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.
Notice of Benefit Determination on Appeal
You will receive written or electronic notice of the benefit determination upon review. In the event your claim is denied on appeal, the notice will provide:
- The specific reason or reasons for the denial of the appeal;
- Reference to the specific Plan provisions on which the benefit determination is based;
- A statement that you are entitled to receive, upon request and free of charge, reasonable access to, and copies of, all documents, records and other information relevant to your claim for benefits;
- A statement describing any voluntary appeal procedures offered by the Plan and a statement of your right to bring an action under Section 502(a) of ERISA;
- If an internal rule or guideline was relied on in making the adverse determination, either the specific rule or guideline, or a statement that such a rule or guideline was relied on in making the adverse determination and that a copy of such rule or guideline will be provided free of charge on request; and
- If the adverse determination is an experimental treatment or similar exclusion or limit, either an explanation of the scientific or clinical judgment for the determination, applying the terms of the Plan to your circumstances, or a statement that such explanation will be provided free of charge upon request.
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: