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Grievances and Appeals The Plan has procedures for you to follow if you are dissatisfied with a decision that Aetna has made or with the operation of the Plan. The process depends on the type of complaint you have. There are two categories of complaints: • Quality of care or operational issues; and • Adverse benefit determinations. Complaints about quality of care or operational issues are called grievances. Complaints about adverse benefit determinations are called appeals. Grievances Quality of care or operational issues arise if you are dissatisfied with the service received from Aetna or want to complain about a participating provider. To make a complaint about a quality of care or operational issue (called a grievance), call or write to Member Services within 30 days of the incident. Include a detailed description of the matter and include copies of any records or documents that you think are relevant to the matter. Aetna will review the information and provide you with a written decision within 30 calendar days of the receipt of the grievance, unless additional information is needed, but cannot be obtained within this time frame. The notice of the decision will specify what you need to do to seek an additional review. Appeals of Adverse Benefit Determinations Aetna will send you written notice of an adverse benefit determination. The notice will give the reason for the decision and will explain what steps you must take if you wish to appeal. The notice will also tell you about your rights to receive additional information that may be relevant to the appeal. Requests for level one appeal must be made orally or in writing within 180 days from the receipt of the notice. However, appeals of adverse benefit determinations involving urgent care may be made orally. The Plan provides for two levels of appeal, plus an option to seek external review of the adverse benefit determination. You must complete: 1) two levels of appeal with Aetna; 2) ERO appeal, where available; and, 3) any administrative appeals made to you by the State of Delaware before bringing a lawsuit against the plan. If you are dissatisfied with the outcome of your level one appeal and wish to file a level two appeal, your appeal must be filed in writing no later than 60 days following receipt of the level one notice of adverse benefit determination. However, appeals of adverse benefit determinations involving urgent care may be made orally. The following summarizes some information about how appeals are handled for different types of claims. Urgent care claim: a claim for medical care or treatment where delay could: • Seriously jeopardize your life or health, or your ability to regain maximum function; or • Subject you to severe pain that cannot be adequately managed without the requested care or treatment. 36 hours Review provided by Plan personnel not involved in making the adverse benefit determination. 36 hours Review provided by Plan personnel not involved in making the adverse benefit determination. Pre-service claim: a claim for a benefit that requires approval of the benefit in advance of obtaining medical care. 15 calendar days Review provided by Plan personnel not involved in making the adverse benefit determination. 15 calendar days Review provided by Plan personnel not involved in making the adverse benefit determination. Concurrent care claim extension: a request to extend a previously approved course of treatment. Treated like an urgent care claim or a preservice claim, depending on the circumstances. Treated like an urgent care claim or a pre-service claim, depending on the circumstances. Post-service claim: a claim for a benefit that is not a pre-service claim. 15 calendar days Review provided by Plan Personnel not involved in making the adverse benefit determination. 30 calendar days Review provided by Plan personnel not involved in making the adverse benefit determination. You may also choose to have another person (an authorized representative) make the appeal on your behalf by providing written consent to Aetna. However, in case of an urgent care claim or a pre-service claim, a physician familiar with the case may represent you in the appeal. Depending on the type of appeal, you and/or an authorized representative may attend the Level Two appeal hearing and question the representative of the Plan and any other witnesses, and present your case. The hearing will be informal. You may bring your physician or other experts to testify. The Plan also has the right to present witnesses. If the Plan's appeals process upholds the original adverse benefit determination, you may have the right to pursue an external review of your claim. See “External Review” for more information. External Review You may file a voluntary appeal for external review of any final appeal determination that qualifies. You must complete the two levels of appeal described above before you can appeal for external review. Subject to verification procedures that the Plan may establish, your authorized representative may act on your behalf in filing and pursuing this voluntary appeal. You must request this voluntary level of review within 60 days after you receive the final denial notice. The filing of a claim will have no effect on your rights to any other benefits under the Plan. However, the appeal is voluntary and you are not required to undertake it before pursuing legal action. If you choose not to file for voluntary review, the Plan will not assert that you have failed to exhaust your administrative remedies because of that choice. An external review is a review by an independent physician, with appropriate expertise in the area at issue, of claim denials and denials based upon lack of medical necessity, or the experimental or investigational nature of a proposed service or treatment. You may request a review by an external review organization (ERO) if: • You have received notice of the denial of a claim; and • Your claim was denied because the care was not medically necessary or was experimental or investigational; and • You have exhausted the applicable Plan appeal process. The final claim denial letter you receive will describe the process to follow if you wish to pursue an external review, and will include a copy of the Request for External Review Form. You must submit the Request for External Review Form to Aetna within 60 calendar days of the date you received the final claim denial letter. The form must be accompanied by a copy of the final claim denial letter and all other pertinent information that supports your request. Aetna will contact the External Review Organization that will conduct the review of your claim. The External Review Organization will select an independent physician with appropriate expertise to perform the review. In rendering a decision, the external reviewer may consider any appropriate credible information submitted by you with the Request for External Review Form, and will follow the applicable plan’s contractual documents and plan criteria governing the benefits. You will generally be notified of the decision of the External Review Organization within 30 days of Aetna’s receipt of your request form and all necessary information. An expedited review is available if your physician certifies (by telephone or on a separate Request for External Review Form) that a delay in receiving the service would jeopardize your health. Expedited reviews are decided within 3-5 calendar days after Aetna receives the request. You are responsible for the cost of compiling and sending the information that you wish to be reviewed by the External Review Organization to Aetna. Aetna is responsible for the cost of sending this information to the External Review Organization.