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Medical - Physician External Review

Starting August 6, 2004, members of the physician settlement agreement with Aetna will be able to obtain independent review of disputed medical necessity issues when a plan member has access under Aetna’s External Review Policy or applicable law. Under this process, an Aetna contracted Independent Review Organization (IRO) will perform an external third party binding review of eligible medical necessity and experimental or investigational coverage denials. State mandates related to external review will take precedence. Physician appeals related to pre-service, concurrent or urgent medical necessity review decisions will be processed as member appeals and will be subject to the Member External Review Process.

Physicians must exhaust Aetna's internal appeals process prior to requesting External Review. Please see Practitioner/Provider Appeal Process  (4 pages) if you have not yet submitted an appeal related to the decision you would like reviewed.

For more information regarding Aetna's Physician External Review Process, including Aetna's Policy and related forms, please see:

• Physician External Review Announcement  (1 page)
• Physician External Review Policy  (3 pages)
• Physician External Review Form  (1 page)