Aetna

Overview

The Aetna Navigator Explanation of Benefits statement is an online image of the paper Explanation of Benefits (EOB) statement. It contains claims details, such as the doctor’s name, date of service, charges for services, what Aetna paid and how much is your responsibility. Once we process a health care claim, we create an online EOB and, depending on your plan and mailing preference, we may mail a paper copy to you. You can turn off mailed EOBs if you prefer to save paper and view them online only. The online EOB remains accessible for 24 months. Depending upon your coverage, Explanations of Benefits may be available for both dental and medical claims.

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Terminology

Claim Explanation of Benefits Terminology:
Term
Description
Amount Remaining (F):
The amount on which any benefits are calculated, after the member has paid his or her copay and/or deductible.
C+D+E+H=I:
These letters identify columns and illustrate how patient responsibility (amount provider may bill you) was calculated.
Date and Type of Service:
The name of the doctor, dentist, or other health care professional or facility that performed the service, date the service was provided, and brief description of the service.
(Provider) May Bill You:
Total that is the member's responsibility. This can include not covered, copayment, deductible, coinsurance and amounts that exceed reasonable charges.
Negotiated or Allowed (B):
Negotiated -- the discounted rate for this service negotiated by Aetna with an in-network doctor, dentist or facility.

Allowed -- the amount Aetna allows for services received out of network. This amount is also called "Reasonable Charges."
Not Payable by Plan (C):
The amount Aetna has pended or denied. We may conclude a charge is not payable because the service is not covered by the patient's plan. Also, a portion of a charge may be not payable if it exceeds the reasonable charge for that service.
Paid At:
The percentage used to calculate benefits. For example, some plans will pay the specified percentage of reasonable charges.
Payment Summary:
Lists the recipient of the payment, date sent and amount paid.
Plan Pays (G):
The amount your plan will pay for this service, not including any adjustments, such as amount paid by another health plan or a late claim interest amount.
Plan Summary for (benefit year):
Summary of plan financial limits for the benefit year listed.
Remarks:
Explain denied or pended charges, or provide additional information.
See Remarks:
A number that refers to a remark in General Remarks section.
Submitted Charges (A):
The amount billed by the doctor, dentist or facility for this service.
Total Patient Responsibility (I):
The total amount for which the patient is responsible. This includes not covered, copayment, deductible and coinsurance amounts.
Your Copay (D):
Copayment required for this service type. The copayment is a flat dollar amount the member must pay each time he or she receives a specified service.
Your Deductible (E):
The deductible is a specified amount the patient must pay before the plan begins paying benefits, usually each calendar year. This shows the amount of the charges for this claim applied to the patient deductible and charged to the member.
Your Share of Amount Remaining (H):
Also known as "coinsurance", this is the portion of the charges for which the member is responsible.

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Frequently Asked Questions

When can I view my Explanation of Benefits statements online?
An EOB appears on your secure Aetna Navigator™ website the day after we print and mail the paper statements. This means you can usually see an EOB online before the paper copy would reach you by mail. We mail EOBs once within a 21-day cycle, with the following exceptions, which we mail as they are processed:
  • Statements with checks attached.
  • Statements related to dependent restrictions.

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Why would an Explanation of Benefits statement not be available?
EOBs may not be available, depending on the date you registered with Aetna Navigator:
  • If you registered before May 14, 2005, Aetna Navigator will only display medical and dental EOBs and dental pretreatment estimates processed after the date of your completed Aetna Navigator registration.
  • If you registered on or after May 14, 2005, Aetna Navigator will display medical and dental EOBs and dental pretreatment estimates processed since May 14, 2005.
NOTE: In some plans, EOBs may not be available at all. For clarification, contact your employer's benefits administrator.

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Why do several members of my family appear on the same Explanation of Benefits statement?
To make it easier for you, we no longer issue separate online and paper EOB statements with redundant information. We now group claims information for all family members in one EOB statement. Your EOB may now display claims for one or more family members.

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How do I view one family member’s claim on an Explanation of Benefits statement?
Select a family member name in the “View claim EOB Activity for” box to view the start of the EOB information for that member. To view another member’s claims in the EOB statement, you can:
  • Scroll up/down the EOB page.
  • Return to the top to select another family member name in the “View Claim Activity For” box.

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Why do you mail me an Explanation of Benefits statement when I’ve elected to not receive them by mail?
Even if you elect to turn off most paper EOBs, we will still mail you certain types of statements:
  • Statements with checks attached.
  • Statements related to dependent restrictions.
  • Pended claims statements.

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How do I tell you to stop mailing me new Explanation of Benefits statements?
Since we post an exact replica of your mailed EOBs online, you can elect to "Turn off Paper" using the link above your Claim EOB List. You can also go to Requests & Changes on your Aetna Navigator home page and follow the instructions under Personal Profile. On the same page, you can provide an email address and authorize us to send you email alerts when you have a new online EOB on Aetna Navigator.

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How do I save an Explanation of Benefits statement to my PC?
If you want to save an EOB to your computer so that you can access it for more than 24 months, select the “Download this EOB” icon in the “You Can…” box to display the EOB and save it to your PC.

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What should I do if I suspect fraud?
If you suspect fraud or abuse involving the services described in any Explanation of Benefits or would like to report other health care fraud-related issues, please call Aetna’s toll-free Fraud Hotline at 1-800-338-6361, or send an email to aetnasiu@aetna.com.

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