Aetna

Claim List and Details FAQs

Overview
Terminology
Frequently Asked Questions
Claims
Eligibility
Benefits/Frequency
Miscellaneous
            

Overview

The Claim List displays a list of your claims. From this list you have the opportunity to view details, if available, on each of your claims by clicking on “Details” within the Total Submitted Charges column.

A claim can have multiple parts and within each part there can be many lines for different services performed. Each line contains the breakdown of the services performed, such as the service dates, who performed the service, and a description of the service. Also included is the financial breakdown of the claim broken down by submitted charges, total paid by Aetna, and the total for which the member is responsible.

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Terminology

 
Term
Description
Not Paid

Expenses that are not covered by the plan, such as charges that are higher than reasonable charges, exceed the maximum benefits allowed by your plan, are for services not covered by your plan, or are another payor's responsibility.

Check Number

Represents the number of the check used to pay the provider or member. This may also show an EFT (electronic funds transfer) number when applicable.

Your Copay

This is the dollar amount, such as $10 or $15, that some plan members pay a provider for each visit or service. The term is commonly used for services received in-network and/or at specified facilities like emergency rooms and is typically the only amount the plan member will pay out-of-pocket.

Date/Service Provided

Indicates the date or range of dates on which the member received the service as well as a brief description of the service.

Your Deductible

Portion of the submitted charge applied to the member's annual deductible, which is the amount the member must pay before plan benefits apply.

Member Name

Person receiving the service. May be the subscriber or a dependent.

You Pay Out of Pocket

Charges the member is responsible for paying. This includes any coinsurance or copay and other amounts the plan does not cover, which include out-of-network charges that are above reasonable and customary. When a claim has more than one part, Member Responsibility will display for each part of the claim as well as a Total Member Responsibility, which is the member's share for all parts of the claim, combined.

Charges at Aetna's Agreed Pricing

In-network providers agree to accept a negotiated amount that includes the member's share and Aetna's payment as payment in full for specified services. If you receive care from an out-of-network provider or if your plan does not have a network element, the maximum amount Aetna will pay is based on reasonable charges, which are the fees (determined by Aetna) that most providers in a given area charge for a specific service in the same setting, i.e., office, home or hospital. Some plans also set annual or lifetime maximum allowable amounts or numbers of services for some types of care after which the plan stops paying benefits.

Your Plan Paid

Payments made by your plan.

Payment Made To

Will show if a payment was made to the provider and/or member.

Remarks

Explanation of denied or pended charges.

Health Care Professional

This column displays the name of the physician, hospital or other provider (e.g., a laboratory) who provided the service.

Status

See Status descriptions below.

Charges Submitted

The amount billed for this service.

Total Paid

The amount Aetna will pay for this service.

Transaction Type

The category of the claim such as medical or pharmacy.

Your Responsibility

Also known as "coinsurance." The portion of the allowable charges for which the member is responsible.


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Frequently Asked Questions

Claims

What does the Claim Status mean?
 
Status
Description
Addt'l Info Requested

Additional information has been requested from you or your provider. The request can be in the form of an Explanation of Benefits (EOB) statement or letter. The requested information must be provided before claims processing can continue.

Completed

The claims review process is completed. When appropriate, an Explanation of Benefits (EOB) statement is produced and then both mailed and posted to your personalized Aetna Navigator™ site.

Estimate in Progress

One or more of the services representing a pretreatment estimate is still under review, and a claim estimate decision has not yet been made. An estimate is different from a claim in that you or your provider is requesting the cost of a particular procedure or treatment before making a decision about its use.

Estimate Received

One or more of the services representing a pretreatment estimate claim has been received in our system and is awaiting claims review. An estimate is different from a claim in that you or your provider is requesting the cost of a particular procedure or treatment before making a decision about its use.

Estimate Sent

The pretreatment review process is complete. When appropriate, an Explanation of Benefits (EOB) statement is mailed to you and posted to your Personalized Aetna Navigator.

In Progress

One or more of the services submitted is still under review and a claim decision has not yet been made.

Not Approved

Services for this claim are not approved by the plan. A duplicate claim received is an example of a claim that is not approved.

Received

The claim has been received and is waiting claims review.

Returned to Provider

The claim has been received and returned to the provider for correction or additional information.

Revised

A claim has been changed due to new information.



How are claims processed?
Life Cycle of a Claim

Understanding the life cycle of a claim helps clarify claim information. This table lists the steps that claims go through from the time they are received until their final status is determined.

Refer to "Claims Status Description" for an explanation of the claims status terms used below.
Step
Status/Description
Claim Coverage Verification

Status: Received
Description: Before a claim is processed, Aetna verifies the member's eligibility and claim information that has been submitted.

Claim To Be Reviewed

Status: In Progress
Description: This occurs after the claim is logged in our system but before any claims processing is started. After a claim is logged into our system, the next step is to process the claim to determine payment status.

Claim Processing

Status: In Progress
Description: The processing system determines how to process the claim. While the claim is being processed, the services included in your claim may be separated into different claims. This enables Aetna to expedite these claims more quickly.


How can I see more details on my claim?
If available, on each of your claims you may click “Details” within the Total Submitted Charges column.

What if I have a question about a specific claim?
On the claim detail page you will see the option, “Questions about this claim?” Click on Send a Message, and your email to Member Services will prefill details about the claim that you will not have to retype for your inquiry.

Some claims do not have a corresponding Explanation of Benefits (EOB). Why?
You’ll receive an EOB only if you must pay part of the claim, such as copay, deductible or coinsurance, or if Aetna needs more information from you or your provider to complete processing the claim.

I do not see any details on my claim. I just see dates and submitted charges. Why?
If the status of your claim is “Received,” “Returned to Provider” or “In Progress,” claim details will not be available until claims processing is complete.

Why are there multiple submitted charges (parts) under my Total Submitted Charge?
One visit to a provider may result in multiple claims. Each claim can contain multiple lines for different services performed. Each line contains the breakdown of the services performed, such as the dates, who performed the service, and a description of the claim. The claim is also broken down by submitted charges, total paid by Aetna, and the total for which the member is responsible.

Why is the Negotiated or Allowable Amount less than the Submitted Charges?
The submitted charges are those charges that the servicing provider would normally charge, but because you are a member of Aetna Health Plans, you receive a discounted rate.

Why is the status of the claim "In Progress" but I see that some parts are completed and payments made?
Although the review of some services submitted under the claim has been completed, one or more services are still in review and a claim decision has not yet been made.

Why would a claim not be displayed?
  • The Claim List feature of Aetna Navigator displays results of our claims process. If you are a member of an HMO or QPOS® plan, your in-network care would not result in an actual claim; however, information of this nature may display on Aetna Navigator Claims List. When you go to a preferred physician, hospital or other health care provider and pay the appropriate copay for that visit there is no additional financial responsibility for the member.
  • Some treatments, such as oral surgery, may be covered as either a dental or a medical claim. Check both the dental and medical Claims Status sections for claims.

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Eligibility

May I enroll at any time for this coverage?
Your plan may include a late entrant provision. This means if you do not enroll during the open enrollment set by your employer, certain services will not be covered for the first 12 months of coverage. Coverage within the first 12 months is usually limited to preventive and diagnostic care. Check your plan documents to find out if your plan includes a late entrant provision and ask your employer about qualifying life events that may allow you to enroll without being subject to limited coverage.
Example: You do not elect dental coverage during open enrollment. If you decide you want dental coverage in the middle of the plan year, your plan may allow you to do so. However, your benefits would be limited because you did not enroll during your employer's open enrollment period or due to a qualifying life event.
Will my child, who is turning 19, still be eligible for coverage?
Yes, children regularly attending school are usually covered until their 23rd or 25th birthday (depending on your plan's upper age limit and state law). Verification of student status is required and can be submitted on each claim form or by calling member services.

If I end my dental coverage before completing a series of scheduled dental treatments, will the remaining treatments be covered?
Your coverage ends on your termination date and dental services completed after that date will not be covered. However, some services - including those that require the dentist to order materials - may be covered if completed within 30 days of the termination date. This exception does not apply to orthodontic services. Refer to your plan documents for more information.
Example: Impressions are taken for a denture and materials are ordered on the 15th of the month, and your coverage ends on the 31st of the same month. The plan will cover the denture only if it is inserted within 30 calendar days of your coverage termination date.

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Benefits/Frequency

Is there a limit on how many services I can receive each year?
Yes, your plan allows for a certain amount of services each calendar year. This includes, but is not limited to:
  • Cleanings
  • Routine Exams
  • X-rays
Frequency varies by plan. Please check your plan documents for details.

I have a pre-treatment estimate from my dentist that was approved by my prior carrier. Is this covered?
If you have a pre-treatment estimate from your dentist that was approved by your prior carrier, simply forward the pre-treatment estimate to:

Aetna Dental
PO Box 14094
Louisville, KY 40512

Since this treatment was approved by your prior carrier, no further clinical review will be required. Once we receive the pre-treatment estimate, we will let you know whether or not your plan covers the specified services and send you an estimate of your benefits. Your benefits may depend in part on whether or not your dentist participates in Aetna's network.

Will this dental plan cover replacement of teeth that were removed before my dental coverage took effect?
  • Yes - If the tooth was removed and replaced before your new coverage effective date.

  • No - If the tooth was removed but not replaced before your new coverage effective date.
Example: Your dental plan took effect at the beginning of the current year. You need a bridge for a tooth that was removed two years ago but never replaced. Since the extraction occurred prior to your effective date, we would not cover the bridge.
If I end my dental coverage before completing a series of scheduled dental treatments, will the remaining treatments be covered?
Your coverage ends on your termination date and dental services completed after that date will not be covered. However, some services - including those that require the dentist to order materials - may be covered if completed within 30 days of the termination date. This exception does not apply to orthodontic services. Refer to your plan documents for more information.
Example: Impressions are taken for a denture and materials are ordered on the 15th of the month, and your coverage ends on the 31st of the same month. The plan will cover the denture only if it is inserted within 30 calendar days of your coverage termination date.
What is an alternate benefit?
An alternate benefit enables us to provide some benefits for services not usually covered by your plan when it makes dental sense in the specific case. The rule can apply in two situations:
  1. To use a benefit for a covered service to reimburse you for a non-covered service. This often works to your advantage since you may receive some benefit for a non-covered service rather than no benefit at all.


  2. When more than one service can be used to treat a condition. This applies only when both services are covered by the plan. If more than one service can be used to treat a covered person's dental condition; Aetna may decide to authorize coverage only for a less costly covered service provided that both of the following terms are met:
    • the service selected must be deemed by the profession to be an appropriate method of treatment; and
    • the service selected must meet broadly accepted national standards of dental practice.
Does my dental plan cover braces?
Orthodontic services are normally covered, but your plan may have limits based on the patient's age. Before services begin, we require a treatment plan from the dentist. After that, Aetna will automatically make quarterly payments. Benefits may be limited or unavailable if the braces were placed prior to the plan effective date. Your dentist will need to send us:
  • Banding date
  • Number of months of treatment
  • Assignment information
  • ADA code
  • Total case fee
  • Primary insurance carrier explanation of benefits (if coordination of benefits is necessary)
  • Prior insurance carrier information, including deductible, coinsurance/copay, maximum and amount paid to date (If patient is continuing active treatment).

Are cosmetic procedures covered?
No, most standard dental plans do not allow coverage for cosmetic procedures.
Example: The dental plan does not cover tooth bleaching, which is considered cosmetic.
Is the removal of wisdom teeth covered?
Most dental plans cover the surgical removal of wisdom teeth, when medically necessary. However, claims for the oral surgery must first be submitted to your medical plan. If your medical plan does not provide coverage, please submit the statement of rejection to your Aetna Dental® plan. (if Aetna is your medical carrier we will handle internally) Please check you plan booklet for details.

Take note of the following if you have Aetna medical coverage:
  • If your plan covers oral surgery under the medical portion of your plan, to receive the maximum benefit you should select a participating oral surgeon under the "Physicians and Medical Professionals" category in our DocFind® online directory.

  • If your plan covers oral surgery under the dental portion of your benefits, to receive the maximum benefit, you should select a participating oral surgeon under the "Dentist" category in DocFind.

Are dental implants covered?
Check your plan documents for possible coverage. Generally, most dental plans do cover crowns, bridges and dentures that are placed on the implant.

Are Temporomandibular Joint Disorder (TMJ) procedures covered?
Generally, most dental plans do not cover TMJ procedures. Your medical plan may cover TMJ.

Are crown build ups covered by my dental plan?
Most dental plans do not cover this service. There is no other covered service that can be used to provide an alternate benefit. Check your plan booklet for details.

How often may I have a crown or denture replaced?
Depending on your benefit plan and, if requested, a clinical claim review, the standard rule allows coverage for a replacement once every 5 or 8 years.
Example: If your dental plan has an 8 year replacement rule, and you replace a 3-year-old denture, it would not be covered. Please check your plan booklet for details specific to your plan.

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Miscellaneous

Primary Care Dentist (DMO® Plans Only)
I have not selected, or I need to change my primary care dentist (PCD). Who may request this change, and when and how can it be requested?
  • Who: You, your covered spouse or partner, or your employer can request a PCD change for any eligible members on file.

  • When: All PCD additions and changes need to be requested by the 15th of the month to be effective the 1st of the following month. PCD additions and changes submitted after the 15th will take effect on the 1st of the month after next.

  • How: PCD additions and changes can be submitted on Aetna Navigator™ member website or by calling member services.

Why do some procedures require review by a dentist consultant?
Most claims pass through our system electronically and are paid automatically based on your plan provisions. A few of the more complex services are referred to consulting dentists for professional review. Services referred to the dentist consultant can include oral surgery, periodontal (gum) treatment, crown and bridge, and procedures that could be considered cosmetic.

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This material is for informational purposes only and contains only a partial, general description of plan benefits or programs and does not constitute a contract. Dental insurance and benefits plans contain exclusions and some benefits are subject to limitations or visit maximums. Aetna arranges for the provision of dental care services. However, Aetna itself is not a provider of dental care services, and therefore, cannot guarantee any results or outcomes. Consult the plan documents (e.g. Booklet, Booklet-certificate, Group Policy) to determine governing contractual provisions, including procedures, exclusions and limitations relating to the plan. The availability of a plan or program may vary by geographic service area and by plan design. While this material is believed to be accurate as of the publication date, it is subject to change.

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