AETNA PPO PLAN - My Benefits Portfolio - Trinity Health

Effective July 1, 2011 (or such later date required by applicable law), the notification will also include:
7) Information sufficient to identify the claim involved, including the date of service, the health care
provider, the Claim amount (if applicable), the diagnosis code and its corresponding meaning, and the
treatment code and its corresponding meaning;
8) The denial code, if any, and its corresponding meaning;
9) A description of the standard, if any, that was used in denying the claim; and
10) A description of available external review processes, including instructions on how to initiate an
appeal.
A 15-day extension of the time period for deciding claims may be allowed, provided that the Claim
Administrator determines that the extension is necessary due to matters beyond its control. If such an
extension is necessary, the Claim Administrator must notify you before the end of the 30-day period of the
reason(s) requiring the extension and the date it expects to provide a decision on your claim. If such an
extension is necessary due to your failure to submit the information necessary to decide the claim, the
notice of extension must also specifically describe the required information. You then have 45 days to
provide the information needed to process your claim. If you do not provide the required information
within the 45-day period, your claim may be denied. If an extension is necessary due to your failure to
submit necessary information, the Plan’s time frame for making a benefit determination is stopped from
the date the Claim Administrator sends you an extension notification until the date you respond to the
request for additional information, or the expiration of the 45-day period within which you were to provide
the additional information, if earlier. The Claim Administrator will notify you of its determination with
respect to your claim within 15 days after the earlier of these dates.
CLAIMS APPEAL PROCEDURES
If your claim has been denied in whole or in part you may appeal the decision. Your written request for
review or reconsideration must be made in writing to the address indicated in the claim denial letter within
180 days after you receive notice of a claim denial. While the Claim Administrator will honor telephone
requests for information, such inquiries will not constitute a request for appeal. You may designate a
representative to act for you in the appeal procedure. Your designation of a representative must be in
writing as it is necessary to protect against disclosure of information about you except to your Authorized
Representative.
As part of your appeal, you or your Authorized Representative have the right to:
1) Submit written comments, documents, records and other information relating to your claim for
benefits that you wish to have considered;
2) Request, free of charge, reasonable access to, and copies of, all documents, records and other
information relevant to your claim for benefits;
3) A review that takes into account all comments, documents, records and other information submitted
by you related to the claim, regardless of whether the information was submitted or considered in the
initial benefit determination;
4) A review that does not defer to the initial claim determination and that is conducted by someone other
than the individual who made the adverse determination, and who is not such person’s subordinate;
and
5) In cases where the claim denial was based in whole or in part on medical judgment, require the
individual reviewing the appeal to consult with a Health Care Professional who has appropriate
training and experience in the field of medicine involved in the medical judgment, who was not
consulted in connection with the initial claim determination, and who is not such person’s subordinate.
Ordinarily, a decision on an appeal will be reached within 30 days after receipt of your appeal.
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