Section 1. How This Plan Works
This Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and other providers that contract with us. These Plan providers coordinate your health care services. We are solely responsible for the selection of these providers in your area. Contact us for a copy of our most recent provider directory or visit our website at www.aetnafeds.com. We give you a choice of enrollment in a High Option or a Basic Option.
HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in addition to treatment for illness and injury. Our providers follow generally accepted medical practice when prescribing any course of treatment.
When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You pay only the copayments, coinsurance, and deductibles described in this brochure. When you receive emergency services from non-Plan providers, you may have to submit claim forms.
You should join an HMO because you prefer the plan’s benefits, not because a particular provider is available. You cannot change plans because a provider leaves our Plan. We cannot guarantee that any one physician, hospital, or other provider will be available and/or remain under contract with us.
OPM requires that FEHB plans be accredited to validate that plan operations and/or care management meet nationally recognized standards. Aetna holds the following accreditations: National Committee for Quality Assurance and/or the local plans and vendors that support Aetna hold accreditation from the National Committee for Quality Assurance. To learn more about this plan’s accreditation(s), please visit the following website:
General features of our High and Basic Options
- You can see participating network specialists without a referral (Open Access).
- You can choose between our Basic Dental or Dental PPO option. Under Basic Dental, you can access preventive care for a $5 copay and other services at a reduced fee. Under the PPO option, if you see an in-network dentist, you pay nothing for preventive care after a $20 annual deductible per member. You may also utilize non-network dentists for preventive care, but at reduced benefit levels after satisfying the $20 annual deductible per member. You pay all charges for other services when utilizing non-network dentists.
- You receive up to a $100 reimbursement every 24 months for glasses or contact lenses under the High Option and up to a $200 reimbursement every 24 months under the Basic Option.
We have Open Access benefits
Our HMO offers Open Access benefits. This means you can receive covered services from a participating network specialist without a required referral from your primary care provider (PCP) or by another participating provider in the network.
This Open Access Plan is available to our members in our FEHBP service area. If you live or work in an Open Access HMO service area, you can go directly to any network specialist for covered services without a referral from your primary care provider. Note: Whether your covered services are provided by your selected primary care provider (for your PCP copay) or by another participating provider in the network (for the specialist copay), you will be responsible for payment which may be in the form of a copay (flat dollar amount) or coinsurance (a percentage of covered expenses). While not required, it is highly recommended that you still select a PCP and notify Member Services of your selection at 800-537-9384. If you go directly to a specialist, you are responsible for verifying that the specialist is participating in our Plan. If your participating specialist refers you to another provider, you are responsible for verifying that the other specialist is participating in our Plan.
How we pay providers
We contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochure. These Plan providers accept a negotiated payment from us, and you will only be responsible for your cost-sharing (copayments, coinsurance, deductibles, and non-covered services and supplies).
This is a direct contract prepayment Plan, which means that participating providers are neither agents nor employees of the Plan; rather, they are independent doctors and providers who practice in their own offices or facilities. The Plan arranges with licensed providers and hospitals to provide medical services for both the prevention of disease and the treatment of illness and injury for benefits covered under the Plan.
Specialists, hospitals, primary care providers and other providers in the Aetna network have agreed to be compensated in various ways:
- Per individual service (fee-for-service at contracted rates),
- Per hospital day (per diem contracted rates),
- Under capitation methods (a certain amount per member, per month), and
- By Integrated Delivery Systems ("IDS"), Independent Practice Associations ("IPAs"), Physician Medical Groups ("PMGs"), Physician Hospital Organizations ("PHOs"), behavioral health organizations and similar provider organizations or groups that are paid by Aetna; the organization or group pays the physician or facility directly. In such arrangements, that group or organization has a financial incentive to control the costs of providing care.
One of the purposes of managed care is to manage the cost of health care. Incentives in compensation arrangements with physicians and health care providers are one method by which Aetna attempts to achieve this goal. You are encouraged to ask your physicians and other providers how they are compensated for their services.
Your rights and responsibilities
OPM requires that all FEHB Plans provide certain information to their FEHB members. You may get information about us, our networks, and our providers. OPM's FEHB website (www.opm.gov/healthcare-insurance) lists the specific types of information that we must make available to you. Some of the required information is listed below.
- Aetna has been in existence since 1850
- Aetna is a for-profit organization
You are also entitled to a wide range of consumer protections and have specific responsibilities as a member of this Plan. You can view the complete list of these rights and responsibilities by visiting our website, www.aetnafeds.com. You can also contact us to request that we mail a copy to you.
If you want more information about us, call 800-537-9384 or write to Aetna at P.O. Box 550, Blue Bell, PA 19422-0550. You may also visit our website at www.aetnafeds.com.
By law, you have the right to access your protected health information (PHI). For more information regarding access to PHI, visit our website at www.aetnafeds.com to obtain our Notice of Privacy Practices. You can also contact us to request that we mail you a copy of that Notice.
Your medical and claims records are confidential
We will keep your medical and claims records confidential. Please note that we may disclose your medical and claims information (including your prescription drug utilization) to any of your treating physicians or dispensing pharmacies.
Medical Necessity
"Medical necessity" means that the service or supply is provided by a physician or other health care provider exercising prudent clinical judgment for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that provision of the service or supply is:
- In accordance with generally accepted standards of medical practice; and,
- Clinically appropriate in accordance with generally accepted standards of medical practice in terms of type, frequency, extent, site and duration, and considered effective for the illness, injury or disease; and,
- Not primarily for the convenience of you, or for the physician or other health care provider; and,
- Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the illness, injury or disease.
For these purposes, "generally accepted standards of medical practice," means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, or otherwise consistent with physician specialty society recommendations and the views of physicians practicing in relevant clinical areas and any other relevant factors.
Only medical directors make decisions denying coverage for services for reasons of medical necessity. Coverage denial letters for such decisions delineate any unmet criteria, standards and guidelines, and inform the provider and member of the appeal process.
Direct Access Ob/Gyn Program
This program allows female members to visit any participating gynecologist for a routine well-woman exam, including a Pap smear, one visit per calendar year. The program also allows female members to visit any participating gynecologist for gynecologic problems. Gynecologists may also refer a woman directly to other participating providers for specialized covered gynecologic services. All health plan preauthorization and coordination requirements continue to apply. If your Ob/Gyn is part of an Independent Practice Association (IPA), a Physician Medical Group (PMG), an Integrated Delivery System (IDS) or a similar organization, your care must be coordinated through the IPA, the PMG, the IDS, or similar organization and the organization may have different referral policies.
Mental Health/Substance Misuse
Behavioral health services (e.g. treatment or care for mental disease or illness, alcohol abuse and/or substance misuse) are managed by Aetna Behavioral Health. We also make initial coverage determinations and coordinate referrals, if required; any behavioral health care referrals will generally be made to providers affiliated with the organization, unless your needs for covered services extend beyond the capability of these providers. As with other coverage determinations, you may appeal behavioral health care coverage decisions in accordance with the terms of your health plan.
Ongoing Reviews
We conduct ongoing reviews of those services and supplies which are recommended or provided by health professionals to determine whether such services and supplies are covered benefits under this Plan. If we determine that the recommended services and supplies are not covered benefits, you will be notified. If you wish to appeal such determination, you may then contact us to seek a review of the determination.
Authorization
Certain services and supplies under this Plan may require authorization by us to determine if they are covered benefits under this Plan. See section 3, "You need prior plan approval for certain services."
Patient Management
We have developed a patient management program to assist in determining what health care services are covered and payable under the health plan and the extent of such coverage and payment. The program assists members in receiving appropriate health care and maximizing coverage for those health care services.
Where such use is appropriate, our utilization review/patient management staff uses nationally recognized guidelines and resources, such as Milliman Care Guidelines© and InterQual® ISD criteria, to guide the precertification, concurrent review and retrospective review processes. To the extent certain utilization review/patient management functions are delegated to integrated delivery systems, independent practice associations or other provider groups ("Delegates"), such Delegates utilize criteria that they deem appropriate.
| Term | Definition |
|---|
|
|
Precertification is the process of collecting information prior to inpatient admissions and performance of selected ambulatory procedures and services. The process permits advance eligibility verification, determination of coverage, and communication with the physician and/or you. It also allows Aetna to coordinate your transition from the inpatient setting to the next level of care (discharge planning), or to register you for specialized programs like disease management, case management, or our prenatal program. In some instances, precertification is used to inform physicians, members and other health care providers about cost-effective programs and alternative therapies and treatments. Certain health care services, such as hospitalization or outpatient surgery, require precertification with Aetna to ensure coverage for those services. When you are to obtain services requiring precertification through a participating provider, this provider should precertify those services prior to treatment. |
|---|
| The concurrent review process assesses the necessity for continued stay, level of care, and quality of care for members receiving inpatient services. All inpatient services extending beyond the initial certification period will require concurrent review. |
|---|
|
| Discharge planning may be initiated at any stage of the patient management process and begins immediately upon identification of post-discharge needs during precertification or concurrent review. The discharge plan may include initiation of a variety of services/benefits to be utilized by you upon discharge from an inpatient stay. |
|---|
-
Retrospective Record Review
| The purpose of retrospective record review is to retrospectively analyze potential quality and utilization issues, initiate appropriate follow-up action based on quality or utilization issues, and review all appeals of inpatient concurrent review decisions for coverage and payment of health care services. Our effort to manage the services provided to you includes the retrospective review of claims submitted for payment, and of medical records submitted for potential quality and utilization concerns. |
|---|
Member Services
Representatives from Member Services are trained to answer your questions and to assist you in using the Aetna Plan properly and efficiently. After you receive your ID card, you can call the Member Services toll-free number on the card when you need to:
- Ask questions about benefits and coverage.
- Notify us of changes in your name, address or phone number.
- Change your primary care provider or office.
- Obtain information about how to file a grievance or an appeal.
Privacy Notice
How we guard your privacy - We’re committed to keeping your personal information safe
What personal information is and what it isn’t - By “personal information,” we mean that which can identify you. It can include financial and health information. It doesn’t include what the public can easily see. For example, anyone can look at what your plan covers.
How we get information about you - We get information about you from many sources, including from you. But we also get information from your employer, other insurers, or health care providers like doctors.
When information is wrong - Do you think there’s something wrong or missing in your personal information? You can ask us to change it. The law says we must do this in a timely way. If we disagree with your change, you can file an appeal. Information on how to file an appeal is on our member website. Or you can call the toll-free number on your ID card.
How we use this information - When the law allows us, we use your personal information both inside and outside our company. The law says we don’t need to get your OK when we do.
We may use it for your health care or use it to run our plans. We also may use your information when we pay claims or work with other insurers to pay claims. We may use it to make plan decisions, to do audits, or to study the quality of our work.
We may use or share your protected health information (PHI):
- With the U.S. Office of Personnel Management (OPM)
- With your employing agency in connection with payment or health care operations
- When required by federal law
We’re also required to share your PHI to OPM for its claims data warehouse. The data is used for its Federal Employees Health Benefits (FEHB) Program.
This means we may share your info with doctors, dentists, pharmacies, hospitals or other caregivers. We also may share it with other insurers, vendors, government offices, or third-party administrators. But by law, all these parties must keep your information private.
When we need your permission - There are times when we do need your permission to disclose personal information.
This is explained in our Notice of Privacy Practices. This notice clarifies how we use or disclose your Protected Health Information (PHI):
- For workers’ compensation purposes
- As required by law
- About people who have died
- For organ donation
- To fulfill our obligations for individual access and HIPAA compliance and enforcement
To get a copy of this notice, just visit our member website. Or call the toll-free number on your ID card.
If you want more information about us, call 800-537-9384, or write to Aetna, Federal Plans, PO Box 550, Blue Bell, PA 19422-0550. You may also contact us by fax at 860-975-1669 or visit our website at www.aetnafeds.com.
Service Area
The following service areas will be for our Aetna Open Access HMO. Under these plans, members may see network specialists without obtaining a referral from their primary care provider (PCP). To enroll in this Plan, you must live in or work in our service area. Our health insurance plan in the State of New York is an Exclusive Provider Organization (EPO) underwritten by Aetna Life Insurance Company (ALIC). You are required to receive services from our network of providers. There are no out-of-network benefits. This is where our providers practice. Our service area is:
Delaware - Enrollment code P3 - Kent, New Castle, and Sussex counties.
New Jersey, Northern – Enrollment code JR – Bergen, Essex, Hudson, Hunterdon, Middlesex, Monmouth, Morris, Ocean, Passaic, Somerset, Sussex, Union and Warren counties.
New Jersey, Southern – Enrollment code P3 – Atlantic, Burlington, Camden, Cape May, Cumberland, Gloucester, Mercer and Salem counties.
New York, The Greater New York City area and Upstate New York – Enrollment code JC – Bronx, Broome, Cayuga, Dutchess, Kings (Brooklyn), Nassau, New York (Manhattan), Onondaga, Orange, Oswego, Putnam, Queens, Richmond (Staten Island), Rockland, Suffolk, Sullivan, Tioga, Ulster and Westchester counties.
Pennsylvania, Philadelphia, and Southeastern PA – Enrollment code P3 – Berks, Bucks, Carbon, Chester, Delaware, Lehigh, Monroe, Montgomery, Northampton, and Philadelphia counties.
Ordinarily, you must get your care from providers who contract with us. If you receive care outside our service area, we will pay only for emergency or urgent care benefits. We will not pay for any other health care services out of our service area unless the services have prior plan approval.
If you or a covered family member move outside of our service area, you can enroll in another plan. If your dependents live out of the area (for example, if your child goes to college in another state), they will be able to access full HMO benefits if they reside in any Aetna HMO service area by selecting a PCP in that service area. If not, you should consider enrolling in a fee-for-service plan or an HMO that has agreements with affiliates in other areas. If you or a family member move, you do not have to wait until Open Season to change plans. Contact your employing or retirement office.
Section 5(d). Emergency Services/Accidents
Important things you should keep in mind about these benefits:
- Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.
- Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.
- We define observation as monitoring patients following medical or surgical treatments to determine if you need more care, need admission or can be discharged. Observation care can be billed as Emergency Room, Outpatient, or Inpatient depending on where services are rendered, benefited accordingly and how it is billed to us within the scope of the facilities contract. Hospital observation cost share is determined as anything greater than 23 hours, and Aetna’s policy is to allow up to 48 hours of hospital observation without preauthorization. After 48 hours, facilities must determine if they are going to discharge or admit the patient from observation and if admitting they will be responsible to preauthorize. Once admitted, inpatient hospital member cost sharing will apply.
What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or could result in serious injury or disability, and requires immediate medical or surgical care. Some problems are emergencies because, if not treated promptly, they might become more serious; examples include deep cuts and broken bones. Others are emergencies because they are potentially life-threatening, such as heart attacks, strokes, poisonings, gunshot wounds, or sudden inability to breathe. There are many other acute conditions that we may determine are medical emergencies – what they all have in common is the need for quick action.
What to do in case of emergency:
Emergencies within our service area
If you need emergency care, you are covered 24 hours a day, 7 days a week, anywhere in the world. An emergency medical condition is one manifesting itself by acute symptoms of sufficient severity such that a prudent layperson, who possesses average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in serious jeopardy to the person’s health, or with respect to a pregnant woman, the health of the woman and her unborn child.
Whether you are in or out of an Aetna HMO service area, we simply ask that you follow the guidelines below when you believe you need emergency care.
- Call the local emergency hotline (e.g., 911) or go to the nearest emergency facility. For non-emergency services, care may be obtained from a retail clinic, a walk-in clinic, an urgent care center or by calling Teladoc. If a delay would not be detrimental to your health, call your primary care provider. Notify your primary care provider as soon as possible after receiving treatment.
- After assessing and stabilizing your condition, the emergency facility should contact your primary care provider so they can assist the treating physician by supplying information about your medical history.
- If you are admitted to an inpatient facility, you or a family member or friend on your behalf should notify Aetna as soon as possible.
Emergencies outside our service area
If you are traveling outside your Aetna service area, including overseas/foreign lands, or if you are a student who is away at school, you are covered for emergency and urgently needed care. For non-emergency services, care may be obtained from a walk-in clinic, an urgent care center or by calling Teladoc. Urgent care may be obtained from a private practice physician, a walk-in clinic or an urgent care center. Certain conditions, such as severe vomiting, earaches, or high fever, are considered “urgent care” outside your Aetna service area and are covered in any of the above settings.
If, after reviewing information submitted to us by the provider that supplied care, the nature of the urgent or emergency problem does not qualify for coverage, it may be necessary to provide us with additional information. We will send you an Emergency Room Notification Report to complete, or a Member Services representative can take this information by phone.
Follow-up Care after Emergencies
All follow-up care should be coordinated by your PCP or network specialist. Follow-up care with non-participating providers is only covered with a referral from your primary care provider and pre-approval from Aetna. Suture removal, cast removal, X-rays and clinic and emergency room revisits are some examples of follow-up care.
| Benefit Description : Emergency within our service area | High Option (You pay
) | Basic Option (You pay
) |
|---|
- Emergency or urgent care at a doctor’s office
| $20 per PCP visit $35 per specialist visit | $15 per PCP visit $35 per specialist visit |
- Services provided at a Walk in clinic or CVS MinuteClinic®
| $0 per visit | $0 per visit |
- Emergency or urgent care at an urgent care center
| $50 per visit | $100 per visit |
- Emergency care as an outpatient at a hospital (Emergency Room), including doctors’ services.
| $125 per visit Note: If you are admitted from the Emergency Room to a hospital, the copay is waived. | $250 per visit Note: If you are admitted from the Emergency Room to a hospital, the copay is waived. |
|
Not covered: Elective care or non-emergency care
|
All charges
|
All charges
|
| Benefit Description : Emergency outside our service area | High Option (You pay
) | Basic Option (You pay
) |
|---|
- Emergency or urgent care at a doctor’s office
| $35 per specialist visit | $35 per specialist visit |
- Services provided at a Walk in clinic or CVS MinuteClinic®
| $0 per visit | $0 per visit |
- Emergency or urgent care at an urgent care center
| $50 per visit | $100 per visit |
- Emergency care as an outpatient at a hospital (Emergency Room), including doctors’ services.
| $125 Note: If you are admitted from the Emergency Room to a hospital, the copay is waived. | $250 Note: If you are admitted from the Emergency Room to a hospital, the copay is waived. |
|
Not covered:
-
Elective care or non-emergency care and follow-up care recommended by non-Plan providers that has not been approved by the Plan or provided by Plan providers.
-
Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area.
-
Medical and hospital costs resulting from a normal full-term delivery of a baby outside the service area.
|
All charges
|
All charges
|
| Benefit Description : Telehealth services | High Option (You pay
) | Basic Option (You pay
) |
|---|
|
| $35 per consult | $35 per consult |
- CVS Health Virtual Care™ consult
| $0 per consult | $0 per consult |
|
Please refer to www.aetnafed.com/tools.php for information on medical and behavioral telehealth services.
Members will receive a welcome kit explaining the telehealth benefits.
Refer to Section 5(e) for behavioral health telehealth consults. | | |
| Benefit Description : Ambulance | High Option (You pay
) | Basic Option (You pay
) |
|---|
Aetna covers ground ambulance from the place of injury or illness to the closest facility that can provide appropriate care. The following circumstances would be covered:
- Transport in a medical emergency (i.e., where the prudent layperson could reasonably believe that an acute medical condition requires immediate care to prevent serious harm); or
- To transport a member from one hospital to another nearby hospital when the first hospital does not have the required services and/or facilities to treat the member; or
- To transport a member from hospital to home, skilled nursing facility or nursing home when the member cannot be safely or adequately transported in another way without endangering the individual’s health, whether or not such other transportation is actually available; or
- To transport a member from home to hospital for medically necessary inpatient or outpatient treatment when an ambulance is required to safely and adequately transport the member.
Air or sea ambulance may be covered. Prior approval is required.
Note: See 5(c) for non-emergency service. | $100 copay Note: If you receive medically necessary air or sea ambulance transport services, you pay a copayment of $150 per day. | $100 copay Note: If you receive medically necessary air or sea ambulance transport services, you pay a copayment of $150 per day. |
Not covered: - Ambulance transportation to receive outpatient or inpatient services and back home again, except in an emergency.
- Ambulette service.
- Air ambulance without prior approval.
- Ambulance transportation for member convenience or for reasons not medically necessary.
Note: Elective air ambulance transport, including facility-to-facility transfers, requires prior approval from the Plan. | All charges | All charges |
Non-FEHB Benefits Available to Plan Members
The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed claim about them. Fees you pay for these services do not count toward FEHB deductibles or catastrophic protection out-of-pocket maximums. These programs and materials are the responsibility of the Plan, and all appeals must follow their guidelines. For additional information, contact the plan at 888-238-6240 or visit their website at www.aetnafeds.com.
Eyewear and exams
Discounts on designer frames, prescription lenses, lens options like scratch coating, tint and non-disposable contact lenses. Save on LASIK laser eye surgery and replacement contact lenses delivered to your door. Save on accessories like eyeglass chains, lens cases, cleaners, and nonprescription sunglasses. Visit many doctors in private practice. Plus, national chains like LensCrafters®, Target Optical® and Pearle Vision®.
Hearing aids and exams
Save on hearing exams, a large choice of leading brand hearing aids, batteries and free routine follow-up services. There are two ways for you to save at thousands of locations through Hearing Care Solutions or Amplifon Hearing Health Care.
Healthy lifestyle choices
Save on gym memberships, health coaching, fitness gear and nutrition products that support a healthy lifestyle. Get access to local and national discounts on brands you know. At-home weight-loss programs with tips and menus. Also save on wearable fitness devices, meditation, yoga, wellness programs and group fitness on demand.
Natural products and services
Ease your stress and tension and save on therapeutic massage, acupuncture or chiropractic care. Get advice from registered dietitians with nutrition services. Save on popular products from health and fitness vendors, like blood pressure monitors, pedometers and activity trackers, devices for pain relief and many other products. Save on teeth whitening, electronic toothbrushes, replacement brush heads and various oral health care kits.
Getting started is easy, just log in to your member website at Aetnafeds.com, once you’re an Aetna member.
DISCOUNT OFFERS ARE NOT INSURANCE. They are not benefits under your insurance plan. You get access to discounts off the regular charge on products and services offered by third party vendors and providers. Aetna makes no payment to the third parties--you are responsible for the full cost. Check any insurance plan benefits you have before using these discount offers, as those benefits may give you lower costs than these discounts.
Discount vendors and providers are not agents of Aetna and are solely responsible for the products and services they provide. Discount offers are not guaranteed and may be ended at any time. Aetna may get a fee when you buy these discounted products and services.
Hearing products and services are provided by Hearing Care Solutions and Amplifon Hearing Health Care.
Vision care providers are contracted through EyeMed Vision Care. LASIK surgery discounts are offered by the U.S. Laser Network and Qualsight. Natural products and services are offered through ChooseHealthy®, a program provided by ChooseHealthy, Inc. which is a subsidiary of American Specialty Health Incorporated (ASH). ChooseHealthy is a registered trademark of ASH and is used with permission.
Section 8. The Disputed Claims Process
You may appeal to the U.S. Office of Personnel Management (OPM) if we do not follow the required claims process. For more information or to make an inquiry about situations in which you are entitled to immediately appeal to OPM, including additional requirements not listed in Section 3, 7, and 8 of this brochure, please call Aetna's Customer Service at the phone number found on your ID card, plan brochure or plan website: www.aetnafeds.com.
Please follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your post-service claim (a claim where services, drugs or supplies have already been provided). In Section 3 If you disagree with our pre-service claim decision, we describe the process you need to follow if you have a claim for services, referrals, drugs or supplies that must have prior Plan approval, such as inpatient hospital admissions.
To help you prepare your appeal, you may arrange with us to review and copy, free of charge, all relevant materials and Plan documents under our control relating to your claim, including those that involve any expert review(s) of your claim. To make your request, please contact our Customer Service Department by writing Aetna, Attention: National Accounts, P.O. Box 14463, Lexington, KY 40512 or calling 800-537-9384.
Our reconsideration will take into account all comments, documents, records, and other information submitted by you relating to the claim, without regard to whether such information was submitted or considered in the initial benefit determination.
When our initial decision is based (in whole or in part) on a medical judgment (i.e., medical necessity, experimental/investigational), we will consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment and who was not involved in making the initial decision.
Our reconsideration will not take into account the initial decision. The review will not be conducted by the same person, or their subordinate, who made the initial decision.
We will not make our decisions regarding hiring, compensation, termination, promotion, or other similar matters with respect to any individual (such as a claims adjudicator or medical expert) based upon the likelihood that the individual will support the denial of benefits.
| Step | Description |
|---|
| 1 | Ask us in writing to reconsider our initial decision. You must: a) Write to us within 6 months from the date of our decision; and b) Send your request to us at: Aetna, Attention: National Accounts, P.O. Box 14463, Lexington, KY 40512; and c) Include a statement about why you believe our initial decision was wrong, based on specific benefit provisions in this brochure; and d) Include copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms. e) Include your email address, if you would like to receive our decision via email. Please note that by providing your email address, you may receive our decision more quickly. We will provide you, free of charge and in a timely manner, with any new or additional evidence considered, relied upon, or generated by us or at our direction in connection with your claim and any new rationale for our claim decision. We will provide you with this information sufficiently in advance of the date that we are required to provide you with our reconsideration decision to allow you a reasonable opportunity to respond to us before that date. However, our failure to provide you with new evidence or rationale in sufficient time to allow you to timely respond shall not invalidate our decision on reconsideration. You may respond to that new evidence or rationale at the OPM review stage described in step 4. |
|---|
| 2 | In the case of a post-service claim, we have 30 days from the date we receive your request to: a) Pay the claim or b) Write to you and maintain our denial; or c) Ask you or your provider for more information. You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days. If we do not receive the information within 60 days we will decide within 30 days of the date the information was due. We will base our decision on the information we already have. We will write to you with our decision. |
|---|
3 |
If you do not agree with our decision, you may ask OPM to review it.
You must write to OPM within:
- 90 days after the date of our letter upholding our initial decision; or
- 120 days after you first wrote to us -- if we did not answer that request in some way within 30 days; or
- 120 days after we asked for additional information.
Write to OPM at: United States Office of Personnel Management, Healthcare and Insurance, Federal Employee Insurance Operations, FEHB 3, 1900 E Street, NW, Washington, DC 20415-3630.
Send OPM the following information:
- A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;
- Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms;
- Copies of all letters you sent to us about the claim;
- Copies of all letters we sent to you about the claim; and
- Your daytime phone number and the best time to call.
- Your email address, if you would like to receive OPM’s decision via email. Please note that by providing your email address, you may receive OPM’s decision more quickly.
Note: If you want OPM to review more than one claim, you must clearly identify which documents apply to which claim.
Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your representative, such as medical providers, must include a copy of your specific written consent with the review request. However, for urgent care claims, a health care professional with knowledge of your medical condition may act as your authorized representative without your express consent.
Note: The above deadlines may be extended if you show that you were unable to meet the deadline because of reasons beyond your control. |
|---|
4 | OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct. OPM will send you a final decision or notify you of the status of OPM’s review within 60 days. There are no other administrative appeals.
If you do not agree with OPM’s decision, your only recourse is to sue. If you decide to file a lawsuit, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services, drugs, or supplies or from the year in which you were denied precertification or prior approval. This is the only deadline that may not be extended.
OPM may disclose the information it collects during the review process to support their disputed claim decision. This information will become part of the court record.
You may not file a lawsuit until you have completed the disputed claims process. Further, Federal law governs your lawsuit, benefits, and payment of benefits. The Federal court will base its review on the record that was before OPM when OPM decided to uphold or overturn our decision. You may recover only the amount of benefits in dispute. |
|---|
Note: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and you did not indicate that your claim was a claim for urgent care, then call us at 800-537-9384. We will expedite our review (if we have not yet responded to your claim); or we will inform OPM so they can quickly review your claim on appeal. You may call OPM's FEHB 3 at 202-606-0737 between 8 a.m. and 5 p.m. Eastern Time.
Please remember that we do not make decisions about plan eligibility issues. For example, we do not determine whether you or a family member is covered under this plan. You must raise eligibility issues with your Agency personnel/payroll office if you are an employee, your retirement system if you are an annuitant or the Office of Workers' Compensation Programs if you are receiving Workers' Compensation benefits.
