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Precertification

You may need prior Plan approval for certain services

Precertification or prior approval is the process by which we evaluate the medical necessity of your proposed surgery, service, or hospital stay (including the number of days required to treat your condition).

In most cases, your physician or hospital will take care of requesting precertification or prior approval.  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.

You must get prior approval for certain services.  Failure to do so will result in a minimum $500 penalty for inpatient hospital admissions or 20% penalty for all other services.

 

Precertification is required for:

 

Inpatient Hospital Stays:

You, your representative, your doctor, or your hospital must call Cigna/CareAllies at 1-800-887-9735. Precertify scheduled admissions 7 days before admission.  Emergency admissions must be certified within 48 hours of the admission, even if you have already been discharged.

 

Warning:

We will reduce our benefits for inpatient hospital stays by $500 if precertification is not obtained.  If the stay is not medically necessary, we only pay for services that are otherwise payable on an outpatient basis.

Exceptions

You do not need to precertify your hospital stay 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:

Contact Cigna/CareAllies at 800-887-9735 to obtain prior authorization for those procedures, services or supplies listed below.

  • Surgical treatment of morbid obesity (bariatric surgery).
  • Intensive outpatient program treatment, partial hospitalization, electroconvulsive therapy, and extended outpatient treatment visits (beyond 45-50 minutes) for mental health or substance misuse treatment.
  • Certain outpatient procedures, including services such as: skin removal or enhancement; treatment of varicose veins; and eye, ear, nose and throat procedures.
  • Unlisted outpatient procedures.
  • Certain musculoskeletal procedures, such as orthopedic surgeries and injections.
  • Durable Medical Equipment, Home Infusion Therapy, Home Nursing Care, and Speech Therapy.
  • Outpatient spinal procedures.
  • Gender reassignment surgery to treat gender dysphoria supported by a qualified mental health professional. Note:  You must obtain prior authorization for the surgery even if the proposed treatment is outside of the 50 United States.  (See Section 5(b) of the SAMBA Health Benefit Plan brochure.)
  • Applied Behavior Analysis (ABA) therapy services for children up to age 18 diagnosed with autism spectrum disorder. Note:  If prior authorization is not obtained, no benefits will be payable and claims for these services will be denied.
  • The following outpatient radiology/imaging services:
  • CT/CAT scan – Computed Tomography/Computerized Axial Tomography
  • MRA – Magnetic Resonance Angiography
  • MRI – Magnetic Resonance Imaging
  • NC – Nuclear Cardiology Studies
  • PET – Positron Emission Tomography
  • Organ/tissue transplants. The prior authorization process for organ/tissue transplants is more extensive than the normal authorization process.  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 800-668-9682 to initiate the pretransplant evaluation.  See Section 5(b) of the SAMBA Health Benefit Plan brochure.

 

Contact Express Scripts at 855-315-8527 to obtain prior authorization for the drugs or supplies listed below.

  • Certain drugs, such as specialty drugs used to treat chronic complex conditions. Refer to Section 5(f), page 73 of the SAMBA Health Benefit Plan brochure for more information.
  • Select drugs that are excluded from the Plan’s prescription drug formulary (click here for a list of these drugs). See Section 5(f). Prescription drug benefits in the SAMBA Health Benefit Plan brochure for additional information.

 

Contact SAMBA at 800-638-6589 or 301-984-1440 (for TDD, use 301-984-4155) for prior authorization and/or additional information regarding services for genetic testing.

 

Warning:

We will reduce our Plan allowance by 20% (except of noted above) if no one contacts us for prior authorization for the listed “Other services.”  In addition, if the services are not medically necessary, we will not pay any benefits.

 

Exceptions

You do not need precertification, prior authorization, or prior approval for the “Other Services” listed above in these cases:

  • If you have other group health insurance, including Medicare, that is the primary payer.
  • The procedure is performed outside the United States, except as noted above.