Aetna External Review Program

How can I determine if my coverage denial is eligible for external review?

If upon 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 next steps necessary to request an external review and a Request for External Review form will be included with the letter.

Is there a cost involved if I request an external review?

Members subject to the interim federal process are not charged a fee for the review. Members subject to a state mandated review may be required to submit a filing fee not to exceed $25 which must be refunded to the member if the external review determination is reversed. Not applicable 

How long will it take for me to receive a decision from the Independent Review Organization (IRO)?

For a standard external review, within no more than 45 days after the receipt of the request for external review by the Independent Review Organization (IRO), the IRO must provide written notice to the member & the health plan of its decision to uphold or reverse the adverse benefit determination.

For expedited cases, the decision must be provided as expeditiously as possible, but no later than 72 hours after receipt of the request.

• Expedited reviews are available if the covered person has a medical condition where the timeframe for completion of a standard external review would seriously jeopardize the life or health of the covered person or would jeopardize the covered person’s ability to regain maximum function, or if the final adverse determination concerns an admission, availability of care, continued stay or health care service for which the covered person received emergency services, but has not been discharged from a facility.

How does the external Review process work?

After exhausting the applicable appeal process, a member or their authorized representative will have four months from the date of receipt of a notice of an adverse determination or final adverse determination to request an external review.

How will I know if my Request is received and eligible for review?

• Notification of eligibility will be sent in writing within 5 business days of receipt of the request.

May I submit additional information to the IRO that was not previously reviewed during the appeal process?

• You may submit additional information to be considered by the IRO within the timeframe designated in the correspondence.

Will the Health plan be able to influence the decision of the IRO based on the Health plans previous decisions?

• The IRO is required to perform a “de nova” review which means without giving deference to the plan’s internal appeals decision-making process.

How long will it take for the IRO to render a decision?

• Within 45 days after the date of receipt of the request for external review the IRO will provide written notice specifying whether the plan’s determination is upheld or reversed, and briefly specify the basis for the determination in accordance with plan documents.

If the IRO decision is still not in my favor do I have any other alternate process to appeal this decision?

• The decision of the IRO is binding on Aetna & the covered person, except to the extent those other remedies are available under applicable state law.