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

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.

Speech Therapy, Unlisted Outpatient 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 TTY, use 301-984-4155).

Partial Hospitalization and Electroconvulsive Therapy 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.

The following Preventive Services are covered (see Section 5a of 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, including Pap smears
• Routine screenings, such as:
  • Fecal occult blood test
  • Double contrast barium enema
  • Total blood cholesterol
  • Chlamydial infections
• Routine Prostate Specific Antigen (PSA) test
• Osteoporosis screenings
• Sigmoidoscopy screening
• Routine screening colonoscopy
• Adult routine immunizations endorsed by the Centers for Disease Control and Prevention (CDC)
• Routine mammograms
• BRCA screening for women whose family history is associated with an increased risk for deleterious mutations in BRCA1 or BRCA2 genes 
• Preventive care and screening services recommended under the U.S. Preventive Services Task Force (USPSTF)

Children Preventive Care:

• Childhood immunizations recommended by the American Academy of Pediatrics
• Office visits for well child care examinations (up to age 18)
• Preventive care services recommended under the U.S. Preventive Services Task Force (USPSTF)

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 Information Center