Aetna External Review Program
Federal External Review Process
Non-grandfathered self funded group health plans & health insurance coverage are subject
to the federal requirements outlined by the DOL. Aetna will administer this process on behalf
of our self funded plan sponsors upon request as an extension of their administrative services contract. Your plan documents will provide a description of the applicable external review process.
If upon final level of appeal the Plan upholds the coverage denial and it is determined that you are eligible for external review, you will be informed in writing of the next steps necessary to request an external review.
In some situations you may not be required to exhaust the internal appeals process if:
- The plan waives the exhaustion requirement;
- The plan is considered to have exhausted the internal appeal process by failing to comply with the requirements of the internal appeals process except those failures that are based on de minimus violations that do not cause, and are not likely to cause, prejudice or harm to the covered person; or
- The covered person simultaneously requests an expedited internal appeal and an expedited external review.
After exhausting the applicable appeal process, you or your authorized representative will have four months from the date of receipt of a notice of an adverse determination or final adverse determination to request an external review.
- Notification of eligibility will be sent in writing within 5 business days of receipt of the request.
- You may submit additional information you wish to be considered to the IRO within the timeframe designated in the correspondence.
- The IRO is required to perform a “de novo” review which means without giving deference to the plan’s internal appeals decision making process.
- Within 45 days after the date of receipt of the request for external review the IRO will provide written notice specifying whether the plan’s determination is upheld or reversed, and briefly specify the basis for the determination in accordance with plan documents.
- The decision of the IRO is binding on Aetna & the covered person except to the extent other remedies are available under applicable state law.
- Expedited reviews are available if the covered person has a medical condition where the timeframe for completion of a standard external review would seriously jeopardize the life or health of the covered person or would jeopardize the covered persons ability to regain maximum function; or if the final adverse determination concerns an admission, availability of care, continued stay or health care services for which the covered person received emergency services, but has not been discharged from a facility.
- A covered person is not charged a fee for an external review under the federal process. For those covered under a state mandated review a filing fee of not more than $25 may be applicable.
Please note some states require a specific form which will be provided in your final correspondence. The form below may be utilized for Aetna’s private federal external review process.