Rights and Resources | Allina Health Aetna

Know your health insurance rights

As an Allina Health | Aetna member, you are entitled to information that helps you:

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

We’re here to help you get to know your rights regarding your plan and your care. We also want to help you understand why we may not pay for certain services.
We know you may not always agree with our decisions. Find out how to:

• File a complaint, grievance or appeal about Allina Health | Aetna, your plan or a health care service, provider or professional
• Appeal the decision when we don't pay for all or part of a claim

You can use our resources to make the best decisions about your doctors, treatments and health plans. If you have a life event that affects your health insurance, like getting married or having a child, we can help you change your coverage. We’ll explain your options

Your rights

As an Allina Health | 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.

It’s important to know your rights and responsibilities. This can help you understand and use your health care benefits.

View my rights and responsibilities

• I am a Allina Health | Aetna Commercial or PPO member

Know your plan details

We give you important details about how your health benefits plan works. These are called disclosures.

Claims and coverage

How we decide what services to cover

We make decisions about what to pay for based on the member’s health plan and generally accepted guidelines and policies

• We don’t reward our employees or anyone else for denying a claim. In fact, we explain the risks of not offering the right 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 needs to be covered. If we don’t think the service is needed, we don’t pay for it.

When we don’t pay for a service, it’s called a denied claim. If we deny your claim, we’ll 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 Allina Health | Aetna.

We comply with federal laws

Allina Health | 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 Allina Health | 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)
• Decide whether new tests, procedures and treatments are experimental or investigational

Allina Health | Aetna’s policies about specific medical technologies are described in clinical policy bulletins.

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

How Allina Health | Aetna pays claims for out-of-network benefits

We discuss 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 aren’t in our network. You can read how we pay for out-of-network care to see how we calculate those payments. Be sure to check the language of your benefit plan to decide which method Allina Health | Aetna uses to pay your out-of-network benefits.

External review

Affordable Care ActThe Patient Protection and Affordable Care Act (PPACA) was enacted on March 23, 2010. The Department of the Treasury, Department of Labor and the Department of Health and Human Services issued interim final regulations implementing the requirements regarding internal claims and appeals and external review processes for group health plans and health insurance coverage in the group and individual markets.In compliance with the Affordable Care Act and modeled after the Uniform Health Carrier External Review Model Act (NAIC Uniform Model Act), covered persons must have the opportunity for an independent review of adverse determinations or final adverse determinations based on medical judgment or a determination that a recommended or requested health care service or treatment is experimental or investigational or for rescission of coverage. Your plan type and the state of your contract or residence will determine whether your coverage denial is subject to state or federal standard regulations.

All non-grandfathered plans (self-funded, insured, group & individual) are subject to some form of external review process. Your plan documents will provide a description of the applicable external review process. You will be provided with the applicable external review rights along with a description of how to pursue an external review in the adverse or final adverse determination letter as you exhaust the internal appeal process.

States that have an external review process that meets certain minimum consumer protections set forth under federal requirements will be allowed to apply their state external review process. Health insurers must comply with the state external review process in those states. If your plan is subject to a state mandated process, a description of that process will be provided in your plan documents.

Claims Denials

How to appeal a denied claim

If we deny a claim and you don’t agree with our decision, you can ask for a review. This is called an appeal. Just log in to your secure member website for more information. Or you can call us at the number on your member ID card.

You can appeal on your own. You can also give someone permission to appeal for you. This is called an authorized representative.

How long do I have to ask for an appeal?

You have 180 days from when you get the notice of the denied claim, unless your plan brochure (or Summary Plan Description) gives you a longer period of time.

What should the request include?

• The group name (usually your employer or organization that sponsors your plan)
• Your name
• Your member ID number (found on your medical ID card)
• Any comments, documents, records and other information you would like us to consider. (If there are documents you need for your claim, just call the Member Services phone number listed on your member ID card. We’ll send them to you free of charge.)

How long will it be before Allina Health | Aetna makes a decision?

How soon we respond depends on:

• State law
• How urgent your appeal is
• Whether your plan offers one or two levels of appeal

Plans that provide for one appeal

• If we had to approve your claim before you got care, we’ll decide within 30 days of getting your appeal.
• For other claims, we’ll decide within 60 days.

Plans that provide for two appeals

• If we had to approve your claim before you got care, we’ll decide within 15 days of getting your appeal.
• For other claims, we’ll decide within 30 days.

In either case, if you don’t agree with our decision, you can ask for a second review. You have 60 days from the date that you get the appeal decision letter to let us know. You can call Member Services at the phone number listed on your member ID card, or write to us.

Urgent Care Claims

We make decisions for urgent care claims more quickly. If your doctor feels that a delay will put your health, your life or your recovery at serious risk or cause you severe pain, that’s an urgent care claim. You or your doctor may ask for an "expedited" appeal. Just call the toll-free number on your Member ID card or the number on the claim denial letter.

• If your plan has one level of appeal, we’ll tell you our decision no later than 72 hours after we get your request for review.
• If your plan has two levels of appeal, we’ll tell you our decision no later than 36 hours after we get your request for review.

What is an external review?

If your claim is still denied after your appeal(s), you may be able to have a third party (independent party) review your denied claim. This is called an external review.

The Affordable Care Act (ACA) created new rules for health plans. Now, health plans that are subject to the law must include an external review process. Learn more about the Allina Health | Aetna External Review Program and if your claim denial is eligible for external review.

Options for changing health coverage

If you have health benefits through your employer, you can change them during "open enrollment." It's typically in the fall. It's your chance to choose a new health plan, pick new benefits or cancel your current plan.

The only other times you can change your health benefits is when you:

• Get married
• Get a divorce or legal separation
• Give birth or adopt a child
• Lose your health coverage because your spouse or domestic partner lost his or her job
• Lose your health coverage because your spouse or domestic partner died

You can check with your employer to learn more.

Options for job-related changes

Losing a job or changing jobs usually means giving up the health insurance plan you have through work. Here are some options for getting new health coverage:

• Find out if you can stay on your employer's health plan for a period of time through the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA).
• Join a government program, such as Medicaid.
• Understand your rights. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) makes it easier for people to change jobs without losing health coverage. 

Options when graduating college

This may be the first time you're thinking about health benefits. To get covered, consider these options:

• Join or stay on your parent's health plan. Contact the employer's Human Resources department for more information.
• Get coverage through a new employer.

COBRA

If your employer is subject to federal COBRA, you may be able to continue your group health plan coverage on a temporary basis. This coverage, however, is only available when coverage is lost due to specific events. For more information, just contact your employer.

Conversion

Conversion is medical coverage for people who are no longer eligible for the group’s medical coverage due to reasons such as:

• Loss of employment
• Expiration of COBRA/continuation or
• Loss of eligibility as a dependent

Coverage continues from when the employer group plan ends to the date of when the individual conversion plan begins. Individual conversion plans don’t require medical underwriting. Individual conversion benefits will be different from the group benefits and will vary depending on where you live.

There’s a limited time to apply for the conversion policy. Members have to apply and pay the first premium within 31 days of termination of group coverage. To figure out if your plan offers a conversion option and to see what benefits are available, you can contact the traditional medical conversion unit at (866) 901-2922. 1235