How do we decide what services to pay for OR How we pay claims
Our goal is to help you get the proper care for your condition. However, we do not pay
for every type of care a person wants.
We make decisions about what to pay for based on the members' health plan and generally accepted guidelines and policies.
When we do not pay for a service it is called a denied claim. 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 there are no appeals left, independent doctors may review your denied claim. This is called an external review.
We comply with Federal laws
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 mandate 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.
We review new technologies
Aetna's policies about specific medical technologies are described in clinical policy bulletins.
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.
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. Read how we pay for out-of-network care and how we calculate those payments. Always check the language of your benefit plan to determine which method Aetna uses to pay your out-of-network benefits.