11/29/2023 0 Comments Aetna timely filing for appealsIn 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. Medical necessity determinations in connection with coverage decisions are made on a case-by-case basis. Please note also that the ABA Medical Necessity Guide may be updated and are, therefore, subject to change. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. 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. 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. Members should discuss any matters related to their coverage or condition with their treating provider.Įach benefit plan defines which services are covered, which are excluded, and which are subject to dollar caps or other limits. Treating providers are solely responsible for medical advice and treatment of members. The ABA Medical Necessity Guide does not constitute medical advice. The Applied Behavior Analysis (ABA) Medical Necessity Guide helps determine appropriate (medically necessary) levels and types of care for patients in need of evaluation and treatment for behavioral health conditions. Use this PDF to learn more about your rights regarding complaints and appeals for HMO members.Ĭalifornia Department of Insurance - for insured Traditional plans onlyĬalifornia Department of Insurance websiteĬontact the California Department of InsuranceĬalifornia Department of Managed Health Care – for insured HMO and DMO plans onlyĬalifornia Department of Managed Health Care websiteĬontact the California Department of Managed Health Careīy clicking on “I Accept”, I acknowledge and accept that: GRIEVANCE FORM for Cancellations, Rescissions and Non Renewals View and print these forms to submit a HMO complaint, appeal, or grievance: View and print these forms to submit a DMO complaint, appeal, or grievance: Use this online form to submit a complaint, grievance, or appeal.
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