![]() Language services, including how to request a copy of the notice in any applicable non-English ![]() Notices, a statement in any applicable non-English language clearly indicating how to access We will include, in the English versions of all The Secretary of Health and Human Services. Population of your county is literate only in the same non-English language as determined by We must make notices available to you in any language where 10 percent or more of the If we do not substantially comply with these requirements, you may be able to immediately Judgment and who was not involved in making the initial decision. Has appropriate training and experience in the field of medicine involved in the medical Necessity, experimental/investigational), we will consult with a health care professional who ![]() When our initial decision is based (in whole or in part) on a medical judgment (i.e., medical Information was submitted or considered in the initial benefit determination. Information submitted by you relating to the claim, without regard to whether such Our reconsideration will take into account all comments, documents, records, and other Medical or vocational experts whose advice we obtained in connection with the initial decision. To allow you reasonable opportunity to respond prior to that date. ![]() We will provide this information sufficiently inĪdvance of the date by which we are required to provide you with our reconsideration decision With any new rationale for our claim decision. We will also provide you, free of charge and in a timely manner, We are required to provide you, free of charge and in a timely manner, with any new orĪdditional evidence considered, relied upon, or generated by us or at our direction inĬonnection with your claim. To make your request, please contact our Customer Serviceĭepartment by writing at Aetna, Attention: National Accounts, P.O Box 14463, Lexington, KY Plan documents under our control relating to your claim, including those that involve anyĮxpert review(s) of your claim. Request, you may arrange with us to review and copy, free of charge, all relevant materials and You or your authorized representative have the right to ask us to reconsider our claim decisionĪs described in Section 8 of the Plan brochure. With knowledge of your medical condition may act as your authorized representative without However, for urgent care claims, a health care professional Such as medical providers, that representative must include a copy of your specific writtenĬonsent with the review request. Note: If anyone other than yourself wishes to file a disputed claim on your behalf with OPM, Note: If you want OPM to review more than one claim, you must clearly identify which Maintain the right to resubmit and pursue your claim and appeal through our claims andĪppeals process, set forth in your Plan brochure. If OPM rejects your request for immediate review on the basis that we met the standard, you ![]() You are entitled, upon written request, to an explanation of our basis for asserting that our United States Office of Personnel Management Information and 5) not part of a pattern or practice of non-compliance. We will be in “substantialĬompliance” if our failure or violation is 1) minor 2) non-prejudicial 3) attributable to goodĬause or matters beyond our control 4) in the context of an ongoing good faith exchange of With these rules, OPM may reject your immediate appeal. However, if OPM finds that we are in “substantial compliance” Violated our claims or appeals procedures, or that our procedures are deficient, you may Rules set forth under the Patient Protection and Affordable Care Act. Our claims and appeals process, set forth in Section 8 of the Plan brochure, is required to comply with See below for more information on your rights under the disputed claims process. Office of Personnel Management (OPM) for review of our reconsideration decision for Section 8 of your Planīrochure explains your rights to ask us to reconsider our claim decision and how to appeal to Sections 3, 7 and 8 of the Plan brochure explain how to file a claim with us. Information on Claims and Appeals to the Office of Personnel Management ![]()
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