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Rights & Resources

Information for Banner|Aetna members

Know your health insurance rights

You are entitled to information that helps you:

  • Make the most of your benefits
  • Get the highest quality care
  • Understand how we make coverage and claims decisions
  • Appeal a denied claim
  • Get care

Resources for your health insurance questions

Appeals, complaints and grievances

You want to protect your benefits. We understand. And we know you may not always agree with our decisions. Find out how to:

Appeal a claim

File a complaint or grievance

Your Rights

As a Banner|Aetna member, you have the right to certain information and services from us.

And from the health care professionals who care for you. This includes the right to appeal a denied claim.

You also have certain responsibilities, such as learning about your health benefits plan.

Know your rights and responsibilities. Doing so can help you understand and use your health care benefits.

View my rights and responsibilities

Know your plan details

We give you important details about how your health benefits plan works. These are called disclosures. Review your disclosure to learn about when you may need a referral or approval for services, specific benefits and what is covered.

See more about disclosure information

Claims & Coverage

How we decide what services to cover

Our goal is to help you get the proper care for your condition. However, we do not pay for every type of care a person wants.

We make decisions about what to pay for based a member's health plan and generally accepted guidelines and policies.

  • We do not reward our employees or anyone else for denying a claim. In fact, we make known the risks of not providing proper care.
  • We make coverage decisions on a case-by-case basis consistent with applicable policies.
  • We review many of the services used by patients. These include tests, treatments, surgeries and hospital stays. We use nationally recognized guidelines to decide whether a service is appropriate and, therefore, covered. If we do not consider the service to be needed, we do not pay for it.

When we do not pay for a service, it is called a denied claim. If your claim is denied, we will send you a letter to let you know. If you don't agree, you can file an appeal. Once there are no appeals left, independent doctors may review your denied claim. This is called an external review.

Aetna and its affiliates provide certain management services for Banner|Aetna.

We comply with Federal laws

Banner|Aetna does not discriminate in providing access to health care services on the basis of race, disability, religion, sex, sexual orientation, health, ethnicity, creed, age or national origin. Federal law mandates that Banner|Aetna comply with Title VI of the Civil Rights Act of 1964, the Age Discrimination Act of 1975, the Americans with Disabilities Act, other laws applicable to recipients of federal funds, and all other applicable laws and rules.

We review new technologies

To decide if our plans benefits should cover new medical technologies, we:

  • Study their safety and effectiveness based on the research
  • Talk to experts
  • Consider guidelines from medical and government groups, including the Agency for Healthcare Research and Quality (AHRQ) and the Centers for Medicare and Medicaid Services (CMS)
  • Determine whether new tests, procedures, and treatments are experimental or investigational

Banner|Aetna's policies about specific medical technologies are described in clinical policy bulletins.

See our clinical policy bulletins

We also review existing tests, procedures, and treatments to see if they can be used in new ways and to determine the appropriate policies for paying claims.

How Banner|Aetna pays claims for out-of-network benefits

We negotiate rates with doctors, dentists and other health care providers to help you save money. We refer to these providers as being "in our network." Some of our benefit plans pay for services from providers who are not in our network. Read how we pay for out-of-network care and how we calculate those payments. Always check the language of your benefit plan to determine which method Banner|Aetna uses to pay your out-of-network benefits.

Read more about in-network and out-of-network benefit

External Review

Banner|Aetna has voluntarily implemented an external review program for self-funded traditional health plan sponsors who elect this program for their employees. Covered persons enrolled in a self-funded health plan should check their plan documents and contact their benefits administrator to find out if this program or any external review process is available to them.

What is the external review program?

The external review program offers members the opportunity to have certain coverage denials reviewed by independent physician reviewers. Once the applicable plan appeal process has been exhausted, eligible members may request external review if the coverage denial for which the member would be financially responsible involves more than $500 and is based on lack of medical necessity or on the experimental or investigational nature of the service or supply at issue.

How can a member determine if a coverage denial is eligible for external review?

If, upon the final level of review, the Plan upholds the coverage denial and it is determined that the member may be eligible for external review, he or she will be informed in writing of the steps necessary to request an external review, and a Request for External Review form will be included with the letter.

If coverage has been denied and the coverage denial letter indicates that the member is not eligible to request external review of the coverage denial, he or she should review the information below to determine if the coverage denial meets eligibility criteria to participate in this program.

  • The cost of the service or supply at issue for which the member would be financially responsible exceeds $500.
  • The applicable plan appeal process has been exhausted.

How does a member request external review of his or her coverage denial?

If the above eligibility criteria have been met and the applicable state external review process does not require otherwise, the member should print the Request for External Review form, follow the instructions provided on the form, and submit all information to Banner|Aetna’s External Review Unit at the address listed on the form for processing.

A second form, Request for Expedited External Review form, is for use by the treating physician, if he or she certifies that a delay in service would jeopardize the member’s health.

How does it work?

The Banner|Aetna External Review Unit will refer the request to an independent review organization (IRO) contracted with Banner|Aetna, and the IRO will choose an appropriate independent physician reviewer (or reviewers, if necessary or required by applicable law) to examine the case. The IRO is responsible for choosing a physician who is board certified in the area of medical specialty at issue in the case. The physician reviewer must take an evidence-based approach to reviewing the coverage determination, and must follow the plan sponsor's plan documents and applicable criteria governing the member's benefits.

How long does the process take?

After all necessary information is submitted, external reviews generally will be decided within 30 calendar days of the request. Expedited reviews are available when a member's physician certifies that a delay in service would jeopardize the member's health. Once the review is complete, the decision of the independent external reviewer will be binding on Banner|Aetna, the plan sponsor and the health plan. Members are not charged a professional fee for the review.

Other questions

Members can call the Member Services toll-free number listed on their ID card if they have any further questions regarding external review. Plan sponsors and producers; please contact your Banner|Aetna representative for additional information.

Please keep in mind that certain states mandate external review of other benefits or service issues or require a filing fee. In addition, certain states mandate the use of their own external reviewer. These state mandates may not apply to self-funded plans.

Aetna and its affiliates provide certain management services for Banner|Aetna.

Transforming health care, together

Together, Banner Health and Aetna aim to offer more efficient and effective patient care at a more affordable cost. We join the right medical professionals with the right technology, so patients benefit from quality, personalized health care designed to help them reach their health ambitions.

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Banner|Aetna is the brand name used for products and services provided by Banner Health and Aetna Health Insurance Company and Banner Health and Aetna Health Plan Inc. Health benefits and health insurance plans are offered and/or underwritten by Banner Health and Aetna Health Insurance Company and/or Banner Health and Aetna Health Plan Inc. (Banner|Aetna). Each insurer has sole financial responsibility for its own products. Banner Health and Aetna Health Insurance Company and Banner Health and Aetna Health Plan Inc. are affiliates of Banner Health and, of Aetna Life Insurance Company and its affiliates (Aetna). Aetna provides certain management services to Banner|Aetna.

This material is for information only and is not an offer or invitation to contract. An application must be completed to obtain coverage. Health benefits and health insurance plans contain exclusions and limitations. Providers are independent contractors and not our agents. Provider participation may change without notice. We do not provide care or guarantee access to health services. Not all health services are covered. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability are subject to change and may vary by location. Information is believed to be accurate as of the production date; however, it is subject to change.

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Banner|Aetna is the brand name used for products and services provided by Banner Health and Aetna Health Insurance Company and Banner Health and Aetna Health Plan Inc. Health benefits and health insurance plans are offered and/or underwritten by Banner Health and Aetna Health Insurance Company and/or Banner Health and Aetna Health Plan Inc. (Banner|Aetna). Each insurer has sole financial responsibility for its own products.  Banner Health and Aetna Health Insurance Company and Banner Health and Aetna Health Plan Inc. are affiliates of Banner Health and, of Aetna Life Insurance Company and its affiliates (Aetna). Aetna provides certain management services to Banner|Aetna.

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Banner|Aetna is the brand name used for products and services provided by Banner Health and Aetna Health Insurance Company and Banner Health and Aetna Health Plan Inc. Health benefits and health insurance plans are offered and/or underwritten by Banner Health and Aetna Health Insurance Company and/or Banner Health and Aetna Health Plan Inc. (Banner|Aetna). Each insurer has sole financial responsibility for its own products.  Banner Health and Aetna Health Insurance Company and Banner Health and Aetna Health Plan Inc. are affiliates of Banner Health and, of Aetna Life Insurance Company and its affiliates (Aetna). Banner Health provides certain management services to Banner|Aetna.

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