. NEA offers a discount to Cigna Dental subscribers.

Save time – submit your claims electronically

To learn more about electronic claims submission with Cigna, log in to the Cigna for Health Care Professionals website (CignaforHCP.com) > Resources > eCourses, or call 800.Cigna24 (800.244.6224).

Not registered to use the website?

Go to CignaforHCP.com and click “Register Now.”

ELECTRONIC CLAIMS SUBMISSION

Cigna Provider Digital Solutions

Offered by: Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company or their affiliates.

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc.

877926 b Den THN-2017-370. 07/17 © 2017 Cigna. Some content provided under license.

FastAttach® discounts are available through the Cigna Network Rewards Program®. To learn more about all of the Cigna Network Rewards, visit CignaforHCP.com > Resources > Dental Resources > Cigna Network Rewards Program.

To contact NEA directly, visit nea-fast.com or call 800.782.5150.

Additional methods for dental electronic attachment submission

› If you would like to send dental attachments electronically via the standard EDI 275 attachment transaction, please visit Cigna.com/EDIvendors for more information.

› Electronic claim attachment submission and helpful resources are also available on CignaforHCP.com.

What is EFT? EFT electronically deposits fee-for-service and capitated claim payments directly into your bank account.

Benefits of enrolling in EFT

› Eliminate paper check mail delivery and handling

› Access funds on the same day as the deposit

› Easily reconcile payments using a single remittance tracking number

Enroll for EFT

› Enroll directly with Cigna by logging in to the Cigna for Health Care Professionals website (CignaforHCP.com > Working with Cigna > Enroll in Electronic Funds Transfer Options), OR

› Enroll with multiple payers, including Cigna, using the Council for Affordable Quality Health Care® (CAQH®) EnrollHubTM tool at https://solutions.CAQH.org

EFT enrollment guidelines

› For savings account deposits, verify that your bank will support EFT

› The enrollment process takes up to four weeks

› If you are using more than one Taxpayer Identification Number (TIN), you must complete a separate enrollment for each TIN

What is ERA?ERA, or the American National Standards Institute (ANSI) 835 Health Care Claim Payment and Advice ERA transaction, is the HIPAA-compliant detailed explanation of how a submitted health care claim was processedBenefits of enrolling in ERA

ERAs can be automatically loaded into your accounts receivable system, which can help:

› Reduce costs and save time

› Reduce posting errors

› Shorten the payment cycle

Enroll for ERA

Inform your electronic data interchange (EDI) vendor that you would like to enroll for Cigna ERA.

ERA enrollment guidelines

› Provide enrollment information as instructed by your EDI vendor

› If you use more than one TIN, complete a separate enrollment for each TIN

› Your EDI vendor will send the completed enrollment information to Cigna for processing

› Cigna will finalize your registration within 10 business days of receiving it

› You may begin receiving ERAs on your next payment cycle

Tips for enrolling in ERA and EFT

› Make sure that your payment bulking preferences are the same for ERA and EFT

› If you are enrolled in ERA and elect EFT bulking by National Provider Identifier (NPI), you should contact your EDI vendor to have your ERA enrollment updated to bulking by NPI

Improve office workflow and productivity, and shorten your payment cycle, by enrolling in electronic funds transfer (EFT) and electronic remittance advice (ERA) with Cigna. When used together, they can help eliminate claims payment paperwork, and improve your cash flow – you’ll no longer need to wait for paper checks to clear.

ELECTRONIC FUNDS TRANSFER & ELECTRONIC REMITTANCE ADVICE

Quick guide

Not registered for the Cigna for Health Care Professionals website?

Go to CignaforHCP.com and click “Register Now.” For step-by-step registration

instructions, click “Learn How to Register.”

Offered by: Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company or their affiliates.

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc.

900976 12/16 © 2016 Cigna. Some content provided under license.

Network General Dentists (NGDs) are expected to render the range of services that are required for graduation from dental school, including root canal therapy, routine extractions, treatment of gingivitis and early periodontitis, and pediatric dentistry. Referrals to network specialists1 are indicated when the procedures necessary for treatment are beyond his or her range of clinical skills.

Referral to a network endodontist

Routine root canal treatment is expected to be performed by the NGD. For endodontic services that require the skills of a specialist2, you can refer directly to the network endodontist for treatment. Provide the patient with a specific referral and all necessary radiographs. Please be specific in your diagnosis to the endodontist. Indicate why the procedure(s) require(s) the skills of a specialist on the referral form (e.g., root canal retreatment).

Radiograph(s) required – Single periapical film

Referral to a network oral surgeon

Routine oral surgery procedures are expected to be performed by the NGD. For oral surgical services that require the skills of a specialist2, you can refer directly to the network oral surgeon for an evaluation. Provide the patient with a specific referral and all necessary radiographs. Please be specific in your diagnosis to the oral surgeon. Include which teeth need treatment and indicate any treatment planned for other services. Indicate why the procedure(s) require(s) the skills of a specialist on the referral form (e.g., impactions). The Cigna referral process should not be followed for services that are not covered by this dental plan, such as the surgical placement of dental implants or orthognathic surgery. Consultations for such services will not be covered.

Radiograph(s) Required – Panorex, single periapical film, or complete series (dependent upon treatment requested)

Referral to a network orthodontist

It is the responsibility of the NGD to evaluate and determine if there is a need for orthodontic treatment. Written referrals are not required for a network orthodontist.

Radiograph(s) Required – Not applicable

Referral to a network pediatric dentist

For Cigna Dental plans that cover services by a network specialist, Cigna Dental allows for the delivery of dental care to children under the age of 7 to be provided by an NGD or network pediatric dentist (NPD). For children under the age of 7 that require the skills of a specialist2, you can refer directly to a network pediatric dentist for treatment.

Cigna Dental expects the NGD to provide dental care for children age 7 or older who are assigned to his/her office. Exceptions for coverage at the NPD for children ages 7 or older are considered for clinical and/or medical reasons. IV Sedation / General Anesthesia (all ages) – Even though in certain situations dental treatment may require sedation, IV sedation and/or general anesthesia is not a covered service at the pediatric dentist office.

Radiograph(s) required – Bitewings and single periapical films

Cigna Dental Care®

SPECIALTY REFERRAL GUIDELINES

1 Some state laws may allow participants to access care from any provider. Contact your Customer Services associate to inquire if your state allows participants to choose any provider.

2 These specialist guidelines are a summary of the Cigna Dental Care Specialty Referral Guidelines. Please refer to your General Dentist Dental Office Reference Guide for complete details.

Please note: If any information contained in these Specialty Referral Guidelines are different from, or in any way conflicts with, the terms of your Network Dentist Agreement and/or any Cigna Dental Office Reference Guide(s), then the terms of the Network Dentist Agreement, and/or the appropriate Cigna Dental Office Reference Guide(s) will supersede the information in these guidelines.

“Cigna Dental Care” is a brand name used to refer to product designs that may differ by state of residence of enrollee, including but not limited to, prepaid plans, managed care plans (including Dental HMO plans), and plans with open access features. The Cigna Dental Care plan may not be available in all states.

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Cigna HealthCare of Connecticut, Inc., and Cigna Dental Health, Inc. and its subsidiaries. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc.

D2004 Rev. 06/18 © 2018 Cigna. Some content provided under license.

Referral to a network periodontist

Treatment of gingivitis and early periodontitis is expected to be performed by the NGD. For periodontal services that require the skills of a specialist2, you can refer directly to the network periodontist for an evaluation. Provide the patient with both a specific referral and all necessary radiographs. Please be specific in your diagnosis to the periodontist. Include which teeth you want treated and indicate any teeth that may have been treatment planned for other services. Indicate why the procedure(s) require(s) the skills of a specialist on the referral form (e.g., osseous surgery). The Cigna referral process should not be followed for services that are not covered by this dental plan, such as the surgical placement of dental implants. Consultations for such services will not be covered.

Radiograph(s) required – Complete series

Call 1.800.Cigna.24 (1.800.244-6224) to:

Verify patient eligibility. Complete and sign the referral form and provide the appropriate diagnostic radiograph to the specialist.

Find a Network Specialist in your area.

Obtain preauthorization to refer to an out-of-network specialist when a Network Specialist is not located within a 25-mile radius.

Cigna Dental Specialty Referral Form

I understand that only those services which meet Cigna Dental Care referral guidelines will be authorized for payment. Certain procedures may require a patient payment in accordance with the applicable Patient Charge Schedule for the group. I understand that the fees listed are based on current coverage. Payment responsibility may change if the Patient Charge Schedule changes or if coverage has terminated prior to the service treatment date. All fees correspond to the Patient Charge Schedule in effect on the date the procedure is initiated and preauthorization is valid for a MAXIMUM of 90 days. Referral authorization is not a guarantee of payment. This form must be attached to the claim form and submitted within 12 months from the date of service.

14420g Rev. 05/2015

CONTRACT HOLDER

STATE

*SPECIALTY DISCOUNT PLAN - I understand that payment for care received from a Network Specialty Dentist is not provided by Cigna Dental Care for these plans. I am entitled to pay at the Contract Fees negotiated by Cigna Dental rather than the Network Specialty Dentists’ usual fees. Under these plans, referrals and preauthorization for payment by Cigna Dental are not necessary for care received at a Network Specialty Dentist. Cigna Dental will not make payments toward this treatment.

DENTAL OFF. #

DOES PATIENT HAVE ANOTHER DENTAL COVERAGE?

DATE:

STATE

REFERRAL TYPE: (Check one) REFERRAL #:

REFERRING DR.

COMPANY (Carrier)

PHONE:

EN OS PE PDPT. CHG. SCH.

IN-HOUSE

( )

ALTERNATIVE PARTICIPANT IDENTIFIER (AMI #)

STREET

RELATIONSHIP:PATIENT

SIGNATURE OF REFERRING DOCTOR

POLICYHOLDER

Yes No

Home ( )

ZIP

PATIENT’S BIRTH DATE

Yes No

SIGNATURE OF PATIENT

STREET

SEND CLAIM TO: Cigna Dental, P.O. Box 188045, Chattanooga, TN 37422-8045

CITY

LICENSE # DENTAL OFF. #

Yes No

SPECIALIST NAME

ZIP CITY

Work ( )

PHONE

SIGNATURE OF PATIENT

REASON FOR REFERRAL (Include tooth # or area(s):

1.800.342.5234 1.800.DIAL.CDH

SPECIALTY DISCOUNT PLAN * (See Footnote)

Self Spouse Dependent

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Cigna HealthCare of Connecticut, Inc., and Cigna Dental Health, Inc. and its subsidiaries. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc.

Cigna Dental Specialty Referral Form

I understand that only those services which meet Cigna Dental Care referral guidelines will be authorized for payment. Certain procedures may require a patient payment in accordance with the applicable Patient Charge Schedule for the group. I understand that the fees listed are based on current coverage. Payment responsibility may change if the Patient Charge Schedule changes or if coverage has terminated prior to the service treatment date. All fees correspond to the Patient Charge Schedule in effect on the date the procedure is initiated and preauthorization is valid for a MAXIMUM of 90 days. Referral authorization is not a guarantee of payment. This form must be attached to the claim form and submitted within 12 months from the date of service.

14420g Rev. 05/2015

CONTRACT HOLDER

STATE

*SPECIALTY DISCOUNT PLAN - I understand that payment for care received from a Network Specialty Dentist is not provided by Cigna Dental Care for these plans. I am entitled to pay at the Contract Fees negotiated by Cigna Dental rather than the Network Specialty Dentists’ usual fees. Under these plans, referrals and preauthorization for payment by Cigna Dental are not necessary for care received at a Network Specialty Dentist. Cigna Dental will not make payments toward this treatment.

DENTAL OFF. #

DOES PATIENT HAVE ANOTHER DENTAL COVERAGE?

DATE:

STATE

REFERRAL TYPE: (Check one) REFERRAL #:

REFERRING DR.

COMPANY (Carrier)

PHONE:

EN OS PE PDPT. CHG. SCH.

IN-HOUSE

( )

ALTERNATIVE PARTICIPANT IDENTIFIER (AMI #)

STREET

RELATIONSHIP:PATIENT

SIGNATURE OF REFERRING DOCTOR

POLICYHOLDER

Yes No

Home ( )

ZIP

PATIENT’S BIRTH DATE

Yes No

SIGNATURE OF PATIENT

STREET

SEND CLAIM TO: Cigna Dental, P.O. Box 188045, Chattanooga, TN 37422-8045

CITY

LICENSE # DENTAL OFF. #

Yes No

SPECIALIST NAME

ZIP CITY

Work ( )

PHONE

SIGNATURE OF PATIENT

REASON FOR REFERRAL (Include tooth # or area(s):

1.800.342.5234 1.800.DIAL.CDH

SPECIALTY DISCOUNT PLAN * (See Footnote)

Self Spouse Dependent

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Cigna HealthCare of Connecticut, Inc., and Cigna Dental Health, Inc. and its subsidiaries. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc.

What is the Cigna Dental Care® alternate benefit provision?

This provision is a benefit design that applies to specific Cigna Dental Care patient charge schedules for crowns and bridges (fixed partial dentures) only. It is applied when there are two or more clinically acceptable ways to treat a dental condition and both are covered procedures. In these cases, the alternate benefit provision limits the plan participant’s coverage to the less costly covered service, provided that it is a professionally accepted, necessary, and appropriate method of treatment. If the patient opts for the more costly service, his or her financial responsibility is equal to:

The patient charge for the less costly service, plus

The difference between the network dentist’s usual fee for the more costly service and the usual fee for the less costly service

Note: The alternate benefit provision does not apply when the restorative material is the only difference between

the two or more covered services.

Alternate benefit provision coverage guidelines

When fixed and removable partial dentures are options to restore patient care:

Condition Coverage determination

One to three missing posterior teeth in one quadrant, and no missing teeth in the contralateral quadrant

Fixed partial denture (fixed bridge) is considered to be the covered service One to two missing posterior teeth in both the left and right quadrants of the same arch

Up to four adjacent missing anterior teeth in the same arch

A fixed partial denture replacing an existing similar fixed partial denture

More than three missing posterior teeth in one quadrant, and no missing teeth in the contralateral quadrant

Removable partial denture is considered to be the covered service

More than four missing posterior teeth in the same arch

Four adjacent missing anterior teeth and one or more missing posterior teeth in the same arch

Treatment plan that includes both a fixed bridge and removable partial denture in the same arch

When crown and a restorative filling are both reasonable treatment options to restore a tooth

Amalgam restorations (fillings) are covered when there is sufficient tooth structure present. In these situations, Cigna considers the filling to be the covered service. However, if the patient elects the crown option, the amount due from him or her is the patient copay for the amalgam restoration plus the difference between your usual fee for the crown and your usual fee for the amalgam restoration: (continued on next page)

Cigna Dental Care

ALTERNATE BENEFIT PROVISION GUIDELINES

“Cigna Dental Care” is a brand name used to refer to product designs that may differ by state of residence of enrollee, including but not limited to, prepaid plans, managed care plans (including Dental HMO plans), and plans with open access features. The Cigna Dental Care plan may not be available in all states.

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Cigna HealthCare of Connecticut, Inc., and Cigna Dental Health, Inc. and its subsidiaries. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc.

D6040 Rev. 06/18 © 2018 Cigna. Some content provided under license.

Example: Procedure code D2750 Crown – Porcelain fused to high noble metal

Patient charge for amalgam restoration (filling) – D2161 $ 50

Dentist's usual fee for crown – D2750 + $ 831

Dentist's usual fee for amalgam restoration – D2161 - $ 155

Amount due to the network dentist from the patient $ 726

When there is insufficient tooth structure to support a filling

Crowns, inlays, or onlays are covered when there is insufficient tooth structure to support a filling. In these situations, Cigna considers the crown, inlay, or onlay to be the covered service. The amount due from the patient is the copay for the service listed in his or her applicable patient charge schedule.

Example: Procedure code D2750 Crown – Porcelain fused to high noble metal

Patient charge for crown – D2750 $ 365

Amount due to the network dentist from the patient $ 365

Additional guidelines

Additional alternate benefit provision guidelines can be found in your Cigna Dental Care General Dentist Dental Office Reference Guide. Registered users of the Cigna for Health Care Professionals website can access this guide by logging in to CignaforHCP.com > Resources > Reference Guides > Dental Reference Guides > General Dentist (GD) Guide.

Other important information

Supplemental payments relating to alternate benefit schedules When crowns and fixed partial dentures are performed under the Cigna Dental Care Value Plans with alternate benefits, Cigna Dental will not automatically generate supplemental payments because the Patient Charge amount or the Alternate Benefit Provision may generate total charges higher than the supplemental payment schedule amount. If the crown or fixed partial denture meets the criteria for coverage and the applicable Patient Charge is less than your supplemental payment schedule amount, please call the Provider Services Unit at 1.800.Cigna24 (1.800.244.6224). Upon review, Cigna Dental will make a manual adjustment and provide the appropriate supplemental payment in your next check.

Patient consultation Before starting any major restorative work, it is important to discuss with your patient potential treatment options, their associated costs, and potential payment options. Once the patient decides on a treatment plan, obtain his or her written consent to perform the procedure and pay any non-covered costs.

Questions?

Please call the Provider Services Unit at 1.800.Cigna24 (1.800.244.6224).

“Cigna Dental Care” is a brand name used to refer to product designs that may differ by state of residence of enrollee, including but not limited to, prepaid plans, managed care plans (including Dental HMO plans), and plans with open access features. The Cigna Dental Care plan may not be available in all states.

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Cigna HealthCare of Connecticut, Inc., and Cigna Dental Health, Inc. and its subsidiaries. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc.

D6037 Rev. 06/18 © 2018 Cigna. Some content provided under license.

Cigna Dental Care® plans in which the alternate benefit provision applies for crown and bridge procedures are shown in the table below.*

Patient charge schedule name Plans with the alternate benefit provision

Value Plan – Alternate Benefit Provisions with & without Orthodontia

06/07/08/09 Series

GAO06, GAOV6, GAN06, GANV6, WAO06, WAOV6, WAN06, WANV6, KAO06, KAOV6, KAN06, KANV6, FAO06, FAOV6, FAN06, FANV6, GAO07, GAOV7, GAN07, GANV7, WAO07, WAOV7, WAN07, WANV7, KAO07, KAOV7, KAN07, KANV7, FAO07, FAOV7, FAN07, FANV7, GAO08, GAOV8, GAN08, GANV8, WAO08, WAOV8, WAN08, WANV8, KAO08, KAOV8, KAN08, KANV8, FAO08, FAOV8, FAN08, FANV8, GAO09, GAOV9, WAO09, WAOV9, KAO09, KAOV9, FAO09, FAOV9

Value Plan – Specialty Access with Alternate Benefit Provisions

06/07/08/09 Series

GAS06, GASV6, WAS06, WASV6, KAS06, KASV6, GAS07, GASV7, WAS07, WASV7, KAS07, KASV7, GAS08, GASV8, WAS08, WASV8, KAS08, KASV8, GAS09, GASV9, WAS09, WASV9, KAS09, WASV9

Value Plan A – Alternate Benefit Provisions with and without Orthodontia

07/08/09 Series

A2O07, A2OV7, A3O07, A3OV7, A4O07, A4OV7, A2N07, A2NV7, A3N07, A3NV7, A4N07, A4NV7, A2O08, A2OV8, A3O08, A3OV8, A4O08, A4OV8, A2NO8, A2NV8, A3N08, A3NV8, A4N08, A4NV8, A2O09, A2OV9, A3O09, A3OV9, A4O09, A4OV9, A2I09

P – Public Sector – Alternate Benefit Provisions P1A00

C – CA Network General Dentists

07/08/09 Series

CO607, CO6V7, C1O07, C1OV7, C1507, C15V7, C2O07, C2OV7, CO608, CO6V8, C1O08, C1OV8, C1508, C15V8, C2O08, C2OV8, CO609, CO6V9, C1O09, C1OV9, C1509, C15V9, C2O09, C2OV9

NB/BC – Baxter NB108, BCR08

Hertz Corporation HC-07

Southeastern Pennsylvania Transit Authority (SEPTA)

PTA15

New Jersey Public Employees’ Health Benefits Programs

SNJ10

New Jersey Public Retirees’ Health Benefit Programs

NJAY1, NJAY2, NJAY3

*Note that most plans with the alternate benefit provision will contain this sentence in the Patient Charge Schedule introductory paragraph: “When using the alternate benefit provision, the listed copay for the applicable procedures may not apply.”

Cigna Dental Care

PLANS WITH ALTERNATE BENEFIT PROVISION

*Current Dental Terminology © American Dental Association

Encounter error report for Jun 26, 2017JOHN D DOE DDS PC

The following encounters were submitted with errors. Please correct the information as appr opriate and return this report to:

Cigna Dental Health, Inc .PO Box 188046Chattanooga, TN 37422-8046

Supplemental payments and offic e visit payments will be pr ocessed when we receive the corrected information.Please make sure the procedure codes are valid, as invalid codes will not be r eturned a second time.

Only indicate changes on this report and please print clearly .

Cigna Dental Health, Inc.

PAGE 1 OF 1

MNMR0387 GW5009A

FOR CUSTOMER SERVICE

1.800.Cigna24 (1.800.244.6224)or visit www.cignaforhcp.com

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REFERENCE INFORMATION

Report date: Jun 27, 2017Report number: MNMR0387Dental office number: XX 654321

ENCOUNTERNUMBER

TREATMENTDATE PCS MEMBER ID MEMBER NAME

ENCOUNTERPROCEDURE NUM

CDT*CODE

CDT*DESCRIPTION

TOOTH/QUAD

18500091 Jun 2, 2017 GG-AA 12379824-01 HOUSTON, AUSTIN E18500091P001 D1351 Sealant

• THE PROCEDURE SUBMITTED REQUIRES A TOOTH NUMBER OR QUADRANT. PLEASE SUBMITNEW ENCOUNTER.

• THE TOOTH NUMBER OR QUADRANT SUBMITTED IS NOT VALID FOR THE PROCEDURE LISTED.PLEASE SUBMIT NEW ENCOUNTER.

• THE BILLED AMOUNT IS REQUIRED FOR PROCESSING.PLEASE SUBMIT NEW ENCOUNTER.

ENCOUNTERNUMBER

TREATMENTDATE PCS MEMBER ID MEMBER NAME

ENCOUNTERPROCEDURE NUM

CDT*CODE

CDT*DESCRIPTION

TOOTH/QUAD

18500089 Jun 2, 2017 123053141-01 LAKE, PHOENIX E18500089P001 D0120 Periodic Oral Exam FM

• THE PATIENT NAME SUBMITTED IS NOT IN THE CIGNA DENTAL CARE SYSTEM AS A COVEREDDEPENDENT FOR THE SUBSCRIBER INDICATED. PLEASE SUBMIT ENCOUNTERS UNDER THENAME AND ID AS REPORTED ON YOUR CIGNA DENTAL CARE ELIGIBILITY REPORT.

• THE PATIENT NAME SUBMITTED IS NOT IN THE CIGNA DENTAL CARE SYSTEM AS A COVEREDDEPENDENT FOR THE SUBSCRIBER INDICATED. PLEASE SUBMIT NEW ENCOUNTER.

*Current Dental Terminology © American Dental Association

Supplemental and office-visit payments closing reportTHE DENTAL OFFICE & ASSOC

If you find any discr epancies in this r eport, please notify us . If you don’t notify us of any discr epancies within 30 days , you accept this report as correct.

Payment summarySEP 2016 YEAR-TO-DATE SEE PAGE

Total payment $0.00 $0.00

MNMR0384 GW5008A

Cigna Dental Health, Inc.

PAGE 1 OF 1

FOR CUSTOMER SERVICE

1.800.Cigna24 (1.800.244.6224)or visit www.cignaforhcp.com

Please have the Participant ID or the employee'ssocial security number available when callingCustomer Service or writing to us.

REFERENCE INFORMATION

Report date: Jun 27, 2017Report number: MNMR0384Dental office number: XX 987654

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MEMBER NAME MEMBER IDTREATMENTDATE

ENCOUNTERPROCEDURE NUM

CDT*CODE TOOTH/QUAD AMOUNT ($) REASON FOR DENIAL

CHOKOLATE, CAKE 12349828-01 Aug 8, 2016 E98767504P001 D0120 FM 20.00 BILLING ERROR - SEE ERROR REPORT

1 Cigna’s post visit survey results for DPPO network participants as of February 28, 2017. 2 Brighter Profile features may vary by Cigna Dental product, provider type or customer plan. 3 myCigna registered user survey results of DPPO network participants as of February 28, 2017.

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Cigna HealthCare of Connecticut, Inc., and Cigna Dental Health, Inc. and its subsidiaries. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc.

D3033PR Rev. 06/18 © 2018 Cigna. Some content provided under license.

DID YOU KNOW? After an appointment, 97% would recommend their Cigna Dental network dentist to family or friends.1 Cigna Dental uses information like this to help drive innovation for both our customers and for our network dentists. We offer each Cigna Dental network provider a free Brighter Profile® on the myCignaSM website/app dentist directory to help attract and retain patients. Cigna Dental customers use this dentist directory as part of their evaluation process when searching for a network dental professional. Participating providers get all of these myCigna features to promote their practices for free: 2

› Online profile highlighting your strengths

› Online appointment requests through

Brighter Schedule® 2

› Verified patient reviews

› Automated patient communications For more information

Activate and optimize your profile by visiting

Brighter.com/Cigna or by calling Brighter

at 1.888.300.4742, Monday through Friday,

between 9:00 a.m. and 8:00 p.m. ET.

myCigna dentist directory users3 had this to say:

29% didn’t have a regular dentist at the time of their search

82% found Brighter Profile® photos somewhat to very useful

92% thought other patient reviews were somewhat to very useful

Some of the employers that offer Cigna Dental

› CBRE

› Charles Schwab

› DaVita Kidney Care

› JetBlue

› Kinder Morgan

› Waste Management

Cigna Dental

PROMOTE YOUR PRACTICE

CIGNA NETWORK REWARDS PROGRAM

Your network participation with Cigna Dental means more than just treating patients – it gives you the opportunity to take advantage of lower costs on key products and services. Membership in the Cigna Network Rewards Program® is automatic and free to dentists who participate with Cigna Dental.

Office and Dental Supplies/Equipment

® 1

CariFree/Oral BioTech – Simple protocol system for as-sessing your patients’ risk factors for decay. Receive a 20% discount on your initial purchase, including training and imple-mentation. Call 1.866.928.4445.

Colorado Heart Rescue – Receive $250 off the ZOLL® AED Plus® defibrillator by visiting coloradoheartrescue.com/products/ZOLL-AEDPlus.html. Enter coupon code CIGDISC.

Dell – Dell Member Purchase Program includes up to 30% off select systems, discounts on thousands of electronics and accessories, and open enrollment into Dell Advantage Loyalty Program (5% eGift-card and free 2nd business day ship-ping). Visit Dell.com/mpp/CIGNA. Need a quote or to place an order? Email healthcare_epp_programs@dell.com with Member ID HS126412907.

Easy Refine D-MMEXUSA – Refines failed crown and bridge-work, grindings, and broken or unwanted jewelry. Receive free shipping and a 5% bonus to the value of your scrap material. Call 1.800.741.3174 or email info@easyrefine.com.

Handpiece Express – Receive 25% off any hand piece re-pair; plus free pickup, 24-hour turnaround, free estimates, and 120-day warranty on repairs. Call 1.800.225.7235.

HealthFirst® – Discounts on emergency medical kits, AEDs, emergency oxygen, spore testing services, and mailback sharps and pharmaceutical waste solutions. HealthFirst will track your emergency medications and keep you up to date. Call 1.800.331.1984 and mention that you are a Cigna net-work dentist.

Heraeus Kulzer Dental – Discounts on selected dental solutions for diagnosis and treatment, and direct and indirect restorative care.

Lenovo® – Save up to 33% on select PC products. Visit lenovo.com/cigna or call 1.800.426.7235, ext. 2264.

Medical Safety Systems, Inc. – Receive 10% off all safety and compliance-related products. Call 1.888.803.9303 or 1.800.829.4257.

Mesa Labs, Inc. – (Previously North Bay Bioscience) has been providing sterilizer monitoring compliance solutions since 1991, including mail-in spore testing services, in-office spore testing, chemical integrators and indicators as well as record keeping. Members are eligible to receive a 10% discount off these products and services by calling 1-800-289-7786 or emailing sporetesting@mesalabs.com.

Oral CDx® BrushTest® – Laboratory test that aids in the early detection and prevention of oral cancer. Receive 20% off all kits by calling 1.877.71BRUSH (1.877.712.7874). Mention that you are a Cigna network dentist.

Procter & Gamble (P&G) – Discounted price of $44.95 ($175 retail value) on special oral health care kits. Complimentary educational seminar on power toothbrushes available. Call 1.800.543.2577.

RGP Dental Inc. – Manufacturer of the Swedish Seating System – assistant stools, straddle stools, and support arms. Discounts up to 30%. Call 1.800.522.9695.

Safeline Monitors – X-ray badge service providing monitor-ing and analysis of staff exposure levels to radiation. Call 1.866.963.8283 or visit safelinemonitors.com. Mention Cigna Network Rewards for your discount toward services. Scrubs & Beyond® – Scrubs and uniforms. Receive 10% off apparel and shoes. Visit scrubsandbeyond.com and enter code wcigna, or call 1.800.310.1580.

Staples Advantage® – National office product supplier offer-ing online ordering and free next-day delivery. Visit staplesadvantage.com/cignapp/. Click Register and then se-lect Cigna Provider. Create your own User ID and Password. Follow the onscreen instructions to complete your registration. Enter the Cigna passcode CDH to complete your order.

Tru-Align® by Interactive Diagnostic Imaging (IDI) – Reduce your patient’s radiation exposure by 60 to 70%, while obtain-ing clear, crisp images. Save 35% on your initial purchase by visiting idixray.com and use code CIGNA35, or call 1.855-IDI-XRAY (1.855.434.9729) and mention that you are a Cigna network dentist.

Cigna Dental

month per office. Limited time offer for Cigna dentists who are first-time subscribers – register by December 31, 2016 and receive a waiver of the $200 FastAttach® registration fee plus receive your first month free ($27 savings). Visit nea-fast.com, click the FastAttach Registration button, and enter promotion code CIGNARZ1M or call 1.800.782.5150, Option 2. Patterson EagleSoft – Free practice management software*, free first three months of eClaims, free data import, and free phone training for eligible Cigna network dentists. Call 1.800.294.8504.

*One time offer per new EagleSoft customer. Requires 12-month support commitment. Offer may be withdrawn at any time without notice.

Post-n-Track™ – No fee web solution for the submission of electronic claims to Cigna. No fees for installation or support. Visit post-n-track.com/Cigna or call 1.860.257.2030.

Apex EDI™, Inc. – Electronic claims processing and related online tools. Sign up at apexedi.com, click the OneTouch™ button and then Sign Up. Enter registration information and code APCIG4617 for a $100 discount off set-up fee, or call 1.800.840.9152.

Appletree™ Answering Service, Inc. – Save up to 25% on virtual receptionist solutions including live telephone, email, and web chat response. Call 1.800.237.2810 or visit appletreeanswers.com/Cigna.

Brighter Profile™ – Want to differentiate yourself from your peers? Enhance your free Brighter Profile to help grow your practice and communicate with Cigna Dental customers. High-light your practice’s strengths and services on the myCigna dentist directory. You can even add photos, professional history, and technologies and amenities. To activate or update your Brighter Profile, visit providers.brighter.com or call Brighter at 888.300.4742.

EZDentalCharting – Receive 10% off options to enhance your patient dental charting system. Visit ezdentalcharting.com or call 1.323.656.2212. Use coupon code CIGNADH. Plus, receive a 50% discount on shipping charges for orders over $100.

National Electronic Attachment, Inc. (NEA) – Transmit sup-porting documents for electronic claims. Unlimited customer service, training, and attachments to 550+ payers for $27 per

Practice Management Tools

Dental Labs

Aconcagua Dental Manufacturing Laboratory Corp. – Discounts on prosthodontics services and supplies for crowns, bridges, fixed and removable dentures, and orthodontic appli-ances. Call 1.787.787.8628.

Biotech Dental Prosthetics – Discounts on fixed prosthetics including crowns and bridges, and cosmetic and implant den-tistry. Call 1.800.564.0556 or visit biotechdentalprosthetics.com.

Creative Dental Studios – Specializing in crown and bridge restorations, with a focus in cosmetic dentistry. For a free starter kit and discount information, call 1.248.470.0859. Free FedEx shipping on all orders.

Larell One Step DentureTM – Fabricate a set of dentures in a one-hour visit without laboratory services. Receive 10% off the starter kit; additional discounts on reorders. Call 1.831.659.9300 or visit larelldentures.com.

Panoussi’s Dental Lab, Inc. – Receive 15% off fixed and re-movable prosthetics by calling 1.661.273.4091 or visiting panoussisdentallab.com.

Port Jefferson Dental Lab, Inc. – Full-service dental labora-tory and certified milling center specializing in zirconia. Call 1.800.686.7535 for discounted dental laboratory services.

Recigno Laboratories, Inc. – Specializes in all types of dental prosthetics using the most advanced technologies. Receive a free starter kit by calling 1.877.825.8311 or visiting recigno.com.

MedSafe – Compliance Solutions – receive 20% off all services including training programs. Visit tcs-inc.us/cignarewards.htm or call 1.800.255.6387, ext. 154.

Procter & Gamble (P&G) – Access continuing education courses at no cost. Log in to CignaforHCP.com > Useful Links: Procter & Gamble Continuing Education Site.

Cross Country Education – Discounts on all live seminars, audio seminars and webinars. Visit crosscountryeducation.com/cce/cigna.jsp or call 1.800.397.0180. During registration, use discount code CIGNA14 to receive $30 off registration.

Dental Enhancements – Receive 25% off all OSHA and HIPAA products and services, and practice growth solution courses and workshops. Visit dentalenhancements.com and enter code 25cigna25, or call 1.888.873.8301 and mention that you are Cigna network dentist.

Education

2

PBHS Website Design and Marketing Services – Website design and online search engine marketing services for the dental community. Discounts up to 20% on popular website solutions. Call 1.800.840.5383 or visit pbhs.com.

Web.com® – Receive a discount on a wide range of online mar-keting services to build awareness about your practice. Free consultation. Call 1.888.245.6574 or visit Cigna.web.com/.

DoctorBaseSM – Expand revenue up to 12% through services that utilize iPhone and Android technology. Receive 35% dis-count off services and waiver of set-up fee. Visit DoctorBase.com. Email info@doctorbase.com and mention code CignaPanda for your discount.

inForm – Discounts (including waiver of setup fee) on email and social media marketing to help build your practice. Call 1.800.840.5383 and use validation code RVRQ1.

Website Development & Services

Cigna Vision Network Savings Program – Discounts on routine vision care services at more than 20,000 locations nationwide. Log in to CignaforHCP.com > Resources > Dental Resources > Network Rewards Program > Vision Network Rewards to print your ID card.

DineWise® – Receive 15% off gourmet frozen meals delivered directly to you. Visit dinewise.com or call 1.800.749.1170. Use discount code Cigna.

Health and Wellness

Just Walk 10,000 Steps-a-Day – Discounted eight-week program includes a pedometer, online tools, and educational materials. Visit cornerstonefitness.com/cigna/10ksteps.html. Prices shown have already been discounted for dentists in Cigna’s network.

Nuvora®, Inc. – Discounts on oral care lozenges that deliver active ingredients to help eradicate cavities, gum diseases, and oral inflammation, while easing dry mouth and killing germs that cause bad breath. Call 1.877.419.2646.

1 This is a discount program. You are required to pay the entire discounted charge directly to participating providers/suppliers.By accessing the Cigna Network Rewards program, you hereby agree to the following Terms and Conditions:

1. It is the dentist’s responsibility to read and understand the terms and conditions set forth by each of the vendors, including return, shipping, and billing policies and/or fees.2. Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Cigna Dental Health, Inc, and their respective parent companies, subsidiaries and affiliates (collectively referred to as “Cigna Dental”) are not responsible for the quality, delivery, warranty, or conditions of any product purchased by the dentist. The vendors are independent contractors, and not agents of Cigna Dental. Cigna Dental is not the agent of the vendors.3. Cigna Dental is not responsible for any of the dentist’s obligations as a purchaser with respect to any product purchased from the vendors or liable for any obligation of the dentist under any contract with the vendors. The dentist is an independent contractor, and not the agent of Cigna Dental. Cigna Dental is not the agent of the dentist.4. When accessing a vendor participating in the Program the dentist agrees that Cigna Dental shall NOT be liable for any damages whether direct, indirect, incidental, or consequential (including lost profits) sustained or incurred in connection with the installation, operation, or use of the products and services purchased by the dentist pursuant to the Network Rewards Program, regardless of the form of the action, whether in contract, tort including negligence, strict liability or otherwise, and whether or not such damages were foreseen or unforeseen.5. The dentist is responsible for all applicable taxes on purchases.6. Discounts and the availability of programs may vary by state, are subject to change, and may be discontinued at any time. Cigna Dental and/or vendor may attempt to notify, but cannot guarantee. 7. These Terms and Conditions address only the use of the Cigna Network Rewards program and do not change anything in any other agreement between Cigna Dental and participating dentists, their employees and their agents.

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Cigna HealthCare of Connecticut, Inc., and Cigna Dental Health, Inc. and its subsidiaries. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Prop-erty, Inc.

D0003 Rev 12/18 © 2018 Cigna. Some content provided under license.2 3

* Regional variance – national schedule shown above. Check with your Cigna Vision Network eye care professional for details.

** Select frames may not be available for savings. This is a discount program, not an insured benefit.

Savings Program

Vision Network

Offered to you through the Cigna Network Rewards Program®

Your participation in the Cigna network means more than just treating patients – it means you have opportunities to take advantage of lower costs for many products and services. We are pleased to offer you discounts on routine vision care services at more than 20,000 locations nationwide. Simply cut out the ID card on the back of this flyer. Then, bring it with you when visiting an in-network eye care professional. If you have any questions, please feel free to contact a Vision Network Savings Program representative at 1.866.935.8128.

Routine vision Customer cost* care services

Contact lenses and professional services: Contact lens professional services (fitting and evaluation) .... $10 off contact lens exam Contact lenses ............................. Check with your Cigna Vision Network eye care professional for any available offers Non-prescription sunglasses** ............................. 20% savings Frequency: Exam and materials .................... Unlimited

Routine vision Customer cost*

care services

Routine vision examination: Including, but not limited to, eye health examination, dilation, refraction, and prescription for glasses .............. $5 off routine exam Standard clear plastic or glass lenses: Single vision ............................... Up to $50 Bifocal ........................................ Up to $75 Trifocal ....................................... Up to $105

Lens options: Standard UV coating .................. Up to $15 Standard scratch resistance ....... Up to $15 Standard polycarbonate ............. Up to $40 Standard anti-reflective coating.... Up to $45 Progressives .............................. 20% savings Other add-ons and services ....... 20% savings

Frames: Most locations ............................ 25% off retail price on frames Pearle Vision, Sears Optical, Target Optical and JCPenney Optical ........................................ 40% off retail price on most frames**

VISION NETWORK SAVINGS PROGRAM

Offered through the Cigna Network Rewards Program®

Vision Network Savings Program

These discounts are only available through a Cigna Vision Network eye care professional. Individuals are responsible to pay the discounted amounts directly to the Cigna Vision eye care professional at the time of service. Stated discounts cannot be used in conjunction with other discounts, promotions or prior orders. Network eye care professionals are independent contractors solely responsible for your routine vision examination and products.

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc.

D0040 Rev 12/18 © 2018 Cigna. Some content provided under license.

Your ID card Please cut out the ID card below and make sure you bring it with you when visiting an in-network eye care professional to take advantage of your discounts.

Locations The Cigna Vision Network offers over 20,000 locations nationwide, including these national retail opticals:

Vision Network Savings Program

offered through the Cigna Network

Rewards Program®

Expiration date: 12/31/2019 Call toll free: 1.866.935.8128 Please read all of the terms and conditions*. This is NOT insurance. Cigna is not responsible for the quality, delivery, warranty, or conditions of any product purchased. All vendors are independent contractors and are subject to change without notice. Access to discounts from these vendors does not constitute an endorsement of any vendor, product, or service.

* Terms and Conditions The following terms and conditions apply to the Cigna Network Rewards Program: 1 It is your responsibility to read and understand the terms and conditions set forth by each of the vendors, including return, shipping, and billing policies and/or fees. 2 Cigna is not responsible for the quality, delivery, warranty, or conditions of any product purchased by you. The vendors are independent contractors, and not agents of Cigna. Cigna is not the agent of the vendors. 3 Cigna is not responsible for any of your obligations as a purchaser with respect to any product purchased from the vendors or liable for any obligation of yours under any contract with the vendors. You are an independent contractor, and not the agent of Cigna. Cigna is not the agent of you. 4 Vendors will be provided with a list of names and addresses so that Cigna Network Rewards Program enrollment can be verified. You are responsible for contacting the vendors directly with respect to any change in name, address, or status. 5 You hereby agree that neither Cigna nor its subsidiaries or affiliates, shall be liable for any damages whether direct, indirect, incidental, or consequential (including lost profits) sustained or incurred in connection with the installation, operation, or use of the products and services purchased by you pursuant to the Cigna Network Rewards Program, regardless of the form of the action, whether in contract, tort including negligence, strict liability or otherwise, and whether or not such damages were foreseen or unforeseen. 6 You are responsible for all applicable taxes on purchases. 7 Discounts and vendors are subject to change and may be discontinued at any time without notice. Cigna and/or vendor will attempt to notify, but cannot guarantee.

Cat. #865564j 06/2018 © 2018 Cigna

25 (2 pkg maximum)

Dental Office Supply Requisition Form

Ship to Information (Please do not use a PO Box address)

Did you know that for the quickest service, you can immediately download and print most items listed on this supply requisition form by going to the Cigna for Health Care Professionals website (CignaforHCP.com)? To request items using this supply requisition form, first complete the Ship to Information section below. (Note: You MUST include your Cigna Dental Office ID#.) Then, complete the Order Information section by indicating the quantity requested for each item. Fax your order to 1.800.632.9234 or mail it to Cigna Dental, c/o R.R. Donnelley, 1750 Wallace Avenue, St. Charles, IL 60174. All orders will be shipped via ground service. Allow 5-10 business days to receive your order. Any item(s) on backorder will ship separately.

Dentist Name Cigna Dental Office ID # Contact Phone Number Email Address (for order acknowledgement)

Ship to the Attention ofName of Office

Office Address (Street) (Suite #) (City) (State) (Zip Code)

ORDER INFORMATION

To place your order, indicate in the “Order Quantity” column how many of each item you want. Or, to obtain these items immediately, log into CignaforHCP.com to download and print your selection(s).

Order Quantity

14420 Specialty Referral Form (Generic)

DescriptionCatalog Number

Units per pkg

Order Quantity

(5 pc maximum)594099Maryland Uniform Referral Form (Maryland only) 1

(4 pkg maximum)15190Dissatisfaction Form (California only) 25

852885Request / Refusal for Interpretation Services in English (California only) 25 (4 pkg maximum)

(4 pkg maximum)852885SPRequest / Refusal for Interpretation Services in Spanish (California only) 25

(4 pkg maximum)852885TCRequest / Refusal for Interpretation Services in Chinese (California only) 25

809044 General Dentist Reference Guide 1 (5 pc maximum)

Units per pkg

DescriptionOrder

Quantity

(5 pc maximum)564014 Endodontist Reference Guide 1

(5 pc maximum)564000 Oral Surgery Reference Guide 1

(5 pc maximum)564015 Orthodontist Reference Guide 1

564001 Pediatric Reference Guide 1

(5 pc maximum)564011 Periodontist Reference Guide 1

(5 pc maximum)552684 PPO Dental Office Reference Guide 1

(5 pc maximum)

Order Quantity

1THN-D-2016 Introduction to PCS at a Glance

1

Order Quantity

887394 Most Commonly Used Procedure Code Comparison _ 01-08 Series

1887393 Most Commonly Used Procedure Code Comparison _ 09 Series

911078Cigna Dental Care Teledentistry Form 1 (5 pc maximum)

MISCELLANEOUS (Download and print these at CignaforHCP.com > Resources > Dental Resources > Patient Charge Schedules)

Units per pkg

DescriptionUnits

per pkgDescription

Units per pkg

DescriptionCatalog Number

Order Quantity

Units per pkg

DescriptionCatalog Number

Catalog Number

FORMS (Download and print these at CignaforHCP.com > Resources > Forms Center > Dental Forms)

Catalog Number

Catalog Number

DENTAL OFFICE REFERENCE GUIDES (Download and print these at CignaforHCP.com > Resources > Reference Guides > Dental Reference Guides)

Cat. #865564j 06/2018 © 2018 Cigna

IBM07 Series

109 Value Plan Series (Specialty Access)868920

109 X Series (Lab Fee Charges)868921

868918 09 X Series Public Sector (Lab Fee Charges) 1

868880 P Series Public Sector 1

868891 P Series Public Sector (Alternate Benefit Provisions) 1

868887 Q Series Coinsurance 1

1HIXV9 Series (for certain Houston Independent School District employees)890036

1840261

868859 R04 Series 1

855175 BE Series (for certain County of San Bernardino employees) 1

868892 09 Value Plan Series (Alternate Benefit Provisions) 1

827985 07 Series — Preventive Care 1107 Series — Split Copays827987

827986 07 Series — Standard Copays 1827969 07 Value Plan A Series (Alternate Benefit Provisions) 1827971 07 Value Plan Series (Alternate Benefit Provisions) 1827970 07 Value Plan Series (Specialty Access) 1

108 C Series849747108 Series — Preventive Care850145108 Series — Split Copays849749108 Series — Standard Copays849745

108 Value Plan A Series849748

108 Value Plan Series (Alternate Benefit Provisions)850149108 Value Plan Series (Specialty Access)849746

108 X Series (Lab Fee Charges)849770

108 X Series Public Sector (Lab Fee Charges)849771868905 09 C Series 1868886 09 Series _ Standard Copays 1

109 Value Plan A Series868919

868855 05 Series 1868856 06 Series — Standard Copays 1

107 C Series (for California Network General Dentists)852564

T2XV9 Series for General Dentists in Arizona ONLY (for certain State of Tennessee employees)

T2XV9 Series for General Dentists (for certain State of Tennessee employees)

SNJ10 Series (New Jersey Public Employees' Health Benefits Program)

SG-09 Series (for certain State of Georgia employees)

RSXV9 Series (for certain Aldine Independent School District employees)

RIXV9 Series (for certain Aldine Independent School District employees)

PTA15 (for certain Southeastern Pennsylvania Transit Authority employees)

NY Series (for certain YP Holdings employees)

NJAY Series (for certain State of New Jersey retirees)

NH Series (for certain Honeywell employees)1NB/BC Series (for certain Shire employees)8929461NB/BC Series (for certain Baxter employees)887423

1881525816950 NH208 Series (for certain Honeywell employees) 1

1881538817032 NS Series (for certain AT&T employees) 1

18815441OH Series (for certain Orlando Health employees)850755

854439 1

1890034

1890035

893797 SCT19 (for certain State of Connecticut employees) 11877425

1881530

1887388

1887389

1T2XV9 Series for Specialists (for certain State of Tennessee employees)887386

1T2XV9 Series for Specialists in Arizona ONLY (for certain State of Tennessee employees)887387

1OKIV9 Series (for certain State of Oklahoma employees)892921PSX09 Series (for certain Pinellas County employees)901706 1

QPAI9 Series (for certain Prudential employees)900545 1

MCSV7 Series (for certain Maricopa County employees)

1L1I09 Series (for certain McKesson employees)877436

863232 1

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Cigna HealthCare of Connecticut, Inc., and Cigna Dental Health, Inc. and its subsidiaries. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc.

Order Quantity

Units per pkg

DescriptionCatalog Number

Order Quantity

Units per pkg

DescriptionCatalog Number

PCS AT A GLANCE (Download and print these at CignaforHCP.com > Resources > Dental Resources > Patient Charge Schedules)

Esca

latio

n pa

th

What is your need? Choose the best Cigna resource:

Standard inquiries including:• Patient eligibility and benefits• Claims• Payments• Resources

CignaforHCP.com

Service inquiries including:• Patient eligibility and benefits• Claims • Payments

1.800.Cigna24 (1.800.244.6224)

Service when escalation is needed or for network participation issues, including:• Dental office changes • Direct deposit/EFT • Copies of contracts or fee schedules • Other consultations

Provider Services Unit1.800.Cigna24 (1.800.244.6224)At the voice prompts:• Say “provider” • Enter your tax identification number • Say “contracting”• Say “dental”

Escalation of issues including:• Claims • Other consultations

Professional Relations ManagerFor territory assignments, log in to CignaforHCP.com > Resources > Dental Resources > Doing Business with Cigna > Professional Relations Team

Leadership of accountability across the dental network and markets

Professional Relations DirectorFor territory assignments, log in to CignaforHCP.com > Resources > Dental Resources > Doing Business with Cigna > Professional Relations Team

NEED TO CONNECT WITH US?

Escalation path for Cigna Dental providers

WE’VE GOT YOUR ANSWER.

All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Connecticut General Life Insurance Company, Cigna HealthCare of Connecticut, Inc., and Cigna Dental Health, Inc. and its subsidiaries. The Cigna name, logo, and other Cigna marks are owned by Cigna Intellectual Property, Inc.

D6032 Rev 1/18 © 2018 Cigna. Some content provided under license.

To connect with us, simply identify your need and reach out to the Cigna resource.

DentalHCPInquiry@Cigna.com for escalated claims ONLYDentistEnrollment@Cigna.com to add a new providerProviderServiceUnitDental@Cigna.com for status of applications and other general questions

Want to contact us by email?