Jane Dotson
If you are looking to claim back money from Aetna Insurance, there are a few things you should know. First, Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates. Health benefits and health insurance plans contain exclusions and limitations. If you have insurance through your job, your spouse's or partner's job, contact the employer's benefits office to understand your benefits and eligibility. If you disagree with a coverage determination, Aetna allows its members to appeal the decision and request an independent external review. You can file a claim by logging into your member website, and you may be able to request funds from your Inspira account dashboard.
| Characteristics | Values |
|---|---|
| Reviewing claims | Review claims payment information online |
| Overpayment | Aetna provides simple steps to refunding |
| Eligibility | Check eligibility and claims status |
| Precertifications | Precertification is a review process to determine whether a service, procedure, prescription drug, or medical device meets the company's clinical criteria for coverage |
| Coverage | Aetna provides the right to appeal the decision |
| Adopting a child | There may be special coverage provisions for a legally adopted child |
| Forms | Call the toll-free number on the back of your Aetna ID card to know which form you need |
| Complaint | Aetna Health of California HMO has steps to make filing a complaint easier |
| Form 1095-A | Comes from the federal government's exchange marketplace or state-based exchange marketplace |
| Form 1095-B | No longer needed to file federal taxes as of 2019 |
| Form 1095-C | Comes from your employer |
| Out-of-network care | Some benefit plans pay for services from providers who are not in the Aetna network |
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What You'll Learn
Appealing a claim denial
If your claim is denied, you have the right to appeal the decision. You can also request an "expedited" appeal by calling the toll-free number on your Member ID card or the number on the claim denial letter. If your plan has one level of appeal, you will be informed of the decision within 72 hours of the request for review. If your plan has two levels of appeal, you will be informed within 36 hours. If your claim is still denied after the appeals, you may request a third party (independent party) to review your denied claim. This is called an external review.
The timeframe for an appeal decision may vary depending on state law, the urgency of your appeal, or whether your plan offers one or two levels of appeal. If your claim required prior authorization, you will receive a decision within 30 days of the appeal. For other claims, a decision will be made within 60 days. If your claim required prior authorization, you will receive a decision within 15 days of the appeal. For other claims, a decision will be made within 30 days. If you disagree with the decision, you can request a second review within 60 days of receiving the appeal decision letter.
In the case of medical necessity determinations, coverage decisions are made on a case-by-case basis. If a member disagrees with a coverage determination, they have the right to appeal the decision and may be eligible for an internal appeal and/or an independent external appeal as per federal or state law. Additionally, members may have the opportunity for an independent external review of coverage denials based on medical necessity or the experimental and investigational status of the service or supply in question. However, this opportunity is only available when the member's financial responsibility is $500 or greater. Nevertheless, state mandates will take precedence with respect to fully insured plans and self-funded non-ERISA plans.
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Using out-of-network providers
Some Aetna plans do not offer any out-of-network benefits, so you are only covered for out-of-network care in an emergency. For other plans, you will pay more than if you stayed in the network, and you will be responsible for the full cost.
If you get care from an NAP provider, you won’t get a balance bill. You’ll pay your usual cost-sharing for out-of-network care. Check your most recent ID card to see if your plan has the program.
If you get a bill from a provider who isn’t in the Aetna network, you’ll need to file a claim. To do so, fill out a form and mail it to the address on your ID card.
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Updating personal information
Keeping your personal information up to date with your health plan is important. If you have an Aetna plan through your employer, inform your employer of any changes to your name or address. Your employer will then send this update to Aetna.
If you purchased your plan directly from Aetna, you can update your name and address by logging in and using the "Contact Us" feature, or by calling Member Services at the number on your ID card. You can also update your contact information online in the "For Members" section of your state's aetnabetterhealth.com website.
If you purchased your plan on the Health Insurance Marketplace, contact the plan directly to update your name and address. First, contact your past employer's benefit office and inform them that you would like to buy a COBRA policy, which allows you to continue your health coverage for a limited time.
It is important to keep your health plan updated with any changes to your personal information, such as your address or phone number, to ensure that you receive important health plan notices and information.
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Obtaining a new ID card
Step 1: Contact Member Services
If you need a new ID card, the first step is to get in touch with Aetna's Member Services. You can find the Member Services contact information on your current ID card. Give them a call, and their representatives will be happy to assist you in requesting a replacement card.
Step 2: Provide Necessary Information
When you contact Member Services, they will likely ask for some information to verify your identity and account details. Make sure to have your member ID number handy. You can usually find this number on your current ID card, welcome letter, or Explanation of Benefits (EOB) that Aetna has sent you. Providing this information will help expedite the process of issuing a new ID card.
Step 3: Update Your Information
If your personal information, such as your name or address, has changed, it is important to update this with Aetna before requesting a new ID card. If you have Aetna insurance through your employer, inform your employer about the change, and they will update it with Aetna. If you purchased your plan directly from Aetna, you can log in to your member account and use the "Contact Us" feature to update your information, or simply give them a call.
Step 4: Await Your New Card
After you have contacted Member Services and provided any necessary updates, all that's left to do is wait for your new ID card to arrive. Aetna will send the new plastic ID card to your home address.
Obtaining a replacement ID card from Aetna is a relatively simple process, and their Member Services representatives are available to guide you through it and answer any questions you may have.
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Reviewing payment information
Payment Methods and Claims:
Aetna offers various payment methods and claims processes for its members. You can review claims payment information online at any time. Providers in the Aetna network should file claims on your behalf, and some out-of-network providers may also do so. However, if you receive a bill from an out-of-network provider, you will need to file a claim by submitting the appropriate form. You can contact the toll-free number on your Aetna ID card for assistance in determining the necessary form.
Precertification and Utilization Review:
Precertification, also known as utilization review, is a process that determines whether a requested service, procedure, prescription drug, or medical device meets Aetna's clinical criteria for coverage. This process does not guarantee payment but is an important step in understanding potential coverage. It is essential to note that precertification has a different definition under Texas law, where it represents a reliable payment assurance for fully insured HMO and PPO members.
Clinical Policy Bulletins (CPBs) and Coverage Determinations:
Aetna's CPBs outline the company's clinical policies, but medical necessity determinations are made on a case-by-case basis. If you disagree with a coverage determination, you have the right to appeal and request an independent external review under certain conditions, typically involving medical necessity or expenses exceeding $500.
Plan Exclusions and Limitations:
It is crucial to understand that health benefits and insurance plans offered by Aetna contain exclusions and limitations. These may include variations in eligibility by state and plan type. Always refer to your plan documents for specific details on what is covered and what is not.
Payment Tools and Guidelines:
Aetna provides tools and guidelines to assist with submitting insurance claims and collecting payments. They also negotiate rates with in-network providers to help you save money. Additionally, they offer resources for managing your account, setting up automatic payments, and updating your payment methods.
By reviewing payment information regularly and understanding the processes outlined above, you can effectively navigate your insurance coverage and benefits with Aetna.
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Frequently asked questions
If you are a health care professional, you can review claims payment information online at any time. If you are a member, you can appeal a decision made by Aetna regarding coverage.
If you are a member, ask your doctor if you need to file a claim at the time of service. If you are a health care professional, providers in the Aetna network should file claims for you. If you receive a bill from a provider who isn't in the Aetna network, you will need to file a claim by filling out a form and mailing it to the address on your ID card.
If your claim is denied, Aetna will send you a letter informing you of the decision. You can then file an appeal. Once there are no appeals left, independent doctors may review your denied claim.
Contact your past employer's benefit office and let them know that you would like to buy a COBRA policy to continue your health coverage for a limited time.
Log in to your member account and go to the "Message Center" to request a copy. Alternatively, you can send a request to Aetna, PO Box 981026, El Paso, TX 79998-1206, or email Aetna Member Services.
