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Certain benefit plans may not be subject to the requirements of the Patient Protection and Affordable Care Act (ACA), such as Self funded Traditional grandfathered plans and exempt plans. These plans have the option of participating in Aetna's Company Sponsored External Review program.
Aetna has voluntarily implemented an external review program for these Self-funded traditional health plan sponsors who elect this program for their employees. Covered persons enrolled in a self-funded health plan should check their plan documents and contact their benefits administrator to find out if this program or any external review process is available to them.
The external review program offers members the opportunity to have certain coverage denials reviewed by independent physician reviewers. Once the applicable plan appeal process has been exhausted, eligible members may request external review if the coverage denial for which the member would be financially responsible involves more than $500 and is based on lack of medical necessity or on the experimental or investigational nature of the service or supply at issue.
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.
If coverage has been denied and the coverage denial letter indicates that the member is not eligible to request external review of the coverage denial, he or she should review the information below to determine if the coverage denial meets eligibility criteria to participate in this program.
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, 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, is for use by the treating physician, if he or she certifies that a delay in service would jeopardize the member's health.
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.
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.
Members can call the Member Services toll-free number listed on their ID card or contact Aetna's National External Review Unit at 1-877-848-5855 ${tty} if they have any further questions regarding external review. Plan sponsors and producers; please contact your Aetna representative for additional information.
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.
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 or contact Aetna's National External Review Unit at 1-877-848-5855 ${tty} 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.
As noted above, when reviewing the information below, please understand that the external review process in some states, if applicable, may differ.
Connecticut External Review Guide (PDF)
Illinois External Review Guide (PDF)
Illinois Request for External Review Form (PDF)
Illinois Appointment of Authorized Representative Form (PDF)
Illinois Physician Certification Expedited Review Form (PDF)
Illinois Physician Certification Experimental/Investigational Review (PDF)
Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates (Aetna).
Health benefits and health insurance plans contain exclusions and limitations.
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Links to various non-Aetna sites are provided for your convenience only. Aetna Inc. and its affiliated 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 affiliated 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 affiliated 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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Links to various non-Aetna sites are provided for your convenience only. Aetna Inc. and its affiliated 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 affiliated 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 affiliated 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 affiliated 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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Each main plan type has more than one subtype. Some subtypes have five tiers of coverage. Others have four tiers, three tiers or two tiers. This search will use the five-tier subtype. It will show you whether a drug is covered or not covered, but the tier information may not be the same as it is for your specific plan. Do you want to continue?
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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.
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Licensee's use and interpretation of the American Society of Addiction Medicine’s ASAM Criteria for Addictive, Substance-Related, and Co-Occurring Conditions does not imply that the American Society of Addiction Medicine has either participated in or concurs with the disposition of a claim for benefits.
This excerpt is provided for use in connection with the review of a claim for benefits and may not be reproduced or used for any other purpose.
Copyright 2015 by the American Society of Addiction Medicine. Reprinted with permission. No third party may copy this document in whole or in part in any format or medium without the prior written consent of ASAM.
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See Aetna's External Review Program
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The information contained on this website and the products outlined here may not reflect product design or product availability in Arizona. Therefore, Arizona residents, members, employers and brokers must contact Aetna directly or their employers for information regarding Aetna products and services.
This information is neither an offer of coverage nor medical advice. It is only a partial, general description of plan or program benefits and does not constitute a contract. In case of a conflict between your plan documents and this information, the plan documents will govern.
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Links to various non-Aetna sites are provided for your convenience only. Aetna Inc. and its affiliates 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 affiliated 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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