Your medical care provider submits claims directly to Aetna for payment. After the deductible has been met, Aetna pays the appropriate amount, and the provider bills you for the appropriate coinsurance. Under the MPO, Aetna is the primary payer of your medical claims.
Aetna has a contract with Medicare that allows them to process claims for all of your medical treatment with the exception of hospice care which is covered directly by Original Medicare.
If you need to file a claim, please refer to the EOC or contact Aetna member services for assistance.
You may obtain claim forms by contacting Aetna or through their website. See Information sources at the front of this SPD.
Q. When must claims be filed?
A. You must submit your medical claims to Aetna within one calendar year of the date you received the service, item, or Part B drug.
Outpatient prescription drug claims
You do not have to file a claim for outpatient prescription drugs if you:
- Use a participating network retail pharmacy and identify yourself as an Express Scripts participant, or
- Purchase drugs through Express Scripts Pharmacy, the home delivery pharmacy.
Otherwise, you must submit a completed Direct Reimbursement Claim Form to Express Scripts. You may obtain a claim form by calling Express Scripts at the number shown in the front of this SPD.
Expenses incurred outside the United States
MPO will cover services outside the United States for emergency or urgent care only. For more information, please refer to the EOC or SOC, or contact Aetna member services (See Information sources at the front of this SPD.)
Claim denial and reconsideration
If all or part of a claim is denied, Aetna will provide you with a written explanation, including the MPO provisions supporting the denial and describing additional information, if any, that may improve the claim's likelihood of being approved. See Evidence of Coverage (EOC) and Administrative and ERISA information.
Right of reimbursement and subrogation
Aetna has the right and responsibility to collect for covered Medicare services for which Medicare is not the primary payer. Please refer to Aetna Medicare Advantage EOC for further details.