Important Disclosure Information
Dental Preferred Provider Organization (PPO) and Participating Dental Network* (PDN)
Members
Note: Specific state variations and plan documents supersede general disclosures
contained within, as applicable. Be certain to review the state-specific language in the
State Variation section, which follows.
Covered Benefits
Your plan of benefits will be determined by your employer
and underwritten or administered by Aetna Life Insurance
Company,151 Farmington Avenue, Hartford, CT, 06156.
The benefits and main points of the Service Agreement or
Group Policy for persons covered under your employer’s
plan of benefits will be set forth in the Booklet-certificate
or Booklet which will be provided to you at a later date.
Covered services may include dental care provided by
general dentists and specialist dentists. However, certain
limitations may apply. For example, the dental plan
excludes or limits coverage for some services, including,
but not limited to, cosmetic and experimental procedures.
The information that follows provides general information
regarding Aetna dental PPO/PDN plans. Members should
consult their plan documents for a complete description of
what dental services are covered and any applicable
exclusions and limitations.
Note that the Exclusive Provider Plan (EPP), the PPO
MAX /PDN MAX plan and the Aetna HealthFund®/
Aetna DentalFund® products operate differently than
the PPO/PDN plan. Check your plan documents for
specifics about how these plans work. This disclosure
information does not apply to these plans/products.
Member Cost Sharing
Members are responsible for any copayments, coinsurance
and deductibles for covered services. These obligations are
paid directly to the provider or facility at the time the
service is rendered. Copayments, coinsurance and
deductibles are described in your plan documents.
Emergency Care
If you need emergency dental care, you are covered 24
hours a day, 7 days a week, anywhere in the world. When
emergency services are provided by a participating
PPO/PDN dentist, your copayment/coinsurance amount will
be based on a negotiated fee schedule.
*In Texas, PPO is known as PDN.
www.aetna.com
07.28.301.1 (3/05)
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Note that the Exclusive Provider Plan (EPP) has a
different emergency care policy than the PPO/PDN
plan. Check your plan documents for specifics about
how the EPP emergency care policy works.
How Aetna Compensates Your Dentist
and Other Providers
Participating PPO/PDN dentists are reimbursed on a fee-forservice basis. Any member coinsurance payments are
based on the dentist’s contracted fee schedule. Nonparticipating providers providing covered services are
reimbursed on a fee-for-service basis, subject to plan terms
and conditions, as determined by Aetna.
You are encouraged to ask your dentists and other
providers how they are compensated for their services.
Clinical Review
Aetna has developed a dental clinical review program to
assist in determining what dental services are covered
under the dental plan and the extent of such coverage.
Some services may be subject to retrospective review.
Only dental consultants who are licensed dentists make
clinical determinations. Members and/or providers are
notified of the reasons for a denial of coverage and of the
applicable appeals process.
Grievances and Appeals
Our grievance process is designed to address member
coverage issues, complaints and problems. If you have a
coverage issue or other problem, call Member Services at
the toll-free number on your ID card. If Member Services is
unable to resolve your issue, complaint or problem to your
satisfaction, you can request that your concern be
forwarded to the regional Grievance and Appeals Unit
located at the following address.
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Northeast Territory - includes Mid-Atlantic and
Mid-Western states (CT, DE, DC, IL, IN, KY, ME,
MD, MA, MI, NH, NJ, NY, OH, PA, RI, VA, WV, WI)
When necessary or appropriate for your care or treatment,
the operation of our health plans, or other related
activities, we use personal information internally, share it
with our affiliates, and disclose it to health care providers
(doctors, dentists, pharmacies, hospitals and other
caregivers), payors (health care provider organizations,
employers who sponsor self-funded health plans or who
share responsibility for the payment of benefits, and others
who may be financially responsible for payment for the
services or benefits you receive under your plan), other
insurers, third-party administrators, vendors, consultants,
government authorities, and their respective agents. These
parties are required to keep personal information
confidential as provided by applicable law. Participating
network providers are also required to give you access to
your medical records within a reasonable amount of time
after you make a request.
Aetna Dental Grievance and Appeals Unit
P.O. Box 14080
Lexington, KY 40512-4080
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South Territory (AL, AR, FL, GA, LA, MS, NC, OK,
SC, TN, TX)
Aetna Dental Grievance and Appeals Unit
P.O. Box 14597
Lexington, KY 40512-4597
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West Territory (AZ, CA, CO, HI, IA, ID, KS, MN,
MO, NE, NV, NM, OR, UT, WA)
Aetna Dental Grievance and Appeals Unit
P.O. Box 1 4021
Some of the ways in which personal information is used
include claims payment; utilization review and
management; medical necessity reviews; coordination of
care and benefits; preventive health, early detection, and
disease and case management; quality assessment and
improvement activities; auditing and antifraud activities;
performance measurement and outcomes assessment;
health claims analysis and reporting; health services
research; data and information systems management;
compliance with legal and regulatory requirements;
formulary management; litigation proceedings; transfer of
policies or contracts to and from other insurers, HMOs and
third party administrators; underwriting activities; and due
diligence activities in connection with the purchase or sale
of some or all of our business. We consider these activities
key for the operation of our health plans. To the extent
permitted by law, we use and disclose personal
information as provided above without member consent.
However, we recognize that many members do not want
to receive unsolicited marketing materials unrelated to
their health benefits. We do not disclose personal
information for these marketing purposes unless the
member consents. We also have policies addressing
circumstances in which members are unable to give
consent.
Lexington, KY 40512-4021
You can also contact Member Services through the
Internet at www.aetna.com.
If you are dissatisfied with the outcome of your initial
contact, you may file a written grievance with our
Grievance and Appeals Unit at the address listed above.
If you are not satisfied after filing a formal grievance, you
may appeal the decision. Your appeal will be decided in
accordance with the procedures applicable to your plan
and applicable state laws. Refer to your plan documents
for further details regarding your plan’s grievance
procedures.
Links to state insurance department websites can be
obtained through the National Association of Insurance
Commissioners (NAIC) at www.naic.org.
Confidentiality and Privacy Notices
Aetna considers personal information to be confidential
and has policies and procedures in place to protect it
against unlawful use and disclosure. By “personal
information,” we mean information that relates to a
member’s physical or mental health or condition, the
provision of health care to the member, or payment for the
provision of health care to the member. Personal
information does not include publicly available information
or information that is available or reported in a
summarized or aggregate fashion but does not identify the
member.
To obtain a hard copy of our Notice of Privacy Practices,
which describes in greater detail our practices concerning
use and disclosure of personal information, please write to
Aetna’s Legal Support Services Department at 151
Farmington Avenue, W121, Hartford, CT 06156. You can
also visit our Internet site at www.aetna.com. You can
link directly to the Notice of Privacy Practices by selecting
the “Privacy Notices” link at the bottom of the page.
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State Variations
In some states, Aetna provides additional consumer disclosures in documents also
posted on our website at www.aetna.com.
Note: State benefits mandates may not apply to employer-funded plans. Contact
Member Services with specific questions about your coverage.
Georgia
Illinois
Members can call 1-877-238-6200 (toll-free) to confirm
that the preferred provider in question is in the network
and/or accepting new patients.
While every provider listed in the provider directory
contracts with Aetna to provide primary care services, not
every provider listed will be accepting new patients.
Although Aetna has identified those providers who were
not accepting patients as known to Aetna at the time the
Provider Directory was created, the status of the physician’s
practice may have changed. For the most current
information regarding the status change of any physician’s
practice, please contact either the selected physician or
Member Services at the number on your ID card.
A summary of any agreement or contract between Aetna
and any health care provider will be made available upon
request by calling the Member Services telephone number
on your ID card. The summary will not include financial
agreements as to actual rates, reimbursements, charges, or
fees negotiated by Aetna and the provider. The summary
will include a category or type of compensation paid by
Aetna to each class of health care provider under contract
with Aetna.
Iowa
Quality Management Program
Hawaii
Aetna utilizes a comprehensive credentialing program to
verify the licensing, education and qualifications of the
providers that participate in our provider network.
Informed Consent
Members have the right to be fully informed prior to
making any decision about any treatment, benefit, or nontreatment.
Kansas
Kansas law permits you to have the following information
upon request:
Your provider will:
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Discuss all treatment options, including the option of
no treatment at all;
1. a complete description of the health care services,
items and other benefits to which the insured is
entitled in the particular health plan which is covering
or being offered to such person;
Ensure that persons with disabilities have an effective
means of communication with the provider and other
members of the managed care plan; and
2. a description of any limitations, exceptions or
exclusions to coverage in the health benefit plan,
including prior authorization policies or other
provisions which restrict access to covered services or
items by the insured;
Discuss all risks, benefits, and consequences to
treatment and non-treatment.
Insurance Division Telephone Number:
You may contact the Hawaii Insurance Division and the
Office of Consumer Complaints at: 1-808-586-2790.
3. a listing of the plan’s participating providers, their
business addresses and telephone numbers, their
availability, and any limitation on an insured’s choice of
provider;
4. notification in advance of any changes in the health
benefit plan which either reduces the coverage or
benefits or increases the cost, to such person; and
5. a description of the grievance and appeal procedures
available under the health benefit plan and an
insured’s rights regarding termination, disenrollment,
nonrenewal or cancellation of coverage.
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Kentucky
5. If the appeal is for a decision not to certify urgent or
ongoing services, it should be requested as an
expedited appeal. An example of an expedited appeal
is a case where a delay in decision-making might
seriously jeopardize the life or health of the member
or jeopardizes the member’s ability to regain maximum
function. An expedited appeal will be resolved within
72 hours. If you do not agree with the final
determination on review, you have the right to bring a
civil action under Section 502(a) of ERISA, if applicable.
Any provider who meets our enrollment criteria and who is
willing to meet the terms and conditions for participation
has a right to become a participating provider in our
network.
Customary Waiting Times
Routine care -
Within 3 weeks
Routine hygiene
Within 6 weeks
Urgent complaint -
Same Day/within 24 hours
Emergency -
Immediately or referred to ER
6. If you are dissatisfied with the outcome of a clinical
appeal and the amount of the treatment or service
would cost the covered individual at least $100.00 if
they had no insurance, you may request a review by
an external review organization (ERO). The request
must be made within 60 days of the final internal
review. A request form will be included in your final
determination letter. It can also be obtained by calling
Member Services. A decision will be rendered by the
ERO within 21 calendar days of your request. An
expedited process is available to address clinical
urgency. If you disagree with the decision regarding
your right to an external review, you may file a
complaint with the Kentucky Department of
Insurance.
Appeals
1. As a member of Aetna, you have the right to file an
appeal about service(s) you have received from your
dental care provider or Aetna, when you are not
satisfied with the outcome of the initial determination
and the request is regarding a change in the decision
for:
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Certification of health care services
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Claim Payment
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Plan interpretation
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Benefit determinations
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Eligibility
7. As a member, you may, at any time, contact your local
state agency that regulates health care service plans
for complaint and appeal issues, which Aetna has not
resolved or has not resolved to your satisfaction.
Requests may be submitted to:
2. You or your authorized representative may file an
appeal within 180 days of an initial determination.
You may contact Aetna’s Member Services Unit at the
number listed on your identification card.
3. A Customer Resolution Consultant will acknowledge
the appeal within five (5) business days of receipt. A
Customer Resolution Consultant may call you or your
dental care provider for dental records and/or other
pertinent information.
Kentucky Department of Insurance
PO Box 517
Frankfort, KY 40602-0517
8. You and your plan may have other voluntary
alternative dispute resolution options, such as
mediation. One way to find out what may be available
is to contact your Plan Administrator, your local U.S.
Department of Labor Office and your State insurance
regulatory agency.
4. Aetna’s goal is to complete the appeal process within
30 days of receipt of your appeal. An appeal file is
reviewed by an individual who was neither involved in
any prior coverage determinations related to the
appeal nor a subordinate of the person who rendered
a prior coverage determination. A dentist or other
appropriate clinical peer will review clinical appeals. A
letter of resolution will be sent to you upon
completion of the appeal. It is important to note that
it is a covered member’s right to submit new clinical
information at any time during the appeal of an
adverse determination or coverage denial to an insurer
or provider.
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Maryland
Michigan
For quality of care issues and life and health care insurance
complaints you may contact:
Contact the Michigan Department of Consumer and
Industry Services at 1-517-373-0220 to verify participating
providers’ licenses or to access information on formal
complaints and disciplinary actions filed or taken against
participating providers.
Aetna Dental Grievance and Appeals Unit
PO Box 14080
Lexington, KY 40512-4080
Telephone:1-877-238-6200
Transition Of Care When A Provider Terminates
From The Network
or
Aetna contracts are designed to provide transition of care
for covered persons should the treating participating
provider contract terminate.
Maryland Insurance Administration Life and Health
Insurance Complaints
525 Saint Paul Place
Baltimore, Maryland 21202-2272
Telephone:1-800-492-6116 (toll-free)
1. Participating providers are contractually obligated for
continued treatment of certain members after
termination for any reason as outlined below:
or
Standard Language for a Michigan Dental
Provider Agreement Regarding Continuation of
Treatment after Termination of the Agreement.
Telephone:1-410-468-2244
Facsimile:1-410-468-2243
For assistance in resolving a billing or payment dispute with
the health plan or a health care provider you may contact:
“Provider shall remain obligated at Company’s sole
discretion to provide Covered Services to: (a) any
Member receiving active treatment from Provider at
the time of termination until the course of treatment is
completed to Company’s satisfaction or the orderly
transition of such Member’s care to another provider
by the applicable Affiliate of Company; and (b) any
Member, upon request of such Member or the
applicable Payor, until the anniversary date of such
Member’s respective Plan or for one (1) calendar year,
whichever is less. The terms of this Agreement shall
apply to such services.”
Aetna Dental Grievance and Appeals Unit
PO Box 14080
Lexington, KY 40512-4080
Telephone:1-877-238-6200
or
Health Education and Advocacy Unit
Consumer Protection Division Office
of the Attorney General 16th Floor
200 Saint Paul Place Baltimore, MD
21202
Telephone:1-410-528-1840
Facsimile:1-410-576-7040
2. In cases of provider termination, in order to allow for
the transition of members with minimal disruption to
participating providers, Aetna may permit a member
who has met certain requirements to continue an
“Active Course of Treatment” for covered benefits
with a non-participating provider for a transitional
period of time without penalty subject to any out of
pocket expenses outlined in the member’s plan design.
Nothing herein shall be construed to require the plan to
pay counsel fees or any other fees or costs incurred by a
member in pursuing a complaint or appeal.
Pennsylvania
This managed care plan may not cover all of your
health care expenses. Read your contract carefully to
determine which health care services are covered. To
contact the plan if you are a member, call the
number on your ID card; all others, call
1-877-238-6200.
www.aetna.com
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Texas
Washington State
Please refer to the plan design overview and summary of
benefits contained in your pre-enrollment packet for a
brief description of the services and benefits covered under
your particular plan, as well as those services and benefits
that are excluded. After enrollment, you can refer to your
plan documents for a more complete description of your
covered services and benefits and the exclusions under
your plan. For information on whether a specific service is
covered or excluded, please contact Member Services at
the toll-free number on your ID card.
The following materials are available: any documents
referred to in the enrollment agreement; any applicable
preauthorization procedures; dentist compensation
arrangements and descriptions of and justification for
provider compensation programs; circumstances under
which the plan may retrospectively deny coverage
previously authorized. *
Virginia
Important Information Regarding Your Insurance
In the event you need to contact someone about this
insurance for any reason please contact your agent. If no
agent was involved in the sale of this insurance, or if you
have additional questions you may contact the insurance
company issuing this insurance at the following address
and telephone number.
Aetna Life Insurance Company
PO Box 14597
Lexington, KY 40512-4597
Telephone:1-877-238-6200
If you have been unable to contact or obtain satisfaction
from the company or the agent, you may contact the
Virginia State Corporation Commission’s Bureau of
Insurance at:
Life and Health Division
Bureau of Insurance
P.O. Box 1157
Richmond, VA 23218
Telephone: 1-804-371-9691
Fax:1-804-371-9944
Written correspondence is preferable so that a record of
your inquiry is maintained. When contacting your agent,
company or the Bureau of Insurance, have your policy
number available.
Aetna Life Insurance Company is regulated as a Managed
Care Health Insurance Plan (MCHIP) and as such, is subject
to regulation by both the Virginia State Corporation
Commission Bureau of Insurance and the Virginia
Department of Health.
*This is a state mandate, which may apply to employer-funded plans
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Notes
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Notice to Members
This material is for informational purposes only and is
neither an offer of coverage nor dental advice. It contains
only a partial, general description of plan benefits or
programs and does not constitute a contract. Aetna does
not provide dental services and, therefore, cannot
guarantee any results or outcomes. Consult the plan
[Schedule of Benefits, Certificate of Coverage, Group
Agreement] to determine governing contractual provisions,
including procedures, exclusions and limitations relating to
your plan.
The availability of a plan or program may vary by
geographic service area. Some benefits are subject to
limitations or visit maximums. Participating dentists and
other providers are independent contractors in private
practice and are neither employees nor agents of Aetna.
The availability of any particular provider cannot be
guaranteed, and provider network composition is subject
to change. Notice of the change shall be provided in
accordance with applicable state law.
Aetna is the brand name used for products and services
provided by one or more of the Aetna group of subsidiary
companies. The Aetna company that underwrites benefits
coverage is Aetna Life Insurance Company. For self-funded
accounts, plan coverage is offered by your employer, with
administrative services only provided by Aetna Life
Insurance Company.
Note that the Exclusive Provider Plan (EPP), the PPO
MAX/PDN MAX plan and the Aetna
HealthFund®/Aetna DentalFund® products operate
differently than the PPO/PDN plan. Check your plan
documents for specifics about how these plans work.
This disclosure information does not apply to these
plans/products.
If you need this material translated into another language, please call Member Services at 1-877-238-6200.
Si usted necesita este documento en otro idioma, por favor llame a Servicios al Miembro al 1-877-238-6200.
www.aetna.com
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