ABN Cigna Form
(A) Notifier(s): James G. Scelfo, MD, PA DBA // Personalized Primary Care
(B) Patient Name:
(C) Identification Number:
Advance Beneficiary Notice of Noncoverage (ABN)
NOTE: If Cigna Health Plans (PPO, HMO and POS) doesn’t pay for (D) Yearly Membership Fee to Personalized Primary Care or the amenities listed on the first page of the PPC Membership Agreement below, you may have to pay.
Cigna does not pay for everything, even some care that you or your health care provider have good reason to think you need. We expect Cigna may not pay for the (D) the yearly Membership Fee to Personalized Primary Care or the amenities listed on the first page of the PPC Membership Agreement below.
The yearly Membership Fee to Personalized Primary Care or the amenities listed on the first page of the PPC Membership Agreement
(E) Reason Cigna May Not Pay:
Is a non covered service not paid by any insurance company
(F) Estimated Cost:
Individual Membership: $1,560.00
Couple Membership: $2,600.00
Child < 2: $520.00
Child > 2: $260.00
WHAT YOU NEED TO DO NOW:
(G) OPTIONS: Check only one box. We cannot choose a box for you.
OPTION 1. I want the (D) listed above, but do not bill Cigna. You may ask to be paid now as I am responsible for payment. I cannot appeal if Cigna is not billed.
OPTION 2. I don’t want the (D) listed above. I understand with this choice I am not responsible for payment, and I cannot appeal to see if Cigna would pay.
(H) Additional Information:
This notice gives our opinion, not an official Cigna decision. If you have other questions on this notice or Cigna billing, please call Cigna Health Plans.
I Agree to the Terms & Policies of this page.
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Form CMS-R-131 (03/08)
Form Approved OMB No. 0938-0566