A list of reports produced by our Department. Links to various non-Aetna sites are provided for your convenience only. Some subtypes have five tiers of coverage. ! For other claims, we'll decide within 30 days. What if your claim is still denied after your appeals? If there are documents you need for your claim, call the Member Services phone number listed on your member ID card. Just enter your mobile number and well text you a link to download the Aetna Health app from the App Store or on Google Play. 
The member's benefit plan determines coverage.
The conclusion that a particular service or supply is medically necessary does not constitute a representation or warranty that this service or supply is covered (i.e., will be paid for by Aetna) for a particular member. You may be able to have a third party (independent party) review your denied claim. You can call Member Services at the phone number listed on your member ID card, or write to us. 1355 0 obj <> endobj 9QD#,/Zao$7kR^X#(v: u8$iABQ3Nfyz~]+cbq9_p;)>p1_c Health benefits and health insurance plans contain exclusions and limitations.
Aetna Inc. and its subsidiary companies are not responsible or liable for the content, accuracy, or privacy practices of linked sites, or for products or services described on these sites. 1366 0 obj
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Members and their providers will need to consult the member's benefit plan to determine if there are any exclusions or other benefit limitations applicable to this service or supply. ?NjZ-m]}=#CcS3s++
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rQyO$@{PER If you are interested in a rewarding position helping Michiganders apply today! 
If we had to approve your claim before you got care, we will decide within 15 days of getting your appeal. You are now being directed to the CVS Health site.
In addition to the form, the external review request should include a copy of the final adverse determination from your health insurer, the reason(s) why you are appealing the decision, and any documentation to support your position. Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates (Aetna). If we had to approve your claim before you got care, we will decide within 30 days of getting your appeal. Please be sure to add a 1 before your mobile number, ex: 19876543210, Learn about the Aetna external review program, Call Member Services at the phone number on your member ID card. This is called an authorized representative. Please log in to your secure account to get what you need. An external review process should only be initiated if: The covered person has exhausted the health carriers internal grievance process. 30 calendar days for a pre-service denial. It will show you whether a drug is covered or not covered, but the tier information may not be the same as it is for your specific plan. 
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We make decisions for urgent care claims more quickly.
If your plan has two levels of appeal, we'll tell you our decision no later than 36 hours after we get your request for review. In both instances, the Director of DIFS will issue an order with the decision of the review. Upon receipt, DIFS will examine your external review request to determine if it meets the requirements under PRIRA. You are not eligible for an expedited external review if it concerns a health care service that has already been received. To request an external review, you or your authorized representative must complete the Health Care Appeals-Request for External Review form. The adverse determination notice will provide the timeframe in which you are required to submit your written appeal. There are two ways to do this: You may appeal on your own. If your request is accepted and involves a contractual dispute, the external review is conducted by DIFS.
Do you want to continue? Please note also that the ABA Medical Necessity Guidemay be updated and are, therefore, subject to change. This is called an appeal. endstream endobj startxref
Each main plan type has more than one subtype. The Applied Behavior Analysis (ABA) Medical Necessity Guidehelps determine appropriate (medically necessary) levels and types of care for patients in need of evaluation and treatment for behavioral health conditions. For other claims, we'll decide within 60 days. Call us toll-free Monday through Friday 8 a.m. to 5 p.m. at877-999-6442. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. WpEW!r+dLH(-YL^(xH,35D"q6XU#O}Nh#x-R!|EbQ 60 calendar days for a post-service denial. %PDF-1.6 % Call the toll-free number on your Member ID card or the number on the claim denial letter. endstream endobj 1356 0 obj <>/Metadata 219 0 R/Outlines 1406 0 R/PageMode/UseOutlines/Pages 1350 0 R/StructTreeRoot 518 0 R/Type/Catalog>> endobj 1357 0 obj <>/MediaBox[0 0 612 792]/Parent 1351 0 R/Resources<>/ProcSet[/PDF/Text]>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> endobj 1358 0 obj <>stream , &$Z.F +)B^duiEXadX_1J[UA~.[95;1>V_WKkK+,WUY3<4:2?U]olh*(-Rgede''%&hb"#BC>~@`Fx, . This is called an external review. An expedited external review is conducted within 72 hours and requires your treating physician to verify, orally or in writing, the necessity of an expedited review. You have 60 days from the date that you get the appeal decision letter to let us know. The information you will be accessing is provided by another organization or vendor. How our department monitors insurance market practices, Insurance Company Contract and Rate Filings. Aetna Inc. and its subsidiary companies are not responsible or liable for the content, accuracy or privacy practices of linked sites, or for products or services described on these sites. lf we deny a claim and you do not agree, you can ask for a review. Were here to answer your questions to help you stay healthy. How soon we respond may vary. When you receive an adverse determination notice, you must notify your health insurer in writing that you want to appeal their decision. Once you file an appeal, the health insurer is required to complete the internal grievance process within: If you do not agree with the health insurers final adverse determination, you have 127 days to file an external review under the Patients Right to Independent Review Act (PRIRA). In the PRIRA external review process, this person is called an authorized representative. You have the right to request an expedited external review in situations where the normal PRIRA review timeframe would seriously jeopardize your life, health, or ability to regain maximum function. R)])})a/+%RRRe. We will send them to you free of charge. If you disagree with a decision your health insurer made regarding your health care claim, you have the right to appeal the decision. hX[O7+eT!6yX`BV%hw%=d0j\B Others have four tiers, three tiers or two tiers. If you do not intend to leave our site, close this message. The Health Care Appeals-Request for External Review form provides space to authorize a representative, who will be DIFS' sole contact in the PRIRA external review process. , By clicking on I Accept, I acknowledge and accept that: Now health plans that are subject to the law must include an external review process. Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. Any comments, documents, records and other information you would like us to consider. Need to talk with DIFS? The ABA Medical Necessity Guidedoes not constitute medical advice. The Affordable Care Act (ACA) created new rules for health plans. 0
# We take pride in the vastly diverse cultures, backgrounds, interests, and expertise of the people who work here. To submit your request in writing you can print and mail the following form: The group name (usually your employer or organization that sponsors your plan), Your member ID number (found on your medical ID card).
Links to various non-Aetna sites are provided for your convenience only. /FZ@%fi.Lxl!%( If your request is accepted and involves issues of medical necessity or clinical review, it is referred for review to an independent review organization. The web Browser you are currently using is unsupported, and some features of this site may not work as intended. e\,W =^ There are two levels of appeal an internal appeal with your health insurer and an external review with the Department of Insurance and Financial Services (DIFS). Get coronavirus facts. This search will use the five-tier subtype. In either case, if you do not agree with our decision, you can ask for a second review. hTGlAv)NNo;{Tor@ rH8qDBH $$$fI\2? @ fll0q'C0,J{})KY$7YmX#g#ALd#@1 You are now being directed to CVS caremark site. If your doctor feels that a delay will put your health, your life or your recovery at serious risk or cause you severe pain, that's an urgent care claim. It depends on a state law, whether your appeal is urgent or your plan offers one or two levels of appeal. For additional information related to DIFS external review process contact DIFS at 877-999-6442. Please update to a modern browser such as Chrome, Firefox or Edge to experience all features Michigan.gov has to offer.
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t|P[P$,'iRDS;= You also may authorize someone to appeal for you. hbbd```b``"wH D+Hc9DL`q@yL@"@O- ` G
In the event that a member disagrees with a coverage determination, member may be eligible for the right to an internal appeal and/or an independent external appeal in accordance with applicable federal or state law. Send us an email at DIFSInfo@michigan.gov, https://dev.michigan.local/som/json?sc_device=json, Appealing a Decision Made by Your Health Insurer, Department of Insurance and Financial Services, Additional Financial and Insurance Services Forms, Health Care Appeals-Request for External Review form, Treating Provider Certification for Experimental/Investigational Denials form, Life Insurance and Annuity Search Service (LIAS), Post-Acute Auto Injury Provider Relief Fund, Financial Education (Banking, Credit Union and Credit Information). 
If your plan has one level of appeal, we'll tell you our decision no later than 72 hours after we get your request for review. Michigan law provides you the right to file an internal appeal if you disagree with your health insurers claim determination, also known as an adverse determination. 1423 0 obj
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Licensing - Consumer Finance and Mortgage. You may authorize in writing any person, such as a doctor, attorney, parent, or spouse, to represent you in the internal grievance process and/or the PRIRA external review process. DIFS Prohibition Orders for Consumer Finance and Credit Union. You have 180 days from when you get the notice of the denied claim, unless your plan brochure (or Summary Plan Description) gives you a longer period of time.
Each benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits.
If the external review concerns a denial based on an experimental and/or investigational service, your treating provider must complete the Treating Provider Certification for Experimental/Investigational Denials formand submit it with your request. For language services, please call the number on your member ID card and request an operator. You or your doctor may ask for an "expedited" appeal. An adverse determination means that an admission, availability of care, continued stay, or other health care service that is a covered benefit has been denied, reduced, or terminated. Members should discuss any matters related to their coverage or condition with their treating provider. The health carrier fails to provide a determination within the timeframe dictated by law. State-chartered Bank and State-chartered Savings Bank forms. Failure to respond in a timely manner to a request for a claim determination is also an adverse determination. Treating providers are solely responsible for medical advice and treatment of members.
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