Employers & Organizations: Notification of changes, eligibility, and provider network FAQs

Notification of changes

Can I e-mail enrollment files to the plan? 
To protect members' privacy, enrollment files may be submitted via enrollment form or fax. E-mail enrollment data will only be accepted if the files are encrypted prior to transmission. Enrollment files for Small Group business must be submitted via paper or fax to the appropriate Plan Sponsor Services Unit responsible for underwriting. A hard copy of the enrollment material must follow any faxed documents.

Who must be notified of a change of address or other administrative change? 
The plan administrator or producer of record can notify the Plan Sponsor Services for a change of address; however, the account manager can be notified also.

How do I change the waiting /elimination/probationary period on a group's policy? 
Our local sales offices provide contact lists for administrative procedures. A request for a revision to the policy must be submitted through the assigned account manager.

What is the maximum waiting /elimination/probationary period a group can impose? 
We require that a probationary period be consistently applied within a class of employees. We may match the current carrier's probationary period; however, our standard maximum is six months.

Eligibility

What is the average turnaround time required to determine a group or a subscriber's eligibility or underwriting status? 
The average turnaround time for a small group (2-50 lives, (1 life, where required by state law)) is determined by the local Aetna underwriting team. State and federal regulations determine how underwriting is applied to the group or the individual.

For our Middle Market and National Account customers, underwriting would be applicable on a group basis. We work with each of our customers or their consultant to determine when they need renewal pricing completed.

Depending on the complexity of the request, a renewal generally takes between one and three weeks to complete.

Provider network

Describe your provider networks (e.g., types of networks for each product). 
Our accessibility standards utilize GeoAccess indicators for urban, suburban and rural zip codes. Where gaps are identified, we will work with the customer to formulate a potential solution for member coverage. DocFind, our Internet provider directory provides a comprehensive listing of the providers in our networks.

We add physicians to our networks upon request as long as they meet our participation criteria. However, when we review our networks for purposes of adequacy, we follow a distinctive set of guidelines to determine the configuration of each network. Based on population size, we focus on the service area and types of services of each target hospital and its affiliated physicians to see that acceptable levels of care are readily available for members of the managed care program.

We have developed these guidelines so our networks give members reasonable access essential and important medical services.

Each of our networks is developed on a local basis, because each area is unique. Access to network providers (i.e., travel distance and time) must be reasonable for members based on local conditions. Geographic factors that may have an impact on accessibility include: 

• Natural geographic boundaries such as rivers and mountains
• Man-made boundaries such as bridges and railway tracks
• Road types ranging from interstate highways to rural roads
• Local travel conditions (other factors such as periodic traffic congestion)

Our local network representatives are responsible for reviewing on a zip code by zip code basis the appropriateness of the service area. They consider the actual geographic distribution of each broad category of services (i.e., primary care, pediatrics, ob/gyn, specialist and facility) when establishing the zip code service area.