A basic understanding of the claims and appeals process will help before beginning any lawsuit against a well-funded organization like Aetna. These monthly disability insurance benefits will provide supplemental income to help cover your needs and expenses while you are not receiving a paycheck. If you suffer a disabling sickness or injury that prevents you from working for an extended period, you may have the right to receive monthly LTD insurance benefits. Millions of American workers have LTD coverage with Aetna. As you can guess, Aetna is not always so quick to pay valid long-term disability (LTD) claims to policyholders and will do what it takes to retain every cent of their annual earnings.
The company has been known to collect tens of billions of dollars in revenues from premiums alone. 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.Aetna is one of the largest and best-known disability insurance providers in the United States. Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. Please note also that the ABA Medical Necessity Guide may be updated and are, therefore, subject to change. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. The member's benefit plan determines coverage. 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. 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. Members should discuss any matters related to their coverage or condition with their treating provider.Įach benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Treating providers are solely responsible for medical advice and treatment of members.
The ABA Medical Necessity Guide does not constitute medical advice. 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 member appeal process applies to appeals related to pre-service or concurrent medical necessity decisions.īy clicking on “I Accept”, I acknowledge and accept that: For these types of issues, the practitioner and organizational provider appeal process applies only to appeals received subsequent to the services being rendered. Utilization review decisions are decisions made during the precertification, concurrent or retrospective review processes for services that require precertification. An adverse initial utilization review decisionĬlaims decisions are all decisions made during the claims adjudication process: For example, decisions related to the provider contract, our claims payment policies or a processing error.A denial for non-inpatient hospital services that were denied for not receiving prior approval.An adverse initial claim decision based on medical necessity or experimental/investigational coverage criteria.An appeal is a written request by a practitioner/organizational provider to change: