Open Choice PPO

Exclusions and other provisions

Special conditions apply to certain medical procedures for injury-related dental and cosmetic injury, for convalescent facility expenses and for treatment of temporo-mandibular joint syndrome (TMJ). Participants are advised to consult the Aetna claims office in advance of commencing treatment for these conditions.

Certain expenses are not covered under the Aetna plan. These comprise expenses for services or supplies not deemed by Aetna as being necessary, reasonable and customary or not recommended by the attending physician. There are also certain exclusions and limitations under the plan. For example, cosmetic surgery and certain experimental or investigational procedures are not covered. In addition, inoculations for travel purposes are not covered. If a participant has any question as to whether a medical procedure or service will be recognized by Aetna as reimbursable under the plan, Aetna Member Services should be contacted at (800) 784-3991 prior to commencement of treatment.

Aetna claims

The address to which Aetna claim forms should be sent is as follows:

Aetna PPO

Aetna Inc.
P.O. Box 981106
El Paso, TX 79998-1106

Aetna Global PPO

Aetna Global Benefits
P.O. Box 30258
Tampa, FL 33630-3258, USA

 

Recourse if a claim is denied

If Aetna denies a claim in whole or in part, the subscriber will receive a written notice from Aetna. This notice will explain the reason for the denial and the appeal procedure. The request for review must be submitted to Aetna within 180 days of receipt of the notice. The subscriber should include the reasons for requesting the review and submit the request to:

Aetna PPO - National Accounts Member Appeals-CRT, Aetna Inc., P.O. Box 14463, Lexington, KY 40512.

Aetna Global PPO - Aetna Global Benefits, P.O. Box 30258, Tampa, FL 33630-3258 USA

Aetna or Aetna Global as the case may be will review the claim and ordinarily notify the subscriber of its final decision within 30 days of receipt of the request. If special circumstances require an extension of time, notification will be given to that effect.

Time limit for filing claims

Subscribers should note that claims for reimbursement must be received by Aetna no later than two years from the date on which the medical expense was incurred. Claims received by Aetna later than two years after the date on which the expense was incurred will not be eligible for reimbursement.