State Specific Processes

Important information for members who reside in a state other than New York
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California 

• CA DMO Dental Grievance Form  (PDF)
• California HMO Grievance Form - California residents can use this electronic form to file an HMO grievance, appeal or complaint. Printable versions (in PDF format) of this grievance form are available in:
  
  • English  (PDF)
    
• A one-page printable document with information about member rights and responsibilities, as well as complaint and appeal procedures, is available:
  • English  (PDF)
  • Spanish  (PDF)
  
  
• California HMO Transition of Care Coverage Policy:
  • English  (PDF)
  • Spanish  (PDF)

Connecticut

• Connecticut External Appeal Consumer Guide
• Right to Appeal: For your information, you have the right to appeal to the Connecticut Insurance Commissioner after you have exhausted all appeals provided by Aetna. Your appeal to the Insurance Commissioner would have to be filed within 30 days of your having received notice of a final determination from Aetna. The Insurance Commissioner's address is P.O. Box 816, Hartford, CT 06142, and the telephone number is (860) 297-3910.

New Jersey  

• Extension of Benefits - A subscriber or dependent may be eligible for continued coverage under the Aetna benefits plan if the subscriber's plan would otherwise terminate but the plan includes a provision for continued coverage for total disability and the subscriber or dependent initiates a request for continued coverage by contacting Aetna Member Services.

  The individual who is totally disabled must meet the extension eligibility requirements on the date that coverage would otherwise end.

  If the request for continued coverage is approved, the continued coverage applies only to the individual who is disabled and not to other family members. In addition, the terms of coverage at the time of the approved extension remain in effect and the continued coverage would be subject to all plan provisions and limitations.

  The following forms must be completed and submitted to Aetna Member Services for consideration. Contact Aetna Member Services using the phone number listed on back of the Aetna Member ID card to obtain the mailing address.

  • Request for Continued Coverage due to Extension of Benefits for Total Disability Form  (PDF) - requires an attending physician statement from the treating practitioner(s) supporting the request.
  • Handicapped Child Attending Physician's Statement/Behavioral Health Attending Physician's Statement  (PDF) for behavioral health conditions (all ages) and medical conditions for dependents age 18 and younger.
  • Adult Medical Attending Physician Statement  (PDF) for medical conditions for subscribers and dependents over the age of 18.
  
  
• Present on Admission Indicator Code
  Effective 10/1/2008, Present on Admission (POA) indicator codes will be required for determining appropriate DRG (Diagnosis Related Grouping) assignment and thus pricing. The code is required for both Commercial and Medicare lines of business. A POA code is a code used to indicate if the corresponding diagnosis was present at the time of admission. A POA code is required for all primary and secondary diagnosis codes; however a POA code is not needed for the admitting diagnosis code. Refer to the below for a list of POA indicator codes.
  
  Value in the POA - Field Meaning
  Y - Diagnosis was present at the time of inpatient admission.
  
  N - Diagnosis was not present at the time of the inpatient admission.
  
  U - Documentation insufficient to determine if condition was present at the time of inpatient admission.
  
  W - Clinically undetermined. Provider unable to clinically determine whether the condition was present at the time of the inpatient admission.
  
  1 or Spaces Unreported/not used - Exempt from POA reporting.

New York 

• Important Notice Concerning New York Disability Claims and Pre-existing Conditions