Citi Benefits Handbook
Aetna may deny a claim because it determines that the care is not appropriate or a service or treatment is experimental or investigational in nature. In either of these situations, you may request an External Review if you or your provider disagrees with Aetna's decision. An External Review is a review by an independent physician, selected by an External Review Organization, who has expertise in the problem or question involved.
To request an External Review, all the following requirements must be met:
- You have received notice of Aetna's denial of a claim;
- Your claim was denied because Aetna determined that the care was not medically necessary or was experimental or investigational;
- The cost of the service or treatment in question for which you are responsible exceeds $500; and
- You have exhausted the applicable internal appeals processes.
Aetna's claim denial letter will describe the process to follow if you wish to pursue an External Review, including a copy of the Request for External Review Form.
You must submit the Request for External Review Form to Aetna within 60 calendar days of the date you received the final claim denial letter. You must also include a copy of the final claim denial letter and all other pertinent information that supports your request. If your deadline to file an external review of your denied claim falls within the defined COVID-19 Outbreak Period, you will have additional time to submit your claim, as the deadline will be recalculated to extend through the Outbreak Period, as noted earlier.
Aetna will contact the Independent Review Organization that will conduct the review of your claim. The Independent Review Organization will select a physician reviewer with appropriate expertise to perform the review. In making a decision, the External Reviewer may consider any appropriate credible information that you send along with the Request for External Review Form and will follow Aetna's contractual documents and plan criteria governing the benefits.
You will be notified of the decision of the Independent Review Organization usually within 30 calendar days of Aetna's receipt of your request form and all necessary information. A quicker review is possible if your physician certifies (by telephone or on a separate Request for External Review Form) that a delay in receiving the requested service or supply would endanger your health. Expedited reviews are decided within three to five calendar days after Aetna receives the request.
Aetna will abide by the decision of the independent reviewer, except where Aetna can show conflict of interest, bias or fraud.
You are responsible for the cost of compiling and sending to Aetna the information that you wish to be reviewed by the Independent Review Organization. Aetna is responsible for the cost of sending this information to the Independent Review Organization and for the cost of the External Review.
For more information about Aetna's External Review program, call the Vision Plan at 1 (877) 787-5354.