Appeal Information Packet and Other Important …

1 Appeal Information Packet and Other Important Disclosure Information Arizona DENTAL INSURER APPEALS PROCESS Information Packet AETNA HEALTH LIFE insurance COMPANY. PLEASE READ THIS NOTICE CAREFULLY AND KEEP IT FOR FUTURE REFERENCE. IT CONTAINS. Important Information ABOUT HOW TO Appeal DECISIONS WE MAKE ABOUT YOUR. DENTAL CARE COVERAGE. Getting Information about the Dental Decisions You Can Appeal Appeals Process You can Appeal the following decisions: 1. We do not approve a service that you or your treating Help in Filing an Appeal : Standardized provider has requested. Forms and Consumer Assistance from 2. We do not pay for a service that you have already the Department of insurance received.

2 We must send you a copy of this Information Packet when 3. We do not authorize a service or pay for a claim you first receive your policy, and within 5 business days because we say that it is not dentally necessary.. after we receive your request for an Appeal . When your 4. We do not authorize a service or pay for a claim insurance coverage is renewed, we must also send you a because we say that it is not covered under your separate statement to remind you that you can request insurance policy, and you believe it is covered. another copy of this Packet . We will also send a copy of this Packet to you or your treating provider at any time 5. We do not notify you, within 10 business days of upon request.

3 To request a copy, just call our Customer receiving your request, whether or not we will authorize Services Department at 1-877-238-6200 or the Member a requested service. Services number printed on your Member ID Card. 6. We do not authorize a referral to a specialist. At the back of this Packet , you will find forms you can use for your Appeal . The Arizona insurance Department ( the Decisions You Cannot Appeal Department ) developed these forms to help people who You cannot Appeal the following decisions: want to file a dental Appeal . You are not required to use 1. You disagree with our decision as to the amount of them. We cannot reject your Appeal if you do not use usual, customary, and reasonable charges.

4 Where them. If you need help in filing an Appeal , or you have applicable, a usual, customary, and reasonable charge is questions about the appeals process, you may call the a charge for a covered benefit which is determined by Department's Consumer Assistance Office at us to be the prevailing charge level made for the service 1-602-912-8444 or 1-800-325-2548, or you may call us at or supply in the geographic area where it is furnished. 1-877-238-6200. We may take into account factors such as the complexity, degree of skill needed, type or specialty of How to Know When You Can Appeal the provider, range of services provided by a facility, and When we do not authorize or approve a service or pay for the prevailing charge in Other areas in determining the a claim, we must notify you of your right to Appeal that usual, customary, and reasonable charge for a service or decision.

5 Your notice may come directly from us, or supply that is unusual or is not often provided in the through your treating provider. area or is provided by only a small number of providers in the area. 1. AZ-INFO Appeal -5 (4/03). 2. You disagree with how we are coordinating benefits Level Three: Expedited External, Independent Dental when you have dental insurance with more than one Review insurer. Standard Appeals 3. You disagree with how we have applied your claims or (For non-urgent services or denied claims). services to your plan deductible. Informal Reconsideration 4. You disagree with the amount of coinsurance or Formal Appeal copayments that you paid. External, Independent Dental Review 5.

6 You disagree with our decision to issue or not issue a We make the decisions at Level One and Level Two. An policy to you. outside reviewer, who is completely independent from our company, makes Level Three decisions. You are not 6. You are dissatisfied with any rate increases you may responsible to pay the costs of the external review if you receive under your insurance policy. choose to Appeal to Level Three. These three levels of 7. You believe we have violated any Other parts of the Appeals are discussed more fully below: Arizona insurance Code. EXPEDITED Appeal PROCESS FOR. If you disagree with a decision that cannot be appealed URGENTLY NEEDED SERVICES NOT YET.

7 According to this list, you may still file a complaint with us by calling our Customer Services Department at 1-877- PROVIDED. 238-6200, or the Member Services number printed on Expedited Dental Review (Level One). your Member ID Card. In addition, you may also file such Your Request: You may obtain Expedited Dental Review complaints with the Arizona Department of insurance , of your denied request for a service that has not already Consumer Affairs Division, 2910 N. 44th Street, been provided if: Second Floor, Phoenix, AZ 85018. You have coverage with us;. We denied your request for a covered service; and Who Can File an Appeal Your treating provider certifies in writing and provides Either you or your treating provider can file an Appeal on supporting documentation that the time required to your behalf.

8 At the end of this Packet is a form that you process your request through the Informal may use for filing your Appeal . You are not required to use Reconsideration (Level One) and Formal Appeal (Level this form. If you wish, you can send us a letter with the Two) Appeal process (about 60 days) is likely to cause a same Information . If you decide to Appeal our decision to significant negative change in your dental condition. (At deny authorization for a service, you should tell your the end of this Packet is a form that your provider may treating provider so the provider can help you with the use for this purpose. Your provider could also send a Information you need to present your case.)

9 Letter or make up a form with similar Information .). Your treating provider must send the certification and DESCRIPTION OF THE APPEALS PROCESS documentation to: I. Levels of Review Name: Aetna Health Inc. We offer expedited as well as standard appeals for Complaint Resolution Team Arizona residents. Expedited appeals are for urgently Address: Box 14021. needed services that you have not yet received. Standard appeals are for non-urgent service requests Lexington, KY 40512-4021. and denied claims for services already provided. Both Phone: 877-238-6200 (Expedited Appeals Only). types of appeals follow a similar process, except that we Fax: 859-455-8650. process expedited appeals much faster because of the Our Decision: Within the following timeframes, we must patient's condition.

10 Call and inform you and your treating provider of our Each type of Appeal has three levels, as follows: decision. We will then mail our decision in writing to both Expedited Appeals you and your treating provider. The written decision must (For urgently needed services you have not yet received) explain the reasons for our decision and tell you the documents on which we based our decision. Level One: Expedited Dental Review Level Two: Expedited Appeal 2. If we deny your request for an Urgent Care Claim Expedited External, Independent Review (Level 1 business day or 36 hours from receipt, Three). whichever is less. An Urgent Care Claim is a claim for Your request: The Member may Appeal to Expedited dental care or treatment where delay could seriously External Independent Dental Review only after the jeopardize the life or health of the Member, the ability Member has appealed through Level One.