State Specific Processes

This Notice applies to you if live in a state other than New York and if you currently have health or dental insurance coverage with Aetna, or if you were insured by Aetna at some point between January 1, 2004 and present, under an insurance policy issued in the State of New York.

If you were/are covered under a Point of Service ("POS") plan, this notice applies to you if either the "referred benefits" or the "self-referred benefits," or both, were covered under a policy or contract issue in New York. ("Referred benefits" are your HMO benefits, for services rendered by or coordinated through your Primary Care Physician. "Self-referred benefits" or "out-of-network" benefits cover services you obtained without going through your Primary Care Physician.)

The information below will be relevant to you if:

• You were covered
  • under a PPO or HMO plan and received health care or dental services, or contacted Aetna with respect to a proposed service, at any time since January 1, 2004
  • under a Point of Service ("POS") plan, with referred benefits covered under a policy issued in New York, or self-referred benefits covered under a policy or contract issue in New York, and received health care services, or contacted Aetna with respect to a proposed service, at any time since January 1, 2004
• Aetna denied your claim, or your request for coverage for proposed services - and in the case of a POS plan, the services in question were referred services or self-referred services, whichever is covered under a policy or contract issue in New York.
• Aetna's denial was based upon a determination that the treatment in question was not medically necessary, or was experimental/investigational or was cosmetic. (The information below is not relevant if your claim was denied for any other reason.)
• You appealed the denial to Aetna ("Level I Appeal") and Aetna upheld the original determination.
• If you are no longer covered by Aetna, the services were rendered while you are an Aetna member

Aetna's Level I Appeal determination notice would have informed you that you had the right to a Level II Appeal. However, because your coverage is or was under a policy issued in the State of New York, you have the right to an independent review as provided by New York law. These reviews are conducted by external appeal agents that are certified by the New York Department of Insurance and have a network of medical experts to which they assign appeals for review.

Though Aetna did not inform you of your right to appeal to New York's "External Appeal Program," we are extending that opportunity to you at this time.

To be eligible:

• You must complete and send the enclosed External Appeal Application to the New York Insurance Department within 53 days of the date of this letter;
• If Aetna's denial was based upon a determination that the treatment was experimental or investigational, your attending physician must complete the Attending Physician Attestation in the External Appeal Application and you must submit that as part of your application.
• Your submission to the Department of Insurance must include:
  • your completed Application,
  • a copy of this notice and
  • a filing fee of $50 made out to Aetna.

View the The External Appeal Application  (PDF)

The Department of Insurance's Standard Description and Instructions relating to the External Appeals Program is available at http://www.ins.state.ny.us/extapp/extappqa.htm#standes 
If you have questions for Aetna please call the Member Services number on your Aetna ID card. If you have questions about the New York External Appeals Program, you may contact the Insurance Department at 1-800-400-8882 or visit the DOI Web site at: http://www.ins.state.ny.us