Jane Dotson
There are several ways to check your Aetna insurance documentation. You can log in to your online account to find a doctor or dentist who accepts your plan or locate a pharmacy near you. You can also search for covered medicine, but you'll need the name of your pharmacy plan. If you're unsure of the plan name, check your Summary of Benefits and Coverage. If you don't have an online account, you can call the member services number on your ID card. Additionally, you can download the Aetna Health app to access your insurance information. If you have Medicare, you can also check your personal coverage and benefit costs by logging in to your secure member website or calling 1-833-570-6670 (TTY: 711) between 8 AM and 8 PM, Monday to Friday.
| Characteristics | Values |
|---|---|
| Accessing plan documents | Log in to your member account |
| Request a copy by post | |
| Email Aetna Member Services | |
| Call 1-855-532-6837 | |
| Aetna member website | AetnaMedicare.com/Login |
| Aetna Medicare Advantage coverage | Summary of Benefits and Evidence of Coverage |
| Medical and hospital benefits | |
| Doctor visits | |
| Emergency and urgent care | |
| Tests and screenings | |
| Hearing, dental, vision, mental health services | |
| Formulary | Lists the prescription drugs covered by your plan |
| Download a copy from your plan web page or secure member website | |
| Visit AetnaMedicare.com/Formulary and enter your plan details | |
| Glossary | Lists general terms used on the site |
| Aetna Life Insurance Company | Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies |
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What You'll Learn
Accessing your member website
To log in, you will need your member ID, which you can find on your Aetna ID card. If you are unsure about your login details or are experiencing issues, you can contact member services using the number on your ID card.
Through your member website, you can access important documents such as your Summary of Benefits and Evidence of Coverage. These documents outline your plan's costs, coverage, and benefits in a clear and concise manner. You can also access a formulary, or drug list, which details the prescription drugs covered by your plan.
Additionally, the member website allows you to search for doctors, dentists, and pharmacies that accept your plan. This can be done by logging into your account and using the search function to locate providers in your network. Overall, the member website provides a convenient and comprehensive platform for managing your Aetna insurance plan and accessing relevant information.
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Understanding Clinical Policy Bulletins
Clinical Policy Bulletins (CPBs) are highly technical documents that outline the medical, dental, and pharmaceutical services that Aetna may or may not cover. They are used by professional staff to make clinical determinations in connection with coverage decisions. Members should review these bulletins with their providers to fully understand Aetna's policies.
CPBs are based on objective, credible sources such as scientific literature, guidelines, consensus statements, and expert opinions. They are not a substitute for medical or dental advice, and treating providers are solely responsible for the advice and treatment of members. Members should discuss any CPB related to their coverage or condition with their treating provider.
The five-character codes included in the CPBs are obtained from the Current Procedural Terminology (CPT), copyrighted by the American Medical Association (AMA). CPBs are also used to decide which services and procedures are considered medically necessary, cosmetic, or experimental and unproven. They help determine what Aetna will and will not cover.
In the event that a member disagrees with a coverage determination, they have the right to appeal the decision and request an independent external review. However, medical necessity determinations are made on a case-by-case basis.
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Requesting a copy of Form 1095
Depending on how you got your health coverage, you may receive one or more versions of Form 1095. Here are the ways to request a copy of Form 1095-B for your records:
Logging into your member account
Log in to your member account and go to the "Message Center."
Sending a request via mail
Send a request to: Aetna, PO Box 981026, El Paso, TX 79998-1206.
Sending a request via email
Email your request to Aetna Member Services.
Making a request over the phone
Call 1-855-532-6837 (TTY) to speak with a representative.
Please note that the IRS announced in 2019 that Form 1095-B is no longer required for filing federal taxes, so Aetna will not mail this form for the reporting tax year. However, you may still request a copy for your records if needed.
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Finding a doctor or dentist who accepts your plan
Finding a doctor or dentist who accepts your Aetna plan is simple.
Firstly, you can log in to your Aetna account to search for doctors, dentists, therapists, and other healthcare providers that are covered by your plan. You can also search for a pharmacy near you. You can even search without logging in; simply choose a plan to find doctors, hospitals, and providers that accept it.
Aetna Smart Compare® is a designation given to doctors in the Aetna network who have consistently provided high-quality, effective care. These doctors will be labelled as “Quality Care,” “Effective Care” or both in your search.
You can also find a range of other healthcare providers to help care for your unique needs, including vision care providers, mental health professionals, and virtual care options.
If you have an Aetna Medicare Advantage plan, you are eligible for a one-time "Welcome to Medicare" visit with a doctor in your first 12 months of having Medicare Part B. This visit is free of charge and will help establish your baseline health and catch any potential health problems early. It includes a review of your medical and social history, a brief checkup, and a medication review.
If you would prefer a printed copy of a directory of doctors covered by your plan, you can request one. Printed directories typically come with both English and Spanish text, but you can also call Member Services if you need assistance in another language.
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Appealing a coverage determination
If you disagree with a coverage determination, you have the right to appeal the decision and request an independent external review. This review can be requested when the service or supply in question, for which the member is financially responsible, is $500 or greater. However, this may differ depending on state mandates with respect to fully insured plans and self-funded non-ERISA plans.
Before an appeal, there is an opportunity for a peer-to-peer review, where providers can present additional information and discuss their cases with a peer reviewer. This is part of the utilization review coverage determination process and incorporates state, federal, CMS, and NCQA requirements.
Aetna's Clinical Policy Bulletins (CPBs) define the company's clinical policy, but medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. The Applied Behavior Analysis (ABA) Medical Necessity Guide helps determine appropriate levels and types of care for patients requiring evaluation and treatment for behavioral health conditions. However, this guide does not constitute medical advice, and treating providers are solely responsible for medical advice and treatment.
Members should discuss any matters related to their coverage or condition with their treating provider. Each benefit plan defines which services are covered, excluded, or subject to dollar caps or other limits.
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Frequently asked questions
You can access your Summary of Benefits and Evidence of Coverage by logging into your plan web page or your Aetna secure member website. You can also call 1-833-570-6670 (TTY: 711) between 8 AM and 8 PM, Monday to Friday.
You can log in to your member account and go to the "Message Center" or send a request to Aetna, PO Box 981026, El Paso, TX 79998-1206. You can also email Aetna Member Services or call 1-855-532-6837.
You can log in to your online account to find a doctor or dentist who accepts your plan.
