How to obtain an independent review of a denied claim

 

Aetna makes available to physicians its voluntary External Review Process for members in certain limited circumstances.

In this review, Aetna contracts with an Independent Review Organization (IRO). The IRO performs a binding review of eligible medical necessity and experimental or investigational coverage denials. Keep in mind:

  • State mandates related to external review take precedence.
  • Physician appeals related to pre-service, concurrent or urgent medical necessity review decisions are processed as member appeals and are subject to the Member External Review Process.
  • Physicians must exhaust Aetna's internal appeals process prior to requesting External Review. Please see Practitioner/Provider Appeal Process  (PDF) to submit an appeal related to a decision you want reviewed.

For more information regarding Aetna's Physician External Review Process, including Aetna's Policy and related forms, please see:

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