Claims & Coverage

How do we decide what services to pay for

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.

  • We do not reward our employees or anyone else for denying a claim. In fact, we make known the risks of not providing proper care.
  • We make coverage decisions on a case-by-case basis consistent with applicable policies.
  • We review 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.

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

  • To decide if our plans benefits should cover new medical technologies, we:
  • Study their safety and effectiveness based on the research
  • Talk to experts
  • Consider guidelines from medical and government groups, including the Agency for Healthcare Research and Quality (AHRQ) and the Centers for Medicare and Medicaid Services (CMS)
  • Determine whether new tests, procedures, and treatments are experimental or investigational

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.

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