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Frequently Asked Questions

Who is eligible to join?

All federal employees and annuitants are eligible to enroll in the SAMBA Health Benefit Plan.

How do I find a Plan participating provider?

Click here to access the Cigna Provider Directory, call Cigna at 1-800-887-9735, or ask the provider if they participate with the CIGNA Open Access Plus Network.

Do I need a referral to see a specialist?

No, SAMBA is a freedom of choice Plan. You can choose to see any provider you wish. SAMBA pays the same benefits for specialist services as for primary cares services. Note: Using our PPO network providers can save you money on your out-of-pocket cost.

How do I submit a claim?

Click here to download a Medical Claim Form. In most cases, providers and facilities file claims for you. Your physician must file on the form CMS-1500; your facility will file on the UB-04 form. Claims should be itemized and show:

  • Name of patient and relationship to enrollee;
  • Plan identification number of the enrollee;
  • Name and address of person or firm providing the service or supply;
  • Date that services or supplies were furnished;
  • Diagnosis;
  • Type of each service or supply; and
  • The charge for each service or supply.

Note: Canceled checks, cash register receipts, or balance due statements are not acceptable substitutes for itemized bills.

In addition:

You must send a copy of the explanation of benefits (EOB) form you received from any primary payer with your claim.
Bills for rental or purchase of durable medical equipment and private duty nursing require a written statement from the physician specifying the medical necessity for the service or supply and the length of time needed.

Mail all medical claims to:
Cigna Payor 62308
P. O. Box 188007
Chattanooga, TN 37422

Mail all correspondence to:
SAMBA
11301 Old Georgetown Rd.
Rockville, MD 20852-2800

How can I find the status of a submitted claim?

There are several options:

  1. Click here to access the My Claim History link.
  2. Click here to send a secure e-mail with your status inquiry.
  3. Call Member Services at 1-800-638-6589, between the hours of 8:00 am and 5:00 pm, Eastern Time, Monday-Friday.

If you are a Health Care Professional, click here to access the WebConnect portal offered through our partnership with Change Healthcare.

What services require precertification or prior authorization?

The Plan requires precertification for:

Inpatient hospital stays:
You, your representative, your doctor, or your hospital must call Cigna/CareAllies at 1-800-887-9735 for hospital precertification. 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 the inpatient hospital stay by $500 if precertification is not obtained.

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

Organ/tissue transplants:
Before your initial evaluation as a potential candidate for a transplant procedure, you or your doctor must contact the CareAllies Cigna Lifesource Transplant Unit at 1-800-668-9682.

Durable Medical Equipment, Home Infusion Therapy, Home Nursing Care, Speech Therapy, Unlisted Outpatient Procedures, Certain Musculoskeletal Procedures, Certain Outpatient Procedures and Outpatient Spinal Procedures.
Call Cigna/CareAllies at 1-800-887-9735.

Services for Genetic Testing:
Call SAMBA at 1-800-638-6589 or 301-984-1440 (for TDD, use 301-984-4155).

Intensive Outpatient Program Treatment, Partial Hospitalization, Electroconvulsive Therapy, and Extended Outpatient Visits for Mental Health or Substance Misuse Treatment:
Contact Cigna/CareAllies at 1-800-887-9735.

 

Gender Reassignment Surgery to Treat Gender Dysphoria Supported by a Qualified Mental Health Professional:
You, your representative, your doctor or facility must call Cigna/CareAllies at 1-800-887-9735 prior to services being rendered.

Certain classes of drugs including, but not limited to, Growth Hormone Therapy (GHT) drugs. Call Express Scripts at 1-855-315-8527 for additional information and preauthorization.

The following Radiology/Imaging procedures:

  • CT/CAT scan – Computed Tomography/Computerized Axial Tomography
  • MRA – Magnetic Resonance Angiography
  • MRI – Magnetic Resonance Imaging
  • NC – Nuclear Cardiology
  • PET – Positron Emission Tomography

You or your doctor must contact Cigna/CareAllies at 1-800/887-9735 before scheduling the procedure.

Does maternity care require precertification?

You do not need to precertify your normal delivery. 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.

What preventative services are covered?

The following Preventive Services are covered (see the official Plan brochure for a complete listing):

Adult Preventive Care:

  • One routine physical exam per year, including certain lab tests and screenings
  • One annual routine gynecological visit for women age 18 or over
  • Routine screenings, such as:
    • Fecal occult blood test for members age 40 and older
    • Pap smear – Cervical cancer
    • Double contrast barium enema every 5 years starting at age 50
    • Total blood cholesterol
    • Chlamydial infections
  • Routine Prostate Specific Antigen (PSA) test
  • Osteoporosis screenings, for women age 60 and older
  • Sigmoidoscopy screening – every 5 years starting at age 50
  • Colonoscopy – every 10 years starting at age 50
  • Adult routine immunizations endorsed by the Centers for Disease Control and Prevention (CDC)
  • Routine mammograms (PPO payable at 100% no deductible) according to the age ranges below:
    • From age 35 to 39 – one during this 5 year period.
    • From age 40 and older – one every calendar year.

Children Preventive Care:

  • Childhood immunizations recommended by the American Academy of Pediatrics
  • Office visits for well child care examinations (up to age 18)
What is our protection against catastrophic cost (out-of-pocket maximum)?

The catastrophic limitation is the maximum out-of-pocket expenses that you and your family members will incur before the SAMBA Health Plan pays covered expenses at 100% for the balance of the calendar year. Please refer to the Summary Plan Description for specific details regarding out-of-pocket maximum limits for PPO and Non-PPO claims.

Am I covered when I travel out of state or overseas?

Yes, you are always covered. The SAMBA Health Plan covers you worldwide.

How much do I pay for prescription drugs?

SAMBA offers two prescription drug options. You may fill your prescriptions at a local participating Plan pharmacy, a non-participating pharmacy, or by mail.

Prescription Drug Copayments

What is the prescription drug formulary?

The formulary identifies preferred name brand drugs that help contain your costs. Your copayment is less for drugs listed on the formulary. Click here to view the formulary list; Prescription Formulary Guide.

If I have Medicare coverage, does my premium cost change?

No. Federal employees may choose from Self-Only, Self Plus One or Self and Family coverage. Other coverage types — such as Medicare enrolled and/or Medicare eligible — are not available. However, by signing up for Medicare, you can drastically reduce your cost sharing.  Some of your SAMBA Health Plan copayments are waived when you are enrolled in Medicare.

What is OBRA (Omnibus Budget Reconciliation Act)?

OBRA is a Federal Law that applies to all retirees enrolled in a Federal Employees Health Benefit (FEHB) plan, who are age 65 and older, and who are not entitled to Part A Medicare coverage or who do not elect to enroll in Medicare Part B coverage. The OBRA law requires all FEHB plans to base claim payment for covered services on an amount equivalent to the amount Medicare would have allowed if the patient was enrolled in Medicare.

What Health and Wellness programs does SAMBA offer?

Please visit MyCigna.com to take a health assessment, review health topics, and see discounts available for SAMBA members.