Open Access Network
Enrolled members must utilize network participating physicians. Referrals to a specialist are not required. In the event the member travels outside of the Network service area, he/she is covered for care rendered for emergencies at any facility. Emergency co-payment will be required.
Point of Service (POS)
Enrolled members can utilize network participating physicians and facilities. They may also use providers and facilities not participating in the network anywhere in the country. Deductibles and co-insurance will apply. Members will be covered anywhere for life threatening emergencies. Claims will be paid at the in-network level.
In the event of a local or national disaster, resulting in relocation of participating members from the local network area, Aetna would move forward to put a plan in place to respond to the needs of the members who were forced to relocate to other areas of Florida or the Nation. Claims received for care rendered outside of the area would be reviewed for consideration to be paid at the in-network level".
In the past Aetna has made arrangements for members to have continued access to their medications. These arrangements have included lifting the "Refill to Soon" restrictions. Information concerning the handling of prescription drugs will be made available one we have been informed of the place that is being utilized.
- Aetna does NOT want to penalize any member or provider who has been adversely impacted by a storm in the effected area
- Aetna will allow claims for the DOS and processed dates in the impacted states regardless of pre-certification or authorization, referrals, medical necessity, and hospital admission dates of service (DOS).
- Services rendered by a non-participating provider will be paid as in network during this timeframe for impacted members
- Aetna will update their systems to handle impacted claims as in network.
- Some of the claims may have adjudicated and been denied as out of network, so manual adjustments may need to be requested. Check your Explanation of Benefits letters and contact Aetna immediately with questions.
- Standard immunizations will be covered for members who are in a high risk group with no history of prior immunization as long as the service is not work-related.
Standard immunizations include Hepatitis A, Hepatitis B, Rotavirus, Diptheria-Tetanus-Pertussis (DTaP), Inactivated Polio Virus, H.
Influenzae type b (Hib), Pneumococcal Conjugate, Measles-Mumps-Rubella (MMR), and Chicken Pox (Varicella).
- Vaccines (e.g., Hepatitis A) will be covered for members who are going to impacted areas as relief workers.
- The systems may deny these claims via auto adjudication if no authorization exists in the system. If that happens, contact Aetna and request reprocessing.