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Aetna External Review Program
What Is External Review? Aetna has voluntarily implemented an external review program for its commercial HMO, QPOS ®, and USAccess ® members, and for members of fully insured traditional based health plans. In addition, self-funded traditional health plan sponsors may also elect this program for their members. Members of self-funded traditional health plans should contact their benefits administrator to find out if this program is available to them. Please keep in mind that certain states mandate external review of other benefits or service issues or require a filing fee. In addition, certain states mandate the use of their own external reviewer. These state mandates may not apply to self-funded plans. In particular, the following states have mandated external review programs that differ considerably from the process described below:
For further details regarding the external review program for a specific state, members may call the Member Services toll-free number listed on their ID card. If they do not have an ID card yet, please advise them to contact their employer's benefits office to obtain this toll-free number. They also may call their state insurance or health department for additional information regarding state-mandated external review procedures. Some states offer websites that provide information about, members’ rights, among other things. Here is a list of sites:
If, upon the final level of review, the Plan upholds the coverage denial and it is determined that the member may be eligible for external review, he or she will be informed in writing of the steps necessary to request an external review, and a Request for External Review form will be included with the letter.
-- The applicable plan appeal process has been exhausted. How does a member request external review of his or her coverage denial? If the above eligibility criteria have been met and the applicable state external review process does not require otherwise, the member should print the Request for External Review form (provided as a pdf), follow the instructions provided on the form, and submit all information to Aetna’s External Review Unit at the address listed on the form for processing. A second form, Request for Expedited External Review form (PDF: 356 KB / 1 page), is for use by the treating physician, if he or she certifies that a delay in service would jeopardize the member’s health. How does it work? The Aetna External Review Unit will refer the request to an independent review organization (IRO) contracted with Aetna, and the IRO will choose an appropriate independent physician reviewer (or reviewers, if necessary or required by applicable law) to examine the case. The IRO is responsible for choosing a physician who is board certified in the area of medical specialty at issue in the case. The physician reviewer must take an evidence-based approach to reviewing the coverage determination, and must follow the plan sponsor's plan documents and applicable criteria governing the member's benefits. How long does the process take? After all necessary information is submitted, external reviews generally will be decided within 30 calendar days of the request. Expedited reviews are available when a member's physician certifies that a delay in service would jeopardize the member's health. Once the review is complete, the decision of the independent external reviewer will be binding on Aetna, the plan sponsor and the health plan. Members are not charged a professional fee for the review. Other Questions Members can call the Member Services toll-free number listed on their ID card if they have any further questions regarding external review. Plan sponsors and producers, please contact your Aetna representative for additional information. If you reside in one of the following states below, please see the additional state specific language. Washington State: The product referred to as HMO is called Primary ChoiceSM and is offered by Aetna Health Inc., a licensed health care service contractor.
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