Health Care Quality

Claims and benefits

Contacting Member Services
Contact customer service to get answers to your questions about claims and benefits.

Review of denied claims
Our goal is to help you get proper care for your condition. However, we do not pay for every type of care that people want. If your claim is denied, we will send you a letter to let you know. If you don’t agree, you can file an appeal. Once the applicable appeals process has been exhausted you may be able to get a review of a denied claim by independent doctors, called an external review.

Understanding coverage decisions
Find out about Aetna's guidelines and policies. We use these to make decisions about your health coverage. Keep in mind that Aetna makes coverage decisions on a case-by-case basis consistent with applicable policies. 

How Aetna pays claims for out-of-network benefits
We negotiate rates with doctors, dentists and other health care providers to help you save money. We refer to these providers as being "in our network." Some of our benefit plans pay for services from providers who are not in our network. Many of those benefit plans pay for out-of-network services based on what is called the “reasonable,” “usual and customary” or “prevailing” charge. Here is how we figure out that charge. Some may base the benefit on some other basis. Always check the language of your benefit plan to find out your level of out-of-network benefits.

How Aetna Pays Claims for Behavioral Health Out-of-Network Benefits
We negotiate rates with doctors, dentists and other health care providers to help you save money. We refer to these providers as being "in our network." Some of our plans pay for services from providers who are not in our network. Many of those plans pay for out-of-network services based on what is called the “reasonable,” “usual and customary” or “prevailing” charge. Here is how we figure out that charge. 

Health care safety and quality

Patient safety information
How to be safe when seeking health care. 

National Committee for Quality Assurance Accreditation
Quality health care. That's what you want. And that's what we are determined to deliver.
The National Committee for Quality Assurance is an independent, nonprofit group. Its mission is to improve health care quality. They review the health plans and services of health care companies. And they develop standards to find areas to improve. We take part in this voluntary audit process. Look up report cards for information on Aetna health plans.

Quality report cards
Health care is not just about cost. Consider quality when making health care decisions. Use these report cards to learn about the quality of your health plan.

Quality improvement information
As an Aetna member, you are entitled to information about Aetna’s programs to improve health care quality. Learn more about quality efforts  under way.

Doctor- and facility-specific cost and clinical information on doctor quality
Look up doctors’ rates and facility costs  (PDF) in certain locations nationwide for many common medical procedures and services. It's the first service of its kind. Find effective, high-performing doctors in 12 specialty categories in the Aetna network. We provide a special designation, called Aexcel®, to these specialists. Armed with this information, you can make more informed decisions for you and your family.

Your rights

Member rights and responsibilities statement
Learn about your rights and responsibilities as a member. For Aetna HMO, PPO and Medicare Advantage members.

Advance directives
Learn about living wills and advance directives. Use these documents to describe what medical care you want, or don't want, when an illness or accident makes it impossible for you to make decisions.

Aetna policies

Non-discrimination statement
Aetna does not discriminate in providing access to health care services on the basis of race, disability, religion, sex, sexual orientation, health, ethnicity, creed, age or national origin. Federal law mandates that Aetna comply with Title VI of the Civil Rights Act of 1964, the Age Discrimination Act of 1975, the Americans with Disabilities Act, other laws applicable to recipients of federal funds, and all other applicable laws and rules.

New technology assessment
Aetna reviews new medical technologies and services to decide if our plans benefits should cover them. We also review existing tests, procedures and treatments to see if they can be used in new ways and to determine the appropriate policies for paying claims.
Steps in evaluating new medical technologies include:

• Studying research and evidence on safety and effectiveness and talking to experts
• Examining guidelines from medical and government groups, including the Agency for Healthcare Research and Quality (AHRQ) and the Centers for Medicare and Medicaid Services (CMS)
• Determining whether new tests, procedures and treatments are experimental or investigational

Aetna's policies about specific medical technologies are described in clinical policy bulletins.

Statement on incentives
Aetna's goal is to help members get proper care for their conditions. But Aetna does not pay for every type of care that is requested. When we do not pay for a service, it is called a denied claim. We make decisions about what to pay for based on the members' health plan and generally accepted guidelines. Members can always protest a denied claim. We do not reward employees or anyone else for denying a claim. In fact, we make known the risks of not providing proper care.

Utilization management
To help make appropriate coverage decisions and to help members get appropriate care, Aetna reviews many of the services used by patients. These include tests, treatments, surgeries and hospital stays. We use nationally recognized guidelines to decide whether a service is appropriate and, therefore, covered. If we do not consider the service to be needed, we do not pay for it.