If you believe you have received an overpayment. first review the coordination of benefits (COB) status of the member.
In some cases, coverage with a maintenance of benefits (MOB) provision will result in a higher-than-expected payment.
Under an MOB provision, we first look at the Aetna normal benefit amount. in the absence of any other carrier. Next. we subtract the primary carrier's payment from the Aetna normal benefit. We then pay the difference. The result can be a higher payment than what a provider would see with 100% allowable coordination of benefits.
For example:
100% allowable COB: $370 bill results in $0 primary carrier payment and $25.04 patient responsibility per primary carrier. We pay $25.04.
MOB provision: $370 bill results in $65.70 Aetna normal benefit. Subtracting the primary carrier payment ($0), we pay $65.70.
Before sending us a check, please consider that your payment may have resulted from applying an MOB provision.
If you are sure that you have received an overpayment, please submit the following information:
Mail this information to the address on the EOB statement or on the member's ID card. Once we receive the information, we will correct the member's file.
If the EOB statement or the member's ID card is not readily available, send information to:
Aetna Inc.
PO Box 14079
Lexington, KY 40512-4079
If we have identified an overpayment and request a refund, please mail the check. along with a copy of the overpayment request letter we sent you, to the address provided in the letter.
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Links to various non-Aetna sites are provided for your convenience only. Aetna Inc. and its subsidiary companies are not responsible or liable for the content, accuracy, or privacy practices of linked sites, or for products or services described on these sites.
Links to various non-Aetna sites are provided for your convenience only. Aetna Inc. and its subsidiary companies are not responsible or liable for the content, accuracy, or privacy practices of linked sites, or for products or services described on these sites.
Links to various non-Aetna sites are provided for your convenience only. Aetna Inc. and its subsidiary companies are not responsible or liable for the content, accuracy, or privacy practices of linked sites, or for products or services described on these sites.
Links to various non-Aetna sites are provided for your convenience only. Aetna Inc. and its subsidiary companies are not responsible or liable for the content, accuracy, or privacy practices of linked sites, or for products or services described on these sites.
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The Applied Behavior Analysis (ABA) Medical Necessity Guide helps determine appropriate (medically necessary) levels and types of care for patients in need of evaluation and treatment for behavioral health conditions. The ABA Medical Necessity Guide does not constitute medical advice. Treating providers are solely responsible for medical advice and treatment of members. Members should discuss any matters related to their coverage or condition with their treating provider.
Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply.
The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna) for a particular member. The member's benefit plan determines coverage. Some plans exclude coverage for services or supplies that Aetna considers medically necessary.
Please note also that the ABA Medical Necessity Guide may be updated and are, therefore, subject to change.
Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. In the event that a member disagrees with a coverage determination, member may be eligible for the right to an internal appeal and/or an independent external appeal in accordance with applicable federal or state law.
