Participants in the Aetna U.S. Healthcare HMO and QPOS plans have
until Sept. 26 to appeal denied claims under an agreement between
the New York State Insurance Dept. and the insurance carrier.
Earlier this year, the Insurance Department fined Aetna $1.5 million
because it failed to notify participants about their right to appeal
when the company refused to cover medical treatment. An estimated
8,000 DC 37 members - municipal employees and state workers - are
enrolled in the Aetna plan.
Under the agreement between the Insurance Dept. and Aetna, participants
will be able to appeal for the first time or submit new appeals for
any coverage that was denied from July 1, 1994 to July 31, 2001.
The agreement also lets participants appeal claims that were partially
or fully denied between Jan. 1, 2000 and Sept. 30, 2001 and resubmit
appeals that were denied.
For more information on the appeals process, call 1-888-305-7649.
New claims must be submitted in writing to New York Claims Appeals,
c/o Aetna, 151 Farmington Ave., Hartford, CT 06156-7206.
To resubmit a denied appeal, write New York Claims Reconsideration,
c/o Aetna, 151 Farmington Ave., Hartford, CT 06156-7208.
Requests for claims reconsideration may be made over the phone (1-888-305-7649).
Written requests for claims reconsideration and appeals must include
either a copy of the explanation of benefits form or the participant's
Aetna ID number, the patient's name, the date the services were rendered
and the name of the health care provider. The requests must also include
any other relevant information, such as the bill, physician statements,
medical records, paid receipts or canceled checks.