Claims FAQs for employers and organizations

Our COB approach is "pursue, then pay." We investigate the availability of other primary benefits before issuing benefits.

When other coverage information is obtained, we flag the online family eligibility record. The claim system will then automatically present a COB flag during claim processing. The notice includes details about the other coverage, which family members the other plan covers, the carrier, type of coverage (e.g., medical only, medical-dental, etc.) and date of the last update.

When a claim is submitted, if we are secondary and the primary carrier's Explanation of Benefits (EOB) is not attached to the claim, the claim is pended for receipt of the primary carrier's EOB.

Upon receipt of the primary carrier's EOB, claims are processed as follows:

• For maintenance of benefits (MOB) or non-duplication plans, the COB allowable expense is our normal benefit (i.e., our negotiated rate reduced by copays, coinsurance, or other applicable plan provisions).
• For standard plans, the COB allowable expense is the lesser of the primary plan's negotiated fee (if the primary plan is also a network plan) or the amount submitted to the primary carrier, subject to R&C limitations.

Once we determine the allowable expense, we subtract the primary carrier's payment from it and pay the balance, if any, as long as the balance does not exceed our normal benefit.

A member seeking urgent care while out of the service area can visit any facility or provider and be reimbursed all but the appropriate copay for covered services. No prior authorization or referral is needed.

For routine treatment, a member is responsible for contacting the PCP for a referral to a physician outside of the home network in order to receive benefits and pay a copay. Members may also visit a provider without a referral and receive a nonreferred benefit level subject to deductible and coinsurance.

We cover emergency care at the preferred level.

Once a claim is denied, the right to appeal is set forth in the initial denial letter. To start the appeals process, the member or a duly authorized representative acting on behalf of the member submits an oral or written request asking for a change in the initial determination decision regarding claim payment, plan interpretation, benefit determination or eligibility.

The member, or provider/representative acting on behalf of the member, has 180 days after receipt of a coverage decision to file an appeal, unless otherwise required by law.

Within five business days of receipt of a written appeal, an acknowledgment letter is sent. This letter states that the member, provider and facility will receive a response no later than 30 days from receipt of the appeal.

HMO, Aetna Open Access HMO, Aetna Open Access^® Elect Choice EPO members:Generally do not need to file claims. We do not require claim forms for in-network services unless members have paid for emergency out-of-area urgent care. Network providers submit claims on behalf of the member. The claim submission process is paperless from the member's point of view when the member uses network providers.

QPOS, USAccess, Managed Choice^® POS, Aetna Open Access Managed Choice^® POS members: We do not require claim forms for in-network services. Network providers submit claims on behalf of the member. The claim submission process is paperless from the member's point of view when the member uses network providers.

Non-network or out-of-area services: The member must submit claims, using our standard claim form for the first submission. Thereafter, the member may use a simplified claim submission process. This process involves using a tear-off, mini claim form that is located on the back of our Explanation of Benefits (EOB.)

Traditional Choice: Members can access care through any licensed provider; there are no networks in this plan. The member must submit claims, using our standard claim form for the first submission. Thereafter, the member may use a simplified claim submission process. This process involves using a tear-off, mini claim form that is located on the back of our EOB.

The length of extension of benefits is determined by the plan selected by the employer. Once the extension of benefits has expired, the member is eligible for COBRA coverage.