The Cigna wellness incentive claim form is a two-page document you complete after a qualifying preventive screening or wellness visit so you can collect the reward your employer’s supplemental wellness plan offers. You can download it from Cigna’s website or ask your benefits coordinator for a copy. Before you fill in anything, pull out your plan documents to confirm which services qualify and how much the reward is worth; the top of the form itself tells you to do this.
What to Gather Before You Start
This form is lighter than a standard medical claim. It uses checkboxes instead of procedure codes, so you do not need billing details from your doctor’s office. Have these on hand:
- Your Social Security Number. The form asks for your SSN, not your Cigna Member ID, because Cigna’s supplemental health division identifies accounts that way.
- Your Group Policy Number, which appears on your benefits enrollment paperwork or your insurance card.
- The exact date of the service, written as month/day/year.
- Your provider’s name, specialty, phone number, fax number, and street address.
One thing people trip over: the form does not ask for CPT codes, HCPCS codes, an NPI, or a Federal Tax ID. If you have filled out standard medical claim forms before, set that habit aside here.
Sections 1 Through 4: Personal and Employment Information
Section 1 collects your full name, SSN, date of birth, home address, daytime phone, and email. It also asks for your Group Policy Number, your employer’s name, and the employer address if it differs from yours. A yes-or-no question at the bottom asks whether you carry Cigna health insurance.
Section 2 asks whether you were an active employee on the date of service. If you were on leave, you have to say what kind: unpaid, paid, FMLA, or another arrangement. Getting this detail wrong can stall the claim, so check with HR if you are not sure of your status on that date.
Section 3 applies only when you are filing for a spouse or dependent child. Enter the claimant’s name, SSN (or check “Do not have SSN”), date of birth, relationship to you, and whether they carry Cigna coverage. Section 4 adds two follow-ups for child claims: whether the child is a full-time student, and if not, whether the child is totally disabled. A disabled adult child claim requires a Social Security Disability Insurance award letter attached to the form.
Section 5: Health Screening Details
Section 5 covers diagnostic and preventive screenings. Enter the date, then check every box that applies. The listed options are:
- Cancer screenings: mammography, Pap smear (women over 18), colonoscopy, flexible sigmoidoscopy, hemoccult stool specimen, bone marrow testing, breast ultrasound, and a general “cancer screenings including blood tests” category.
- Cardiovascular and metabolic tests: blood test for triglycerides or cholesterol (HDL/LDL), fasting blood glucose, stress test on a bicycle or treadmill.
- Other screenings: osteoporosis screening, chest X-ray, lead poisoning screening, thermography, and COVID screening, testing, or vaccination.
If your screening does not match any listed category, check “Other health screening or test” and write a description. Below the checkboxes, fill in the provider’s name, specialty, phone, fax, address, and the treatment period if the screening spanned more than one visit.
Section 6: Wellness Visit Details
Section 6 covers routine wellness exams rather than targeted screenings. Enter the visit date and check the relevant boxes:
- Adult general health exams, which cover the office visit plus any labs or immunizations given during the appointment.
- Routine gynecological exams.
- Routine prostate exams.
- Routine dental exams.
- Routine vision exams.
- Well child care, including office treatment, labs, or immunizations for a dependent child.
“Other wellness visit or exam” works as a catch-all. Enter the provider’s contact information and treatment period underneath. If you had a screening and a wellness visit on the same date, say blood work drawn during an annual physical, fill out both sections on the same form.
Watch one detail: the visit must be billed as preventive, not diagnostic. A preventive visit checks on your general health or catches problems early. A diagnostic visit addresses a specific symptom or complaint. If your doctor’s office codes the visit as diagnostic, it likely will not qualify for the wellness incentive even when the services performed were identical. Under the Affordable Care Act, most preventive services from an in-network provider come at no out-of-pocket cost, so there should not be a copay on the visit itself.
Virtual Wellness Visits
Cigna supports virtual wellness screenings through MDLIVE and similar telehealth platforms. Annual wellness screenings and routine care visits can run by phone or video, and Cigna notes these are available at no additional cost on many plans. If your virtual visit produces orders for biometrics, blood work, or preventive imaging, those get completed at a local lab or facility and still count toward your incentive. Coverage depends on your plan and location, so log in to myCigna before scheduling to confirm that a telehealth preventive visit qualifies under your benefits.
How to Submit the Form
Sign and date the form at the bottom of page two. A parent or guardian signs when the claimant is under 18. You have three submission routes:
- Online through myCigna.com. Cigna says online submissions process faster than the other methods.
- By mail to Cigna Supplemental Health Solutions, P.O. Box 188028, Chattanooga, TN 37422.
- By fax (some plans accept it) or by email to SuppHealthClaims@CignaHealthcare.com for supplemental health claims.
For standard Cigna medical claims the filing deadline is 180 days from the date of service. Your wellness incentive plan may run on its own clock; the form directs you to your plan documents for qualification details, so check there or call the number on your Cigna ID card for your specific window. Submitting well before any deadline is the simplest way to protect a reward you have already earned.
What Happens After You Submit
Cigna processes most standard medical claims within about 7 to 10 business days. Wellness incentive claims route through the supplemental health division, which may follow a different timeline depending on your employer’s plan. Allow extra time if you mailed the form. There is no tracking number for mailed submissions, but you can call Cigna’s supplemental health line at 1-800-754-3207, Monday through Friday, 8 a.m. to 8 p.m. ET, to confirm receipt.
How the reward reaches you depends on your employer’s plan design. Some plans deposit funds into a Health Savings Account or Health Reimbursement Account. Others issue gift cards, cut your premium contributions, or credit a wellness account. Your plan documents or benefits coordinator can tell you which form the reward takes and when to expect it.
If Your Claim Is Denied
The common reasons for rejection are straightforward: the visit was coded diagnostic instead of preventive, the service is not on the plan’s approved list, or a required field on the form was left blank. Before filing a formal appeal, call the customer service number on your Cigna ID card. A representative can often tell you what went wrong and whether a corrected form will fix it.
If the call does not resolve things, Cigna’s appeals and grievance process applies. For employer-sponsored plans the procedure is governed by your Group Service Agreement or Group Insurance Certificate, so pull those documents first. Appeal and grievance forms are available through the Forms Center in myCigna or by request from customer service. Cigna advises starting by phone, then following up in writing with any supporting documentation your provider can supply.
Taxes on Your Reward
Cash and cash-equivalent wellness rewards, including gift cards, prepaid cards, and direct payments, count as taxable income. The IRS has stated that cash rewards earned through a wellness program are included in gross income and subject to employment taxes. This applies at any dollar amount; cash is never excludable as a de minimis fringe benefit under federal tax rules.
Rewards that flow through a tax-advantaged medical account are the exception. Employer contributions to an HSA or FSA made as a wellness incentive follow the normal tax treatment for those accounts and are generally not included in your gross income at the time of contribution. A gift card for completing a biometric screening is income and should appear on your W-2. If your plan lets you choose between a cash reward and an HSA contribution, the HSA option is worth more after taxes.