Precertification is required for:
Inpatient Hospital Stays:
You, your representative, your doctor or your hospital must call CIGNA/CareAllies at 1-800-887-9735 for medical and mental health precertifications. Precertify scheduled admissions 7 days (whenever possible) before admission. Emergency admissions must be certified within 48 hours of the admission, even if you have already been discharged.
NOTE: We will reduce our benefits for inpatient hospital stays by $500 if precertification is not obtained.
Exceptions
You do not need to precertify in these cases:
- You are admitted to a hospital outside of the United States;
- You have another group health insurance policy that is the primary payer for the hospital stay;
- Medicare Part A is the primary payer for the hospital stay.
Note: If you exhaust your Medicare hospital benefits and do not want to use your Medicare lifetime reserve days, then SAMBA becomes your primary payer and you do have to precertify the admission;
- The admission is for maternity care. You may remain in the hospital up to 48 hours after admission for a regular delivery and 96 hours after admission for a cesarean delivery. Extended stays must be precertified.
Other Services that Require Prior Authorization:
- Covered outpatient services for the treatment of mental conditions and substance abuse. Your provider must submit a treatment plan to CIGNA/CareAllies prior to your 9th outpatient visit. Contact CIGNA/CareAllies at 1-800-887-9735 for information about submitting the treatment plan.
Note: If preauthorization is not obtained we will reduce our Plan allowance by 20%.
- Surgical treatment of morbid obesity (bariatric surgery). Contact CIGNA/CareAllies at 1-800-887-9735.
- Growth hormone therapy (GHT) drugs. Call Medco Health at 1-800-753-2851 for preauthorization.
- Certain prescription drugs and supplies. Contact Medco Health at 1-800-753-2851 for additional information.
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