76 Your physician (or another provider) may either : • Complete the following items, as applicable, on the Attending Physician’s Statement section of the claim form: − Date of Service; − CPT - 4 (the code for physician services and other health care services found in the Current Procedural Terminology, Fourth Edition, as maintained and distribu ted by the American Medical Association); − ICD - 10 (the diagnosis code found in the International Classification of Diseases, 10th Edition, Clinical Modification as maintained and distributed by the U.S. Department of Health and Human Services); − Billed char ge; − Number of units (for anesthesia and certain other claims); − Federal taxpayer identification number (TIN) of the provider; − Billing name and address; and − If treatment is due to accident, accident details. OR • Attach all itemized bills or doctor’s statements that describe in full the services rendered. W arning: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit may be guilty of a crime and may be subject to fines and confinement in prison. Filing a Claim Y ou may file claims for health benefits and appeal adverse claim decisions yourself or have an authorized representative do it for you. Often, the provider will make the claim on your behalf directly to Cigna. If your claim is denied, in whole or in part, y ou will receive a written notice of the denial from Cigna. The notice will explain the reason for the denial and the review procedures, including any applicable statute of limitation within which the claimant may file a claim in a court of law. Urgent Care Claims — Submit Directly to Cigna If the Plan requires advance approval of a service, supply or procedure before a benefit will be payable, and if the Plan or your physician determines that it is an urgent care claim, you will be notified of the decision not later than 72 hours (shorter depending on medical urgency of the case) after the claim is received. The decision will be made by Cigna unless the decision relates to your eligibility to participate, in which case it will be made by the Fund Of fice, acting on behalf of the Board of Trus tees. If there is not sufficient information to decide the claim, you will be notified of the information necessary to complete the claim as soon as possible, but not later than 24 hours after receipt of the claim . You will be given a reasonable additional amount of time, but not less than 48 hours, after the end of that additional time period (of after receipt o f the information, if earlier). Other Health Claims (Pre - Service and Post - Service) — Submit Directly to Ci gna If the Plan requires you to obtain advance approval of a service, supply or procedure before a benefit will be payable, a request for advance approval is considered a pre - service claim. You will be notified of the decision not later than 15 calendar da ys after re ceipt of the pre - service claim.