Haris Ashley
If you have medical insurance through your job, your spouse's job, or your partner's job, you can contact your employer's benefits office to verify proof of your medical insurance. You may also be able to find your summary of benefits online by logging into your member account. If you have Aetna Medicare, you can find your plan's contact details online. If you have a printed copy of your Annual Notice of Change, Evidence of Coverage, or formulary, you can verify your insurance by calling the number on your ID card.
| Characteristics | Values |
|---|---|
| Clinical Policy Bulletins (CPBs) | Define Aetna's clinical policy |
| Medical necessity determinations | Made on a case-by-case basis |
| Member's right to appeal | In case of disagreement with a coverage determination |
| Independent external review | Opportunity for members in case of coverage denial |
| Precertification | Utilization review process to determine if a service meets the company's clinical criteria for coverage |
| Applied Behavior Analysis (ABA) Medical Necessity Guide | Determines appropriate levels and types of care for patients with behavioral health conditions |
| Member website | To get reimbursed, file a claim, request funds, and find forms |
| Aetna Medicare | An HMO, PPO plan with a Medicare contract |
| Aetna Medicare SilverScript members | Can manage prescriptions, sign up for mail delivery, view order status, find drug pricing, and identify savings options |
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What You'll Learn
Contacting your employer's benefits office
If you have insurance through your job, your spouse's job, or your partner's job, you should contact your employer's benefits office. They can give you a summary of your benefits, which you may also be able to find online by logging into your member website.
Aetna plans include extra benefits just for members, which can help you save money. To get started, log in to your member website to learn about the discounts your plan offers. Once you receive your new ID card, you can log in to file your claim. You will be asked a few questions about your claim, and you can upload your bill. If you would prefer to send a paper copy, you can log in to your member account to get a medical claim form, which you can then complete and mail to the address on the back of your member ID card.
If you bought an Aetna plan on the Health Insurance Marketplace, you should first contact your past employer's benefits office to let them know that you would like to buy a COBRA policy, which will allow you to continue your health coverage for a limited time. Companies with more than 20 employees are required to make you aware of your options for buying this coverage.
If you are a Medicare member, you can easily find your plan's contact details. For general inquiries, you can reach Aetna's corporate headquarters at 1-888-US-AETNA (1-800-872-3862). The corporate headquarters phone lines are staffed Monday through Friday, 8 AM to 6 PM ET. For questions about pharmacy or CVS Caremark Mail Service Pharmacy, call 1-800-227-5720 (TDD: 1-800-823-6373). Hours of operation are Monday through Friday 7 AM to 11 PM ET, Saturday 7:00 AM to 9:30 PM ET, and Sunday 8 AM to 6 PM ET.
You can also contact Aetna's customer service Twitter representatives, or visit the Caremark.com website if you are an Aetna Medicare SilverScript member. On the Caremark.com website, you can manage prescriptions, sign up for mail delivery, view order status, find drug pricing, and identify savings options.
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Logging into your member account
Locating the Login Page
To log in to your Aetna member account, you can start by visiting the official Aetna website. On the website, look for the "Log In" or "Sign In" option, typically located in the top right corner or within the main navigation menu. Clicking on this option will direct you to the login page.
Entering Credentials
Once you reach the login page, you'll need to enter your login credentials. This typically includes your username or email address and password. Make sure to enter this information accurately to avoid any issues. If you have forgotten your password, most login pages offer a "Forgot Password" option, allowing you to reset it by following a few simple steps.
Two-Factor Authentication
In some cases, for added security, Aetna may require two-factor authentication. This means that after entering your initial credentials, you will need to provide an additional form of verification. This could be a code sent to your mobile device or email address. Entering this code will be necessary to complete the login process.
Navigating the Member Portal
After successfully logging in, you will have access to your member portal. Here, you can explore various features and services. For example, you can refill your medicine, file a claim, request funds, and find relevant forms. The member portal is designed to be user-friendly, allowing you to navigate easily between different sections.
Accessing Additional Services
Aetna also offers a range of additional services that you can access through your member account. For instance, if you have Aetna Medicare Supplement Insurance (Medigap), you can manage your premium payments through trusted payment services like InstaMed or Payer Express. Additionally, if you are a Medicare member, you can conveniently find your plan's contact details and reach out for assistance.
Remember, if you encounter any issues during the login process or have specific questions about your insurance plan, you can always contact Aetna's customer support for further assistance. They are available to help you with any concerns or queries you may have regarding your member account and insurance coverage.
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Understanding precertification
Precertification is the process of determining whether a requested service, procedure, prescription drug, or medical device meets the company's clinical criteria for coverage. It is important to note that precertification is not a guarantee of payment for care or services, as this is determined by the specific terms of the member's plan.
Aetna provides precertification lists and criteria to help healthcare professionals understand what requires preauthorization. These lists can be accessed through the CPT code lookup tool on the Aetna website. Additionally, healthcare providers can call the precertification number on the member's ID card to inquire about specific services or procedures.
Precertification is required for inpatient admissions and select ambulatory procedures and services. It applies to procedures and services on the Aetna Participating Provider Precertification List, the Aetna Behavioral Health Precertification List, and any services that require precertification under the member's plan. Medicare Advantage members can also request an organization determination for a coverage decision.
It's important to note that verbal or written requests for information about benefits or services not on the precertification lists are not part of the precertification process. Healthcare providers should refer to the member's plan to determine coverage for specific services or procedures.
By following the precertification process, Aetna ensures that members receive appropriate healthcare services backed by the latest medical evidence. This process also helps members understand their coverage decisions before receiving procedures, services, or supplies.
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Appealing a coverage decision
If you disagree with a coverage determination, you can appeal the decision. This can be done by submitting an online form, or by fax or mail. You can also call or print and complete the appropriate forms.
If your request for medical coverage is denied, you can request an appeal. This is a formal way of asking for a review and change of a coverage decision. If you have a Medicare Advantage plan, you'll need to request a coverage decision (organisation determination). If this is denied, you can then request a medical appeal.
If you are an inpatient, you'll receive a notice called "An Important Message from Medicare about Your Rights". You'll need to sign this to indicate that you understand your rights as a hospital patient. This includes your right to appeal your discharge decision if you think you're being discharged from the hospital too soon. You can also appeal if you disagree with a claim or utilisation review decision.
If you are a healthcare provider, you can submit a dispute online through the Availity website. An appeal is a written request to change an adverse initial claim decision based on medical necessity or experimental/investigational coverage criteria, or a denial for non-inpatient hospital services that were denied for not receiving prior approval.
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Using a pharmacy outside the network
In most cases, you need to use a pharmacy in your plan’s network for your plan to cover your drugs. Each Aetna Medicare plan may have a different pharmacy network. However, there may be times when you need to use an out-of-network pharmacy. In such cases, you can complete the claim form and mail it to the address on the claim form. You can also use your Aetna member website to get reimbursed or find a form.
Aetna has a broad network of over 65,000 pharmacies, including more than 23,000 preferred pharmacies. You can check if a drug is covered by your Medicare plan and look up prices using the drug search tool. You can also order new CVS Pharmacy prescriptions online. CVS Caremark® Mail Service Pharmacy is part of the preferred pharmacy network. You can sign up for mail delivery, view order status, find drug pricing, and identify savings options on the Caremark.com website.
You can also find a network retail or specialty pharmacy near you using the search tool. To get started, enter your zip code. If you need a prescription drug that’s not usually found at a retail pharmacy, try a specialty pharmacy like CVS Specialty® Pharmacy.
If you take medicine for a long-term condition, mail-order prescriptions may help you save time and help you avoid running out of the drugs you need.
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Frequently asked questions
You can verify proof of medical insurance with Aetna by logging into your member account.
You can find a claim form on the Aetna website. Complete and mail it to the address on the back of your member ID card.
If you bought your plan on the Health Insurance Marketplace, you should first contact your past employer's benefits office. If you are a Medicare member, you can find your plan's contact details on the Aetna website.
In case of an emergency, or when traveling, you may need to use a pharmacy that is not in the Aetna network. In that case, complete the claim form and mail it to the address on the claim form.
In the event that a member disagrees with a coverage determination, Aetna provides its members with the right to appeal the decision. Members may also have the opportunity for an independent external review of coverage denials based on medical necessity.
