Citi Benefits Handbook
If Aetna notifies you of an Adverse Benefit Determination — that is, a denial, reduction, termination of or failure to provide or make payment (in whole or in part) for a service, supply or benefit — you may submit an appeal.
An Adverse Benefit Determination may be based on:
- Your eligibility for coverage;
- The results of any utilization review activities;
- A determination that the service or supply is experimental or investigational;
- A determination that the service or supply is not medically necessary; or
- Contractual issues.
The Vision Plan provides two levels of appeal. It will also provide an option to request an External Review of the Adverse Benefit Determination.
You have 180 calendar days following receipt of notice of an Adverse Benefit Determination to request your first-level appeal. Your appeal may be submitted in writing and should include:
- Your name;
- Your employer's name;
- A copy of Aetna's notice of an Adverse Benefit Determination;
- Your reasons for making the appeal; and
- Any other information you would like to have considered.
You may file your appeal in writing or by telephone:
- In writing: send your appeal to Customer Service at the address on your Aetna Vision Plan ID card; or
- By telephone: call the Aetna Vision Plan at 1 (877) 787-5354.
You may also choose to have another person (an authorized representative) make the appeal on your behalf by providing written consent to Aetna.
A first-level appeal of an Adverse Benefit Determination shall be made by Aetna personnel who were not involved in making the Adverse Benefit Determination.
Aetna shall issue a decision within 30 calendar days of receipt of the request for an appeal.
If Aetna upholds an Adverse Benefit Determination at the first level of appeal, you or your authorized representative has the right to file a second-level appeal. The appeal must be submitted within 60 calendar days following receipt of notice of a first-level appeal.
A second-level appeal of an Adverse Benefit Determination of an urgent care claim, a preservice claim or a post-service claim shall be made by Aetna personnel who were not involved in making the Adverse Benefit Determination.
Aetna shall issue a decision within 30 calendar days of receipt of the request for a second-level appeal.
Exhaustion of Process
You must exhaust the applicable first-level and second-level processes of the Aetna appeal procedure before you do any of the following regarding an alleged breach of the policy terms by Aetna Life Insurance Company or any matter within the scope of the appeals procedure: