Aetna External Review Program

Aetna External Review Program

Certain benefit plans may not be subject to the requirements of PPACA.  Members of a self funded grand -fathered plan whose plan sponsor elected Aetna’s Company Sponsored External Review option for their employees may request an independent review of certain coverage decisions.  Check your plan documents to determine the applicable external review process if any, that may be available.

Has the member received a coverage denial?

• Is coverage being denied either because of the service or supply is not medically necessary; or because it is considered experimental or investigational?
• Does the cost of the service or supply at issue for which the member would be financially responsible exceed $500?
• Has the member exhausted the applicable plan appeal process?

If the member answers "yes" to all of these questions, they may be eligible to participate in Aetna's external review program.

Aetna has voluntarily implemented an external review program for plans not subject to Health Care Reform & the Patient Protection Affordable Care Act (PPACA).  Self-funded traditional health plan sponsors may elect this program for their members. Members of self-funded health plans should contact their benefits administrator to find out if this program is available to them.

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. In particular, the following states have mandated external review programs that differ considerably from the process described below:

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. 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.

What is the external review program?

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.

How can a member determine if a coverage denial is eligible for external review?

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.

• The cost of the service or supply at issue for which the member would be financially responsible exceeds $500.
• The applicable plan appeal process has been exhausted.

How does a member request external review of his or her coverage denial? 

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. The Request for External Review form  (PDF)should be submitted within 60 calendar days of the date of the final level of review letter from the Plan.

A second form, Reqest 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.

How does it work?

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.

How long does the process take?

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.

Other Questions

Members can call the Member Services toll-free number listed on their ID card if they have any further questions regarding external review. Plan sponsors and producers; please contact your Aetna representative for additional information.

Washington State: The product referred to as HMO is called Primary ChoiceSM and is offered by Aetna Health Inc., a licensed health care service contractor.