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Aetna timely filing for appeals4/10/2023 ![]() ![]() Provider participation may change without notice. Providers are independent contractors and are not agents of Banner l Aetna. This material is for information only and is not an offer or invitation to contract. 98point6 is a registered trademark of 98point6 inc. 98point6 is not available in all Banner|Aetna plans offered through employers. Aetna and CVS Pharmacy® are part of the CVS Health family of companies. Aetna and MinuteClinic, LLC (which either operates or provides certain management support services to MinuteClinic-branded walk-in clinics) are both within the CVS Health family.Īccess to the 98point6 application is included in all Banner|Aetna ACA individual & family plans. Aetna and Banner Health provide certain management services to Banner|Aetna. Each insurer has sole financial responsibility for its own products. Banner|Aetna is an affiliate of Banner Health and of Aetna Life Insurance Company and its affiliates (Aetna). OMHA provides additional information on other levels of appeals to help you understand the appeals process in a broad context.Health benefits and health insurance plans are offered, underwritten, and/or administered by Banner Health and Aetna Health Insurance Company and/or Banner Health and Aetna Health Plan Inc. OMHA is not responsible for levels 1, 2, 4, and 5 of the appeals process. Please note that the Office of Medicare Hearings and Appeals is responsible only for the Level 3 claims appeals and certain Medicare entitlement appeals and Part B premium appeals. If during your Level 1 appeal ("reconsideration") your Medicare Advantage plan does not decide in your favor, it is required to forward your appeal to an independent outside entity for a Level 2 review. If your Medicare Advantage plan fails to meet the established deadlines, it is required to forward your appeal to an independent outside entity for a Level 2 review. Your plan does not meet the response deadline. Your Level 1 appeal ("reconsideration") will automatically be forwarded to Level 2 of the appeals process in the following instances: If you are receiving services in an inpatient hospital, skilled nursing facility, home health agency or comprehensive rehabilitation facility, you may request an immediate review by a Quality Improvement Organization, if you disagree with your Medicare Advantage plan's decision to discharge you or discontinue services. You or your physician may request an expedited reconsideration by your Medicare Advantage plan in situations where the standard reconsideration time frame might jeopardize your health, life, or ability to regain maximum function. Special Circumstances for Expedited Review 60 days if the decision involves a request for payment.30 days if the decision involves a request for a service.In most cases, your plan will notify you of its reconsideration decision within: When You Will Get a Response (i.e., "reconsideration decision") You may request reconsideration by your Medicare Advantage plan within 60 days of being notified by your Medicare Advantage plan of its initial decision to not pay for, not allow, or stop a service ("organization determination").At Level 1, your appeal is called a request for reconsideration. ![]() Your Medicare Advantage plan must inform you in writing on how to request an appeal.How to Request an Appeal (i.e., "request for reconsideration") You may contact your plan or consult your plan materials for detailed information about requesting an appeal and your appeal rights. If you are in a Medicare Advantage plan, you can appeal the plan's decision to not pay for, not allow, or stop a service that you think should be covered or provided.
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