Appeals & External Review


Appeals: Plans/issuers are required to have an internal appeals process (compliant with existing Department of Labor [DOL] requirements) that allows enrollees to review their files, to present evidence and testimony as part of the appeals process, and to receive continued coverage pending the outcome of the appeals process. Notice of the appeals process is required to be provided to enrollees in a culturally and linguistically appropriate manner.

External review: Plans/issuers must also have an external review process. The requirements of the external review process are dependent upon whether a plan is subject to the “state standard” or the “federal standard” under the interim final regulations.

Aetna’s take and action

  • We are working on updates to our processes to bring our plans into compliance with each of the above requirements. An enforcement grace period was granted through July 1, 2011 for certain requirements, and extended through January 1, 2012 for a subset of those requirements.
  • We have undertaken a systems project to bring us into compliance with the requirement that plans include additional information on explanation of benefits statements.
  • We have expanded the availability of the external review process to support processes for grandfathered and non-grandfathered plans. Self-funded plans can obtain this service through Aetna or they can secure it on their own.

Questions and answers

View all Appeals and External Review Q&As 

Related Resources

Regulations on Health Plan Appeals