Aetna UCR Settlement Website

FAQs


1.      Q. What is this all about?


         A:  This class action involves the way Aetna paid claims when members of their health insurance plans used out-of-network medical providers for covered healthcare benefits. The lawsuit claims that Aetna paid inadequate reimbursements for these services by using the Ingenix databases and other methods to determine the amounts paid. 

2.      Q:  What benefits does the Settlement provide?

         A:  The Settlement provides up to $120,000,000.00, less expenses, to be distributed in accordance with the Settlement Agreement.  For more detailed information about how Berdon will calculate your proportionate or pro-rata share of the Settlement proceeds, please see Section VI of the Notice beginning on the bottom of page 3.  

3.      Q:  Why did I receive this information when I was never a Subscriber or out-of-network Provider?

         A:  You received a Notice because your name and address was given to us by Aetna as someone who was an Aetna subscriber or provider. 

4.      Q:  Why did I receive more than one Notice?

         A:  You may have received more than one Notice, either because your name appeared more than once in the Aetna records, or you may have had more than one ID number if you changed your job during the Class Period, or your employer may have changed health plans during the Class Period.

5.      Q:  I believe I am a Class Member, but I did not receive the Notice and attached Claim Forms.  How can I get a copy of these documents?

         A:  You can download a PDF copy of the Notice and attached Claim Forms
here or from Berdon’s website at www.berdonclaims.com.

​6.      Q:  What are my choices?

         A:  You have 3 choices:  you may file a claim and may share in the distribution of the Net Settlement Fund; you may request exclusion from the Class, but you will not share in the distribution of the Settlement and you will not be bound by any judgment or Court order; or you may do nothing at all, and you will not share in the distribution of the Settlement, but will be bound by any judgment or Court order. Filing a Claim Form is the only way to share in the distribution of proceeds in this lawsuit.

7.      Q:  What do I need to do in order to file a claim in this class action and receive a payment?

         A:  To be eligible for a payment, you must fill out the appropriate Claim Form completely, sign and mail it to Berdon at the address on page 7 of the Claim Form for Subscribers, or on page 11 of the Claim Form for Providers, and make sure it is postmarked no later than March 28, 2014.  In addition, you must include any required documentation. 

8.      Q:  How much money am I likely to receive from this class action?

         A:  We can’t estimate what your payment might be until all claims are reviewed and processed.  Berdon will determine what your proportionate share of the Net Settlement Fund will be based on the Settlement Agreement and whether you choose Option 1 or Option 2.  The Settlement Agreement and Notice explain the formulas used to calculate each claimant’s proportionate or pro-rata share of the Settlement proceeds.  For more  detailed information please see Sections V and VI on pages 3 and 4 of the Notice.  

9.      Q:  When can I expect to receive my payment?

         A:  Because this is a proportional or pro-rata distribution, all claims will be paid at the same time.  Since Aetna insures millions of people, we expect to receive a very large number of claims, so this process may take a substantial amount of time.  All claims are first reviewed and evaluated and then claimants with deficient claims are given a chance to cure them.  After the Court approves the distribution, payments will be made to eligible claimants based on the Settlement Administrator’s findings.  Please be patient.

10.    Q:  If I missed the filing deadline, will my late claim be accepted?

         A:  We suggest that you file your claim anyway, even if you missed the filing deadline. The final decision as to whether your late claim will be accepted or rejected will be made by the Court.

11.    Q:  How can I exclude myself from this Settlement?

         A:  If you do not want to be a Settlement Class Member and participate in the Settlement (including being eligible to receive monetary payments), then you must mail to Berdon a signed Request for Exclusion with your name, address, and federal Social Security Number or Tax Identification Number, and include a statement that you wish to be excluded from the Settlement Class.  Your request for exclusion must be postmarked no later than February 26, 2014.

12.    Q:  Who is a Subscriber?

         A:  A Subscriber is a person who, at any time from March 1, 2001 through August 30, 2013 was a member of an Aetna healthcare insurance plan who received covered out-of-network healthcare benefits from an out of network health care Provider and whose resulting claims for reimbursement included partially allowed claims. 

13.    Q:  Who is a Provider?

         A:  A Provider is a healthcare professional who furnished a Subscriber with out-of-network medical services or supplies that were covered by that Subscriber’s Aetna insurance policy, at any time from June 3, 2003 through August 30, 2013, and whose resulting claims for reimbursement included partially allowed claims. 

14.    Q.  What is a Provider Group?

         A.  A Provider Group is an out-of-network facility, including hospitals, ambulatory surgical centers, and skilled nursing centers, only when it either billed Aetna for out-of-network Providers; or was paid by Aetna based on the Ingenix database, and the member plan was based in New Jersey.

15.    Q.  I have an Explanation of Benefits or explanation of payment from Coventry Health Care, which was acquired by Aetna.  Am I in the Class?

         A.  No.

16.    Q:  I am the primary insured.  Should my claim have information for the medical services and supplies I personally received, or those for the entire family, including the dependents listed in my coverage?

         A:  You need to submit one Claim Form for each Insurance Policy ID number. Your claim should include information for all family members covered by your policy.

17.    Q:  Is any additional information needed if I am preparing a Claim Form on behalf of another person? 

         A:  If you are preparing a Claim Form on behalf of another person, you must include your contact information, so the Settlement Administrator can reach you if there are any questions about the claim.  If you are signing the Claim Form on behalf of another person, you must include your capacity to sign, for example, as the subscriber’s parent, guardian, custodian, executor, or administrator. If you are signing the claim form on behalf of a provider, you must include your capacity to sign as the provider’s executor or administrator.  If you are signing the claim form on behalf of an out-of-network provider group, you must be an authorized employee of the group and have authority to submit the claim on behalf of the group. 

18.    Q:  What is an Option 1 Subscriber claim?

         A:  An Option 1 Subscriber claim is a simplified claim where the claimant is required to indicate only the number of years, from March 2001 through August 2013, during which you were a member of any Aetna Plan that included provisions for covered out-of-network services or supplies.  As an Option 1 Subscriber claimant, you may be entitled to receive up to $40.00 for each year you received such out-of-network services or supplies which resulted in a partially allowed claim, up to $30 for 2001 claims, and up to $30 for 2013 claims. Option 1 Subscriber claimants do not need to provide supporting documentation. If you make an Option 1 Subscriber claim, you may not file an Option 2 claim.  Your membership in an Aetna healthcare plan should be counted in whole years, and any portion of a given year should be treated as an entire year.

19.    Q:  What is an Option 2 Subscriber claim?

         A:  You can file an Option 2 Subscriber claim if you are a Subscriber who received a Provider’s bill for a covered out-of-network benefit that was not paid by Aetna, but which you paid partially or in full yourself.  If you file an Option 2 Subscriber claim, you must send documentation for each of your out-of-pocket payments.  Please see page 10 of the Claim Form for further details.  If your Option 2 claim is rejected, your claim will be considered under Option 1.

​20.    Q:  What is an Option 1 Provider claim?

         A:  An Option 1 Provider claim is a simplified claim where the Provider is required to indicate only the number of years, from June 2003 through August 2013, during which you were an Aetna Plan member Provider or Provider Group that provided covered out-of-network services or supplies.  As an Option 1 Provider claimant, you may be entitled to receive up to $40.00 for each year you provided covered out-of-network services or supplies, which resulted in a partially allowed claim, up to $20 for 2003 claims, and up to $30 for 2013 claims.  Option 1 Provider claimants do not need to provide supporting documentation.  If you make an Option 1 Provider claim, you may not file an Option 2 claim.  Your membership as an Aetna healthcare Provider should be counted in whole years, and any portion of a given year should be treated as an entire year.

21.    Q:  What is an Option 2 Provider claim?

         A:  You can file an Option 2 Provider claim if you are a Provider who received an Assignment from a Subscriber and you issued a bill to your patient for an amount that was not paid either by Aetna or the patient in full.  Your Option 2 Provider claim is based on the unpaid portion of that bill.  If you file an Option 2 Provider claim, you must send documentation for each of your out-of-pocket bills.  Please see pages 13 and 14 of the Claim Form for further details.  If your Option 2 claim is rejected, your claim will be considered under Option 1.

22.    Q:  Which claim Option should I make?  Option 1, or Option 2?

         A:  The Settlement Administrator cannot assist you in determining which Option is the most advantageous for you. However, if your Option 2 claim is rejected, your claim will be considered under Option 1.

23.    Q:  I am a Provider, but the Subscriber did not assign their claim to me.  May I still file an Option 2 claim?

         A:  No.  As a Provider, you are eligible to participate as a claimant only if you received an Assignment from a Subscriber, for which you must provide documentation, if you submitted a claim to Aetna for reimbursement of covered out-of-network services or supplies, and if you have not transferred, sold or assigned the claim.

24.    Q:  Am I restricted to one claims category?

         A:  Whether you are a Subscriber or a Provider, if you choose to make an Option 1 claim, you may not also choose to make an Option 2 claim.  If you are both a Subscriber and a Provider (you are a Provider and you had health insurance through Aetna yourself) you may be eligible as a Provider and as a Subscriber.

25.    Q:  What do I need to do to get from the Settlement Administrator a report of claims information regarding the Covered Out-of-Network Services or Supplies I received or provided?

         A:  You must first authorize the Settlement Administrator to release the report of your claims information by completing the Claims Information Request Authorization Form on page 15 of the Claim Form.  In the alternative, you may download a copy
here.  The “Notice Number” requested on the authorization form can be found above the bar code under the return address on the outside of your Notice, if you received it by mail.  If you do not see a “Notice Number,”  enter “Not Available.” Your completed and signed authorization form should be sent to the Settlement Administrator, by mail, fax or email (see page 6 of the Notice for the Settlement Administrator’s complete contact information). 


26.    Q:  Some of the information on the report of services I received is either missing or wrong.  How can I complete or correct it?

         A:  Make your changes and corrections on the report you requested and received from the Settlement Administrator.  If you need additional space, you can download the data tables available on the website
www.berdonclaims.com, or attach to the Claim Form separate numbered sheets in the same  format as the data table on the website.  Be sure to print your name and policy ID number at the top of each sheet.  Remember: you must send proper documentation for all changes and updates.  See page 10 for Subscribers or page 14 for Providers for information regarding valid supporting  documentation.

27.     Q: Some information, like date of service, name of Provider and allowed amount, is not printed on the list of services or supplies report I received from the Settlement Administrator.  Why not, and what should I do?

         A:  Because the Settlement Administrator did not necessarily receive complete records from Aetna, some of your information has not been printed on the report of services or supplies you received.  To include omitted records, complete the data tables downloaded from
www.berdonclaims.com, or attach to the Claim Form separate numbered sheets in the same format as the data table on the website.  Be sure to print your name and policy ID number at the top of each sheet.  Remember you must send proper documentation for all changes and updates.  See page 10 for Subscribers or 14 for Providers for information regarding valid supporting documentation.

28.    Q:  Are all of my claims as a Subscriber for the services or supplies submitted to Aetna eligible in this case?

         A:  No, not all of the claims you submitted to Aetna are eligible in this case.  Your claim may be based only on covered out-of-network services or supplies; you must have received the service or supply from March 1, 2001 through August 30, 2013; and the allowed amount reimbursed to you must have been greater than zero dollars. 

29.    Q.  Are all of my claims as a Provider for the medical services or supplies submitted to Aetna eligible in this case?

         A:  No, not all of the claims you submitted to Aetna are eligible in this case.  Your claim can be based only on the covered out-of-network medical services or supplies you provided; you must have provided the service or supply from June 3, 2003 through August 30, 2013; and the allowed amount reimbursed to you must have been greater than zero dollars. 

30.    Q:  I have a number of healthcare services claims that Aetna denied completely. Can I make a claim for such denied medical services?

         A:  No.  You cannot make a claim for services or supplies that were denied by Aetna.  This class action deals only with covered out-of-network healthcare benefits.  If Aetna determined that an out-of-network service or supply was not covered, the Explanation of Benefits (EOB) you received from Aetna would state that the allowed amount equals zero dollars, and it would not be an eligible claim in this case.

31.    Q:  May I file and Option 2 Subscriber claim if I did not pay any portion of the balance bill?

         A:  No, You are eligible to participate as a claimant in Option 2 Subscriber only if you paid your Provider some portion of a balance bill for partially allowed claims for covered out-of-network services or supplies.

32.    Q:  How can I get a copy of my Explanation of Benefits (EOB)?

         A:  You should obtain copies of EOBs from your own records, or from your Provider if you are a Subscriber. 

33.    Q:  I think I have assigned my claims to my out-of-network Provider.  How does that affect my claim in this class action?

         A:  If you assigned your claim to your out-of-network Provider, that Provider can make a claim. 

34.    Q:  I am a Subscriber; what type of supporting documentation is acceptable?

         A:  For each partially allowed claim that you list, you must clearly identify the service or supply provided, the date of service, the Subscriber’s name, the Provider’s name, the amount billed by the provider, the amount allowed by Aetna, and the amount the subscriber paid in response to the balance bill. Do not send any originals to the Settlement Administrator, because they will not be returned.

         For each out-of-pocket payment, provide the balance bill and a copy of:
          -   your cancelled check; or
         -    receipts for cash payments; or
         -    credit card statement; or
         -    an invoice from your out-of-network Provider showing that you made payment; or
         -    the internal record from your out-of-network Provider showing your payment and
​         -    the Explanation of Benefits (EOB) form issued by Aetna (unless the transaction is listed on the report you received from the Settlement Administrator)

35.    Q:  I am a Provider, what type of supporting documentation is acceptable?

         A:  Out-of-network Providers filing Option 2 claims and seeking increased damages must include the code or description of the service or supply, the date of the service of supply, the Subscriber’s name, the amount billed, attestation of assignment, the amount of the balance bill, and whether any payment of the balance bill was received or promised.  Do not send any originals to the Settlement Administrator, because they will not be returned.

         For each partially allowed claim you list, provide a copy of:
            -   the Assignment reflecting the Subscriber’s signature; or your attestation under penalty of perjury that an Assignment exists;
            -   documentation showing that a balance bill was sent to the Aetna Plan Subscriber prior to August 30, 2013 relating to the partially allowed claim;
​            -   documentation from practice management systems or accounting records showing that the balance bill was not paid, in whole or in part.

36.    Q:  Do I need to send an EOB for covered services and supplies listed on the report I received from the Settlement Administrator?

​         A:  No.  You only need to send an EOB for covered services and supplies that were not provided to you on the report you received from the Settlement Administrator.

37.    Q:  What is an allowed amount?

         A:  An allowed amount is the amount Aetna determined to be eligible for reimbursement to a Subscriber or out-of-network Provider for covered out-of-network services or supplies.  If Aetna determined that an out-of-network service or supply was not covered, the allowed amount would be zero dollars.  An allowed amount must be greater than zero dollars to be used to calculate a recognized loss.

38.    Q:  What is a denied claim?

​         A:  A denied claim means any claim line for which the allowed amount equals $0.  Denied claims are not included in this Settlement.

39.    Q:  Where do I send my completed Claim Form?

         A:  Mail your completed and signed Claim Form and any required documentation for Option 2 claims to the Settlement Administrator, postmarked no later than March 28, 2014.  Use the address found on page 7 (Subscriber) or on page 11 (Provider) of the Claim Form.

40.    Q:  How can I notify you of an address change?

         A:  You must send written notification, including the name of this litigation: Aetna UCR Litigation, your name, your old address, your new address, the Notice Number, and your policy or Subscriber ID number.

By Mail To:                 Aetna UCR Litigation
                                   c/o Berdon Claims Administration LLC
                                   P.O. Box 15000
                                   Jericho, NY 11853-0001
or

By Fax To:                  (516) 393-0031

41.   Q:  What do I need to do to file a simplified claim as a Subscriber?

        A:   Subscribers may choose to file a simplified claim, which is Option 1. Beginning on page 7 of the Claim Form, check the box to indicate that you wish to make an Option 1 claim.  Next complete Section A on page 8.  You should then proceed to the bottom of page 10 (Certification), where you sign and date your claim.  Your completed Claim Form must be submitted to the Settlement Administrator by first class mail, at the address appearing on page 7, postmarked no later than March 28, 2014.

              Class Members making an Option 1 claim are not required to provide supporting documentation in connection with their coverage.

42.   Q:  What do I need to do to file an Option 2 Subscriber claim?

        A:   Subscribers who received balance bills from their out-of-network Providers may file their claims based on the out-of-pocket amounts they paid.   On page 7 of the Claim Form, check the box to indicate that you wish to make an Option 2 claim.  Next, complete Section A on page 8 and Section B on page 9.  We recommend that you use the claims information report provided to you by the Settlement Administrator to complete the chart.  For each out-of-pocket payment to your out-of-network Providers, you must supply supporting documentation.  Various types of supporting documentation acceptable for this purpose are described on page 10 of the Claim Form.  You should then sign and date your claim.  Your completed Claim Form must be submitted to the Settlement Administrator by first class mail, at the address appearing on page 7, postmarked no later than March 28, 2014.

43.   Q:  What do I need to do to file a simplified claim as a Provider?

        A:   Providers have the choice of filing a simplified claim, which is Option 1.  On page 11 of the Claim Form, check the box to indicate that you wish to make an Option 1 claim.  Next, complete Section A on page 12.  Then proceed to the bottom of page 14 (Certification), where you sign and date your claim. Your completed Claim Form must be submitted to the Settlement Administrator by first class mail, at the address appearing on page 11, postmarked no later than March 28, 2014.

              Class Members making an Option 1 claim are not required to provide supporting documentation.

44.   Q:  What do I need to do to file an Option 2 Provider claim?

        A:  Providers who received Assignments from their patients may file their claims based on the balance bill amounts the Subscribers did not pay them, in whole or in part.  Beginning on page 11 of the Claim Form, check the box to indicate that you wish to make an Option 2 claim.  Next, complete Section A on page 12 and Section B on page 13.  We recommend that you use the claims information report that you can request from the Settlement Administrator to complete the chart.  For each partially allowed claim that you list, you must supply supporting documentation.  Various types of supporting documentation acceptable for this purpose are described on page 14 of the Claim Form.  Then sign and date your claim (Certification section). Your completed Claim  Form must be submitted to the Settlement Administrator by first class mail, at the address appearing on page 11, postmarked no later than March 28, 2014.

45.   Q:  I am a legal heir of a deceased Class Member. How can I make a claim based on the services received and/or supplies purchased by that Class Member?

        A:  Legal heirs of deceased Class Members must properly identify themselves in the Certification section on page 10 of the Claim Form. Additionally, they must include copies of death certificates or letters of estate administration to confirm their authority.

46.   Q:  If you receive a Settlement check do I have to pay taxes on it?

        A:  No, it is not a taxable event.  It is a reduction of your premium.  We will not send 1099s.  For any other tax questions, you will need to contact your tax advisor.

47.    Q.  Can you tell me the number of years I was a member of Aetna?  I do not know the exact number of years I was a plan member.  What should I do?  How should I fill out the Claim Form?

         A.  We are not able to provide the number of years you have been a member of an Aetna plan. You should review your records, or ask your employer.  If you cannot ascertain the number of years based on your records, please provide a good faith estimate on the Claim Form.  That will be acceptable.

48.    Q.  I mailed my Claim Form to you; can you tell me if you received it? 

         A.  Unless you sent the documents via a traceable method (return receipt, fed ex), we are unable to provide you with a status of receipt.  If there is a problem with your claim, the Settlement Administrator will notify you and you will be given ample time to cure any deficiencies.

49.    Q.  How do I get a copy of the Settlement Agreement?

         A.  You can get a copy of the Settlement Agreement, and certain other documents filed with the Court,
here or by visiting the Aetna UCR case link on the Settlement Administrator’s website at www.berdonclaims.com.

50.    Q.  Why is Option 2 limited to partially allowed claims?

         A.  When Aetna made the out-of-network reimbursements challenged in this case, it paid less than it should have, according to the Plaintiffs, but it paid some amount.  That’s why claims that were not allowed at all are not part of this lawsuit.  In addition, all amounts that Aetna did not pay based on deductibles, and co-payments, co-insurance, and coordination of benefits are not part of this lawsuit and are not eligible for reimbursement.

51.    Q.  How do I get a balance bill for my Option 2 claim?

         A.  If you are a Subscriber, the bill from your doctor for the difference between the billed charge and the amount allowed by Aetna is the balance bill.  You may have received this either in the mail or in your doctor’s office.  Submit the balance bill along with proof of payment. 

         If you are a Provider, your bill to your patient for the difference between the billed charge and the amount allowed by Aetna is the balance bill.  You must submit it along with proof that it was in fact billed to your patient, and not paid, in whole or part. 

52.    Q.  How do I show I have an eligible balance bill?

         A.  If you are a Subscriber, you may submit a copy of the balance bill together with a cancelled check or credit card receipt or statement showing your payment of the balance bill.  If you paid your doctor in cash, submit a receipt.  You may also submit (a) a receipt showing payment of the balance bill  together with an explanation of benefits or other documentation showing Aetna’s reimbursement for the partially allowed claim, or (b) your doctor’s records showing that your doctor sent you a balance bill and that you paid it.  Your doctor’s office may provide these records to you. 

​         If you are a Provider, you may submit records from your practice management system or your accounting records showing that your balance bill was sent prior to August 30, 2013 and remains unpaid, in whole or part.

53.    Q.  I am a Provider; how do I prove I have an Assignment?

         A.  There are two ways a Provider can prove the existence of an Assignment of a claim from an Aetna patient.  First, you may submit a copy of the actual Assignment which includes the signature of your patient.  Second, you may submit an attestation under oath that the Assignment exists.

54.  Q.  How does a third party acting on behalf of physicians request the report for multiple physicians?

         A.  The third party may request the report for multiple physicians by following the same procedure as an individual physician requesting a report.  The third party will also need to supply proof of authority to request the report.

55.   Q.  I am part of a medical group. Do I have to file a claim individually?

         A.  A provider group can file on behalf of its members and may do so without notifying the individual members.  Check with your group to see whether it has filed on your behalf. If the group has not filed, you can file a claim on your own behalf. You can also file a separate claim for any time during the Class Period that you were not part of the provider group.

56.    Q.  May I file my claim electronically?

          A.  Although you must submit your Claim Form by first-class mail, you can submit copies of any required documentation electronically.  If you prefer to  submit your supporting documentation in an electronic format, such as scanned image files (“.bmp”) or PDF files, you can submit a CD that contains these files.  Please make sure that all CDs are clearly labeled.  You can also submit documentation by e-mail to
aetna@berdonclaimsllc.com.  The supporting documentation can be from your practice management system and/or accounting records.  Berdon prefers that you submit electronic supporting documentation that is prepared in Microsoft Excel format or tab-delimited text files.  Mail your claim documentation on a CD, or as paper copies to:         

Aetna UCR Litigation
c/o Berdon Claims Administration LLC
P.O. Box 15000
Jericho, NY 11853-0001



 Q.      Will I have to go to court? 


           A. Members of the Settlement Classes who support the Settlement do not need to be present at the hearing or take any action to indicate their approval, as Class Counsel for the Settlement Classes will be present to address any questions or concerns raised by the Court. (See page 4 Section VII from Notice)


2.      Q. Does this cost money?

         A. No, we encourage you to fill out the claim form and have it postmarked and returned to us by March 28, 2014.


3.      Q. How do I complete this?    

         A. In order to be included in this class action settlement you will need to complete the Claim form starting on page 7 of the Notice you received. 


         Subscribers will need to choose the best option for you to submit your claim from the two options listed. You will need to fill out Section A whether you are subscriber filing under either Option 1 or Option 2. Section B is only required if you are filing under Option 2.   


          Providers will need to choose the best option for you to submit your claim from the two options listed. You will need to fill out Section A whether you are subscriber filing under either Option 1 or Option 2. Section B is only required if you are filing under Option 2.      


 4.      Q. I would like to contact Aetna directly. 


         A. You may contact Aetna if you choose. They may be unable to provide information to you regarding your specific claimant information.  (if asked you do not have Aetna’s direct contact information to provide)


5.      Q. What if my subscriber claim is less than $200 (Option 2 Only)? 


         A. Any submissions involving $200 or less will be declared ineligible for reimbursement from the Subscriber Settlement Fund and no payment will be issued from that Fund.  However, your submission will be considered for eligibility under the General Settlement Fund.  (Page 9 note at bottom of Notice)


6.      Q. What if my provider claim is less than $750 (Option 2 Only)?

         A. The aggregate amount of Balance Bills included in your claim against the Provider Settlement Fund must exceed $750 for Individual Out-of-Network Providers and $1,000 for Out-of-Network Provider Groups. Any submissions involving less than these amounts will not be considered eligible for reimbursement from the Provider Settlement Fund and no payment will be issued. Provider Settlement Claims declared ineligible will be considered for eligibility under the General Settlement Fund.


 


Option 1
Option 2Option 1
Option 2

• Sim​plified claim form

• Subscriber provides enrolled dates (from 2001 through 2013) they were a member of any Aetna healthcare plan that included covered out-of-network services or supplies

No proof or other documentation

required






• Subscribers who received covered out-of-network service and have paid partially or in full yourself (out-of-pocket)

• Documentation required for each out-of-pocket payment (page 10 of claim form details required documentation)

• Instructions begin on page 7 of the Claim Form
• Simplified claim form

•  Provider indicates number of years (from 2003 through 2013) they were a provider of any Aetna healthcare plan that included provisions for covered out-of-network services or supplies.

•  No supporting documentation required.






•  If you are a provider who received assignment from a subscriber and you issued a bill to your patient for an amount not paid by Aetna, your patient, or anyone else, in part of in full. 

•  Claim is based on unpaid portion of that bill.

•  Documentation (pages 13 & 14 of claim form) is required for each out-of-pocket payment • Instructions begin on page 11 of the Claim Form



























AETNA Glossary of Terms

 

Out of Network OON

         A health insurance provider that is not in network with Aetna 

 

Out of Pocket 

         If the bill was paid (in whole or part) by the subscriber (not paid by insurance), the subscriber is out of pocket for that amount of payment

 

EOB – Explanation of Benefits 

         The form sent to the subscriber showing the allowed amount paid by Aetna for the covered service or supply

 

Subscriber 

         Persons who were Aetna plan members from March 1, 2001 until August 30, 2013, who received a covered service or supply from an Aetna ONET provider and whose claims for reimbursement included partially allowed claims

 

Provider 

         Persons or entities who were ONET with Aetna from June 3, 2003 until August 30, 2013,provided covered services or supplies to Aetna plan members, and whose claims for reimbursement included partially allowed claims

 

Balance Bill 

         A bill sent by a provider to a subscriber that shows the unpaid portion of the amount the provider originally billed to Aetna for the covered out of network services and supplies

 

Allowed Amount

         Amount Aetna reimbursed a subscriber or provider for covered services or supplies

  

SUPPLEMENTAL FAQs

PROVIDER OPTIONS

SUBSCRIBER OPTIONS