Section 3. How you get care

What's in this Section:
•   Identification Cards
•   Where you get covered care
•   What you must do to get covered care
•   How to Get Approval for Your hospital stay
•   How to Get Approval for Other services


Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive services from a Plan provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation (for annuitants), or your electronic enrollment system (such as Employee Express) confirmation letter.

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 1-800/638-6589 or 301/984-1440 (for TDD, use 301/984-4155) or write to us at SAMBA, 11301 Old Georgetown Road, Rockville, MD 20852-2800. You may also request replacement cards through our Web site: www.SambaPlans.com.
Where you get covered care You can get care from any "covered provider" or "covered facility". How much we pay and you pay depends on the type of covered provider or facility you use. If you use our preferred providers, you will pay less.
•   Covered providers We consider the following to be covered providers when they perform services within the scope of their license or certification:
  • doctor of medicine (M.D.)


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  • doctor of osteopathy (D.O.)


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  • doctor of podiatry (D.P.M.)

    Other covered providers include, but are not limited to:


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  • dentist (D.D.S., D.M.D.)


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  • chiropractor


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  • qualified clinical psychologist


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  • clinical social worker


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  • optometrist


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  • nurse midwife


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  • nurse practitioner/clinical specialist


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  • licensed acupuncturist (LAC)


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  • Christian Science practitioner listed in the Christian Science Journal


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Medically underserved areas. Note: We cover any licensed medical practitioner for any covered service performed within the scope of that license in the states OPM determines are medically underserved. For 2009, the states are: Alabama, Arizona, Idaho, Illinois, Kentucky, Louisiana, Mississippi, Missouri, Montana, New Mexico, North Dakota , South Carolina, South Dakota, and Wyoming.
•   Covered facilities Covered facilities include:
  • Ambulatory surgical center - a facility that operates primarily for the purpose of performing same-day surgical procedures.


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  • Birthing center - a licensed or certified facility approved by the Plan that provides services for nurse midwifery and related maternity services.


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  • Hospital -


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    1. An institution that is accredited under the hospital accreditation program of the Joint Commission on Accreditation of Healthcare Organizations, or


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    2. Any other institution that is operated pursuant to law, under the supervision of a staff of doctors and with 24-hour-a-day nursing service by a registered graduate nurse (R.N.) or a licensed practical nurse (L.P.N.), and primarily engaged in providing acute inpatient care and treatment of sick and injured persons through medical, diagnostic and major surgical facilities, all of which must be provided on its premises or under its control.

    Christian Science sanatoriums operated, or listed as certified, by the First Church of Christ, Scientist, Boston, Massachusetts, are included.

    In no event shall the term hospital include a skilled nursing facility, a convalescent nursing home, or any institution or part thereof which: a) is used principally as a convalescent facility, nursing facility, or facility for the aged; b) furnishes primarily domiciliary or custodial care, including training in the routines of daily living; or c) is operated as a school or residential treatment facility.
  • Rehabilitation facility - an institution specifically engaged in the rehabilitation of persons suffering from alcoholism or drug addiction which meets all of these requirements:


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    1. It is operated pursuant to law.


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    2. It mainly provides services for persons receiving treatment for alcoholism or drug addiction. The services are provided for a fee from its patients, and include both: (a) room and board; and (b) 24-hour-a-day nursing service.


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    3. It provides the services under the full-time supervision of a doctor or registered graduate nurse (R.N.).


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    4. It keeps adequate patient records which include: (a) the course of treatment; and (b) the persons progress; and (c) discharge summary; and (d) follow-up programs.

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What you must do to get covered care It depends on the kind of care you want to receive. You can go to any provider you want, but we must approve some care in advance.
•   Transitional care Specialty care: If you have a chronic or disabling condition and
  • lose access to your specialist because we drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB Plan, or


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  • lose access to your PPO specialist because we terminate our contract with your specialist for reasons other than for cause,

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you may be able to continue seeing your specialist and receiving any PPO benefits for up to 90 days after you receive notice of the change. Contact us or, if we drop out of the Program, contact your new plan.

If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can continue to see your specialist and your PPO benefits continue until the end of your postpartum care, even if it is beyond the 90 days.
•   If you are hospitalized when your enrollment begins We pay for covered services from the effective date of your enrollment. However, if you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at 1-800/638-6589 or 301/984-1440 (for TDD, use 301/984-4155). If you are new to the FEHB Program, we will reimburse you for your covered services while you are in the hospital beginning on the effective date of your coverage.

If you changed from another FEHB plan to us, your former plan will pay for the hospital stay until:
  • You are discharged, not merely moved to an alternative care center; or


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  • The day your benefits from your former plan run out; or


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  • The 92nd day after you become a member of this Plan, whichever happens first


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These provisions apply only to the benefits of the hospitalized person. If your plan terminates participation in the FEHB in whole or in part, or if OPM orders an enrollment change, this continuation of coverage provision does not apply. In such cases, the hospitalized family members benefits under the new plan begin on the effective date of enrollment.
How to get approval for...

•   Your hospital stay		 Precertification is the process by which prior to your inpatient hospital admission we evaluate the medical necessity of your proposed stay and the number of days required to treat your condition. Unless we are misled by the information given to us, we won't change our decision on medical necessity.

In most cases, your physician or hospital will take care of precertification. Because you are still responsible for ensuring that your care is precertified, you should always ask your physician or hospital whether they have contacted us.
Warning:

 We will reduce our benefits for the inpatient hospital stay by $500 if no one contacts us for precertification. If the stay is not medically necessary, we will not pay any benefits.
How to precertify an admission
  • You, your representative, your doctor, or your hospital must call CIGNA/CareAllies at 1-800/887-9735 7 days (whenever possible) before admission.


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  • If you have an emergency admission due to a condition that you reasonably believe puts your life in danger or could cause serious damage to bodily function, you, your representative, the doctor, or the hospital must telephone us within two business days following the day of the emergency admission, even if you have been discharged from the hospital.


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  • Provide the following information:


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    • Enrollees name and Plan identification number;


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    • Patients name, birth date, and phone number;


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    • Reason for hospitalization, proposed treatment, or surgery;


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    • Name and phone number of admitting doctor;


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    • Name of hospital or facility; and


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    • Number of planned days of confinement.


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  • We will then tell the doctor and/or hospital the number of approved inpatient days and we will send written confirmation of our decision to you, your doctor, and the hospital.

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Maternity care You do not need to precertify a maternity admission for a routine delivery. However, if your medical condition requires you to stay more than 48 hours after admission for a vaginal delivery or 96 hours after admission for a cesarean section, then your physician or the hospital must contact us for precertification of additional days. Further, if your baby stays after you are discharged, then your physician or the hospital must contact us for precertification of additional days for your baby.
If your hospital stay needs to be extended: If your hospital stay - including for maternity care - needs to be extended, you, your representative, your doctor, or the hospital must ask us to approve the additional days.
What happens when
you do not follow
the precertification
rules		 If no one contacts us, we will decide whether the hospital stay was medically necessary.
  • If we determine that the stay was medically necessary, we will pay the inpatient charges, less the $500 penalty


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  • If we determine that it was not medically necessary for you to be an inpatient, we will not pay inpatient hospital benefits. We will only pay for any covered medical supplies and services that are otherwise payable on an outpatient basis.

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If we denied the precertification request, we will not pay inpatient hospital benefits. We will only pay for any covered medical supplies and services that are otherwise payable on an outpatient basis.

When we precertified the admission but you remained in the hospital beyond the number of days we approved and did not get the additional days precertified, then
  • for the part of the admission that was medically necessary, we will pay inpatient benefits, but


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  • for the part of the admission that was not medically necessary, we will pay only medical services and supplies otherwise payable on an outpatient basis and will not pay inpatient benefits.

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Exceptions: You do not need precertification in these cases:
  • You are admitted to a hospital outside the United States.


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  • You have another group health insurance policy that is the primary payer for the hospital stay.


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  • 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 we will become the primary payer and you do need precertification.

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Other services Certain services require prior authorization from us. You must obtain prior authorization for:
  • 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. In determining when your treatment plan must be submitted, we count all outpatient psychotherapy visits, even if you use different providers. If you change providers, a new treatment plan must be submitted. Call CIGNA/CareAllies at 1-800/887-9735. Refer to pages 49 and 51 for additional information.


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  • Certain prescription drugs and supplies. Contact Medco Health at 1-800/753-2851 for additional information.


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  • Growth hormone therapy (GHT) drugs (see Section 5(f)). Call Medco Health at 1-800/753-2851 for preauthorization. If we determine GHT is not medically necessary, we will not cover the GHT or related services and supplies.


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  • Surgical treatment of morbid obesity (bariatric surgery). Contact CIGNA/CareAllies at 1-800/887-9735.

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Note: The prior authorization process for organ/tissue transplants is more extensive than the normal authorization process. See Section 5(b) on page 40.
Warning: We will reduce our Plan allowance by 20% if no one contacts us for prior authorization. In addition, if the services are not medically necessary, we will not pay any benefits.



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