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Submitted URL: https://click.e.myplanportal.com/u/?qs=607398ad79f78a1dc8ab7629ddb51de8097a5a2e5a658b4dc2d7ede5bf6a882d795bd65c16fd317244048ae4a6...
Effective URL: https://www.aetna.com/individuals-families/member-rights-resources/rights/disclosure-information.html?cid=eml-m-104449...
Submission: On January 03 via api from US — Scanned from DE
Effective URL: https://www.aetna.com/individuals-families/member-rights-resources/rights/disclosure-information.html?cid=eml-m-104449...
Submission: On January 03 via api from US — Scanned from DE
Form analysis 6 forms found in the DOM
/search-results.html
<form class="searchform--desktop searchformdesktop" action="/search-results.html">
<div class="megamenu__nav--search">
<label for="globalSearch" class="nav__search--text">Search</label>
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<input type="text" name="query" class="nav__search--input" id="globalSearch" placeholder="Search">
<input type="hidden" name="offset" value="0">
<button class="nav__close--icon clear-input" aria-label="clear search"></button>
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</form>/search-results.html
<form class="searchform--desktop searchformmobile" action="/search-results.html">
<div class="megamenu__nav--search">
<label for="mobileSearch" class="nav__search--text">Search</label>
<button class="nav__search--icon" aria-label="search"></button>
<input type="text" name="query" class="nav__search--input" id="mobileSearch" placeholder="Search">
<input type="hidden" name="offset" value="0">
<button class="nav__close--icon clear-input" aria-label="clear search"></button>
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</form>POST
<form class="formstyle--fullbox generic-aet-form container section " novalidate="novalidate" method="POST" data-aeth-script="form" aria-live="polite" data-use-paginationtext="Step {0} of {1}" data-loaded="true">
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<div class="errorSummary hidden" aria-hidden="true">
<div class="summaryTitle">
<span tabindex="-1" class="errorMsg"><strong>Error or missing data. Please check your entries for an error message.</strong></span>
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<div class="px-0 xmlfiltercontainer generic-aet-form " data-aeth-script="xmlComponent" data-xmlfile="/content/aetna/en/individuals-families/member-rights-resources/rights/xml/ivl-plan-disclosures.xml" data-loaded="true">
<!-- Loading spiner -->
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<div class="loading-wrapper">
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<h4 class="loading-text">Loading, please wait</h4>
<div class="loading-spinner-cont">
<div class="loading-spinner">
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<div></div>
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<option value="Illinois">Illinois</option>
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<div class="row">
<div class="form__wrapper col-sm-12 col-lg-6 offset-lg-3 ">
<!-- PAYFLEX ERROR SUMMARY -->
<div class="errorSummary hidden" aria-hidden="true">
<div class="summaryTitle">
<span tabindex="-1" class="errorMsg"><strong>Error or missing data. Please check your entries for an error message.</strong></span>
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<div class="form-body">
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<!-- Loading spiner -->
<div class="loading-msg-cont" style="display: none;">
<div class="loading-wrapper">
<div class="loading-msg">
<h4 class="loading-text">Loading, please wait</h4>
<div class="loading-spinner-cont">
<div class="loading-spinner">
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<select name="state" id="content_section_responsivegrid_40355_responsivegrid_inline_cta_1809651787_formcontainer_formpar_xmlfilter_copy_copy__filtergroup-state" class="selectItem customSelect xmlcontentfilter_state">
<option value="">Select</option>
<option value="Alabama">Alabama</option>
<option value="Alaska">Alaska</option>
<option value="Arizona">Arizona</option>
<option value="Arkansas">Arkansas</option>
<option value="California">California</option>
<option value="Colorado">Colorado</option>
<option value="Connecticut">Connecticut</option>
<option value="Delaware">Delaware</option>
<option value="District of Columbia">District of Columbia</option>
<option value="Florida">Florida</option>
<option value="Georgia">Georgia</option>
<option value="Hawaii">Hawaii</option>
<option value="Idaho">Idaho</option>
<option value="Illinois">Illinois</option>
<option value="Indiana">Indiana</option>
<option value="Iowa">Iowa</option>
<option value="Kansas">Kansas</option>
<option value="Kentucky">Kentucky</option>
<option value="Louisiana">Louisiana</option>
<option value="Maine">Maine</option>
<option value="Maryland">Maryland</option>
<option value="Massachusetts">Massachusetts</option>
<option value="Michigan">Michigan</option>
<option value="Minnesota">Minnesota</option>
<option value="Mississippi">Mississippi</option>
<option value="Missouri">Missouri</option>
<option value="Montana">Montana</option>
<option value="Nebraska">Nebraska</option>
<option value="Nevada">Nevada</option>
<option value="New Hampshire">New Hampshire</option>
<option value="New Jersey">New Jersey</option>
<option value="New York">New York</option>
<option value="North Carolina">North Carolina</option>
<option value="North Dakota">North Dakota</option>
<option value="Ohio">Ohio</option>
<option value="Oklahoma">Oklahoma</option>
<option value="Oregon">Oregon</option>
<option value="Pennsylvania">Pennsylvania</option>
<option value="Rhode Island">Rhode Island</option>
<option value="South Carolina">South Carolina</option>
<option value="South Dakota">South Dakota</option>
<option value="Tennessee">Tennessee</option>
<option value="Texas">Texas</option>
<option value="Utah">Utah</option>
<option value="Vermont">Vermont</option>
<option value="Virginia">Virginia</option>
<option value="Washington">Washington</option>
<option value="West Virginia">West Virginia</option>
<option value="Wisconsin">Wisconsin</option>
<option value="Wyoming">Wyoming</option>
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</div>
</div>
<div class="comboCont forminput generic-form-input ">
<div class="forminput__wrap">
<label for="content_section_responsivegrid_40355_responsivegrid_inline_cta_1809651787_formcontainer_formpar_xmlfilter_copy_copy__filtergroup-product"><span class="forminput__label">Product</span></label>
<select name="product" id="content_section_responsivegrid_40355_responsivegrid_inline_cta_1809651787_formcontainer_formpar_xmlfilter_copy_copy__filtergroup-product" class="selectItem customSelect xmlcontentfilter_state">
<option value="">Select</option>
</select>
</div>
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</div>
<!-- Results container -->
<div class="xmlfilter__resultcontainer block--hidden responsive-input ">
<div role="region" aria-live="polite" class="resultsFromXml">
<div class="xmlContentFilterResults">
<div class="descriptionResult">
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</form>POST
<form class="formstyle--fullbox generic-aet-form no__container section " data-form-name="transparency-disclosure" novalidate="novalidate" method="POST" data-aeth-script="form" aria-live="polite" data-use-paginationtext="Step {0} of {1}"
data-loaded="true">
<div class="row">
<div class="form__wrapper col-sm-12 ">
<!-- PAYFLEX ERROR SUMMARY -->
<div class="errorSummary hidden" aria-hidden="true">
<div class="summaryTitle">
<span tabindex="-1" class="errorMsg"><strong>Error or missing data. Please check your entries for an error message.</strong></span>
</div>
</div>
<div class="form-body">
<div class="aem-Grid aem-Grid--12 aem-Grid--default--12 aem-Grid--md--12 aem-Grid--xs--12 ">
<div
class="xmlfilter aem-GridColumn--offset--xs--0 aem-GridColumn aem-GridColumn--default--newline aem-GridColumn--xs--none aem-GridColumn--offset--md--0 aem-GridColumn--default--12 aem-GridColumn--offset--default--0 aem-GridColumn--xs--12 aem-GridColumn--md--none aem-GridColumn--md--12">
<div class="px-0 xmlfiltercontainer generic-aet-form " data-aeth-script="xmlComponent" data-xmlfile="/content/aetna/en/individuals-families/member-rights-resources/rights/xml/transparency-disclosures.xml" data-loaded="true">
<!-- Loading spiner -->
<div class="loading-msg-cont" style="display: none;">
<div class="loading-wrapper">
<div class="loading-msg">
<h4 class="loading-text">Loading, please wait</h4>
<div class="loading-spinner-cont">
<div class="loading-spinner">
<div></div>
<div></div>
<div></div>
<div></div>
<div></div>
<div></div>
<div></div>
<div></div>
<div></div>
<div></div>
<div></div>
<div></div>
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</div>
</div>
</div>
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<div class="row">
<div class="col-sm-12 xmlfilter__parentcontainer se-results">
<!-- Title -->
<!-- Dropdowns -->
<div>
<div class="filter__container " data-resulttype="pdflink" data-opennewtab="true" data-resulttextfield="file-name" data-resultlinkfield="url" data-resulttablelinks="[]" data-resulttableheadings="," data-resultsortby="file-name">
<div class="comboCont forminput generic-form-input ">
<div class="forminput__wrap">
<label for="content_section_responsivegrid_40355_responsivegrid_formcontainer_copy_formpar_xmlfilter_copy_19606_filtergroup-file-name"><span class="forminput__label">Disclosures</span></label>
<select name="file-name" id="content_section_responsivegrid_40355_responsivegrid_formcontainer_copy_formpar_xmlfilter_copy_19606_filtergroup-file-name" class="selectItem customSelect xmlcontentfilter_state">
<option value="">Select a plan type</option>
<option value="Aetna Student Health | Machine readable files">Aetna Student Health | Machine readable files</option>
<option value="Fully Insured plans | Machine readable files">Fully Insured plans | Machine readable files</option>
<option value="Individual ACA plans | Machine readable files">Individual ACA plans | Machine readable files</option>
<option value="Small Group AFA | Machine readable files">Small Group AFA | Machine readable files</option>
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<div class="xmlfilter__resultcontainer block--hidden responsive-input ">
<div role="region" aria-live="polite" class="resultsFromXml">
<div class="xmlContentFilterResults">
<div class="descriptionResult">
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</form>POST /aem-services/api/gatewayservice/post
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data-thankyoupage="https://www.aetna.com/individuals-families/using-your-aetna-benefits/aetna-mobile/health-app/thank-you-aetna-app.html" action="/aem-services/api/gatewayservice/post" data-sfmc-connection="true"
data-use-paginationtext="Step {0} of {1}" data-loaded="true">
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<div class="form__wrapper col-sm-12 col-lg-6 offset-lg-3 ">
<!-- PAYFLEX ERROR SUMMARY -->
<div class="errorSummary hidden" aria-hidden="true">
<div class="summaryTitle">
<span tabindex="-1" class="errorMsg"><strong>Error or missing data. Please check your entries for an error message.</strong></span>
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<div class="form-body">
<div class="aem-Grid aem-Grid--12 aem-Grid--default--12 aem-Grid--xs--12 ">
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<div class="hiddenfield aem-GridColumn--default--9 aem-GridColumn aem-GridColumn--default--newline aem-GridColumn--offset--default--0"><input type="hidden" name="resubscribe" value="true">
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<div class="hiddenfield aem-GridColumn--default--9 aem-GridColumn aem-GridColumn--default--newline aem-GridColumn--offset--default--0"><input type="hidden" name="keyword" value="NUMBER">
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<div class="hiddenfield aem-GridColumn--default--9 aem-GridColumn aem-GridColumn--default--newline aem-GridColumn--offset--default--0"><input type="hidden" name="sfmcAction" value="/sms/v1/messageContact/MTMwNzo3ODow/send">
</div>
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<input type="submit" value="Send me a text" class="btn btn--primary">
</div>
</div>
</form>Text Content
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Fed No Surprises Act
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* The health guide
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* Frequently asked questions
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Fed No Surprises Act
Read about your rights and protections against surprise medical bills.
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* Find a doctor
* Find a medication
* Explore Aetna sites
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EXPLORE PLANS
* Medicare
* Health coverage
* Dental, vision and supplemental
* Pharmacy
* Medicaid
*
MEMBER SUPPORT
* Account management
* The health guide
* Additional resources
*
* EXPLORE AETNA SITES
* Individuals & Families
* Affordable Care Act
* Medicare
* Medicaid
* Providers
* Employers
* Agents & Brokers
* Partners
* Careers
* About Us
MEDICARE
* Browse Aetna Medicare plans
* Find a doctor
* Check our drug list
* Understand Medicare
* Find a plan to meet your needs
* Enroll in Medicare
HEALTH COVERAGE
* ACA individual and family health plans
* Health plans through an employer
* Options without employer coverage
* Student plans
* International plans
DENTAL, VISION AND SUPPLEMENTAL
* Dental plans
* Find a dentist
* Vision plans
* Find an eye doctor
* Supplemental plans
PHARMACY
* Get pharmacy plan information
* Find a pharmacy
MEDICAID
* Medicaid plans
* Find a doctor
ACCOUNT MANAGEMENT
* Log in to your member website
* Find a form
* Get your ID card opens in secure site
* Check a claim opens in secure site
* View coverage opens in secure site
THE HEALTH GUIDE
* All health resources
* Living healthy
* Understanding health care
* Managing health
ADDITIONAL RESOURCES
* Mental health
* Women's health
* Health insurance rights and resources
* Contact us
* Frequently asked questions
* Prior authorization guidelines
IMPORTANT DISCLOSURE INFORMATION
This information can help you understand what your plan covers, the costs of and
rules for using your plan, how to file a grievance and more.
WE MEET QUALITY STANDARDS
WE MEET QUALITY STANDARDS
We follow health plan accreditation standards of the National Committee for
Quality Assurance (NCQA) to offer you quality health plans. Learn how we meet
those standards — plus how you can get plan details online or by phone, find
out about your rights and responsibilities, understand plan costs and more.
Read More Read Less
* Meeting NCQA standards – English (PDF)
* Meeting NCQA standards – Spanish (PDF)
CONSUMER DISCLOSURES FOR HEALTH, DENTAL AND VISION PLANS
INDIVIDUAL & FAMILY PLANS
In certain states we offer health plans for you and your family. Just select a
state to find documents that describe these plans, along with state-specific
disclosure requirements to help you determine the right coverage.
Dental — a stand-alone plan for individuals
Individual dental disclosure (PDF)
Health plans
Error or missing data. Please check your entries for an error message.
LOADING, PLEASE WAIT
State Select CaliforniaDelawareFloridaGeorgiaIllinoisMissouriNevadaNew
JerseyNorth CarolinaTexasVirginia
GROUP PLANS
We also offer group health, dental and vision plans (available through an
employer). Just select a state to find documents that describe these plans,
along with state-specific disclosure requirements to help you determine the
right coverage.
Error or missing data. Please check your entries for an error message.
LOADING, PLEASE WAIT
State Select
AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of
ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew
HampshireNew JerseyNew YorkNorth CarolinaNorth
DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth
DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
Product Select
Beginning January 1, 2022, covered dental services provided to Texas members
through Teledentistry by a licensed health professional, will be covered the
same as if the services were performed in an in-person setting.
TRANSPARENCY IN COVERAGE
Error or missing data. Please check your entries for an error message.
LOADING, PLEASE WAIT
Disclosures Select a plan type Aetna Student Health | Machine readable
filesFully Insured plans | Machine readable filesIndividual ACA plans | Machine
readable filesSmall Group AFA | Machine readable files
DIRECT BROKER COMMISSIONS SCHEDULE FOR INDIVIDUAL & FAMILY PLANS
State
Amount per enrolled member per month*
California
$20
Florida
$28
Georgia
$25
Illinois
$25
Missouri
$20
North Carolina
$25
Nevada
$25
New Jersey
$20
Texas
$25
Virginia
$20
State
California
Amount per enrolled member per month*
$20
State
Florida
Amount per enrolled member per month*
$28
State
Georgia
Amount per enrolled member per month*
$25
State
Illinois
Amount per enrolled member per month*
$25
State
Missouri
Amount per enrolled member per month*
$20
State
North Carolina
Amount per enrolled member per month*
$25
State
Nevada
Amount per enrolled member per month*
$25
State
New Jersey
Amount per enrolled member per month*
$20
State
Texas
Amount per enrolled member per month*
$25
State
Virginia
Amount per enrolled member per month*
$20
*Commissions are payable to a maximum of five members per policy.
BROKER BONUS PROGRAM FOR INDIVIDUAL & FAMILY PLANS
In addition to direct commissions, your broker may also be eligible for a bonus
program. It’s a one-time bonus for new members enrolled with 2023 effective
dates according to the schedule below. Note: The broker bonus program applies
only to policies sold in these states for the 2023 calendar year. Certain other
conditions apply.
FLORIDA, NORTH CAROLINA AND TEXAS**
New enrolled members
(by state and quarter)
Earned credit per new enrolled member
0-24 members
N/A
25-49 members
$25
50-149 members
$50
150+ members
$75
New enrolled members
(by state and quarter)
0-24 members
Earned credit per new enrolled member
N/A
New enrolled members
(by state and quarter)
25-49 members
Earned credit per new enrolled member
$25
New enrolled members
(by state and quarter)
50-149 members
Earned credit per new enrolled member
$50
New enrolled members
(by state and quarter)
150+ members
Earned credit per new enrolled member
$75
**Excludes Buncombe county in North Carolina and Bexar and El Paso counties in
Texas.
ARIZONA, DELAWARE, GEORGIA, ILLINOIS, MISSOURI, NEW JERSEY, NEVADA AND VIRGINIA
New enrolled members
(by state and quarter)
Earned credit per new enrolled member
0-14 members
N/A
15-29 members
$25
30-59 members
$50
60+ members
$75
New enrolled members
(by state and quarter)
0-14 members
Earned credit per new enrolled member
N/A
New enrolled members
(by state and quarter)
15-29 members
Earned credit per new enrolled member
$25
New enrolled members
(by state and quarter)
30-59 members
Earned credit per new enrolled member
$50
New enrolled members
(by state and quarter)
60+ members
Earned credit per new enrolled member
$75
WOMEN’S HEALTH AND CANCER RIGHTS ACT (WHCRA)
WOMEN’S HEALTH AND CANCER RIGHTS ACT (WHCRA)
If you have had or are going to have a mastectomy, you may be entitled to
certain benefits under the WHCRA of 1998. We’ll determine what your coverage
will be based on our consultations with you and the attending physician
regarding:
* All stages of reconstruction of the breast on which the mastectomy was
performed
* Surgery and reconstruction of the other breast to produce a symmetrical
appearance
* Prosthesis
* Treatment of physical complications of the mastectomy, including lymphedema
You’ll also receive benefits if you’ve had a mastectomy as a result of breast
cancer while covered under a different health plan. Your coverage is provided in
accordance with your plan design and is subject to plan limitations, copays,
deductibles, coinsurance and referral requirements, if any, as noted in your
plan documents.
For more information, contact Member Services at the number on your ID card. You
can also find resources from the Centers for Medicare & Medicaid Services and
the National Institutes of Health.
* Women's Health and Cancer Rights Act
* Breast Reconstruction After Mastectomy
ADDITIONAL RESOURCES
Brush up on benefits details and your rights as a health care consumer so you
can make the right decisions about your care.
RIGHTS AND RESPONSIBILITIES
Understand your rights as an Aetna HMO or PPO member.
Your rights
STATE-SPECIFIC INFORMATION
Find health plan policies and guidelines for various states.
State details
LOSING GROUP COVERAGE
Explore your options if you’ve lost your group coverage.
Coverage choices
SPENDING ACCOUNT GUIDELINES
Learn about IRS rules for different flexible spending accounts (FSAs).
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CHANGING YOUR COVERAGE
Get guidance for changing your health plan as your life changes.
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FEDERAL NO SURPRISES ACT
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Surprise billing resources
LEGAL NOTICES
Note about employer-funded plans: State mandates do not apply to self-funded
plans governed by ERISA. If you are unsure if you’re plan is self-funded and/or
governed by ERISA, please confer with your benefits administrator. Specific plan
documents supersede general disclosures contained within, as applicable.
Managed plans offered by HMO entities are: Aetna Health Network OnlyTM, Aetna
Primary CareSM Plan HMO, Aetna Health Network OptionSM, Aetna Open Access® HMO,
Aetna Choice® POS and QPOS®.
Managed plans offered by Aetna Life Insurance Company are: Managed Choice® POS,
Aetna Choice® Plan POS, Aetna Open Access® Managed Choice, Open Choice® PPO,
Aetna Choice® Plans PPO, Aetna Open Access® Elect Choice, Aetna Choice® POS,
Aetna SelectSM and Open Access Aetna SelectSM.
Dental plans are offered, underwritten or administered by: Aetna Health Inc.,
Aetna Health of California Inc., Aetna Health Insurance Company of New York,
Aetna Health Insurance Company, Aetna Life Insurance Company (Aetna), Aetna
Dental Inc. and/or Aetna Dental of California Inc.
Policy forms issued in OK include: GR-/GR-9N, GR-29/GR-29N-29N.
See all legal notices
Also of interest:
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APPLIED BEHAVIOR ANALYSIS MEDICAL NECESSITY GUIDE
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The Applied Behavior Analysis (ABA) Medical Necessity Guide helps determine
appropriate (medically necessary) levels and types of care for patients in need
of evaluation and treatment for behavioral health conditions. The ABA Medical
Necessity Guide does not constitute medical advice. Treating providers are
solely responsible for medical advice and treatment of members. Members should
discuss any matters related to their coverage or condition with their treating
provider.
Each benefit plan defines which services are covered, which are excluded, and
which are subject to dollar caps or other limits. Members and their providers
will need to consult the member's benefit plan to determine if there are any
exclusions or other benefit limitations applicable to this service or supply.
The conclusion that a particular service or supply is medically necessary does
not constitute a representation or warranty that this service or supply is
covered (i.e., will be paid for by Aetna) for a particular member. The member's
benefit plan determines coverage. Some plans exclude coverage for services or
supplies that Aetna considers medically necessary.
Please note also that the ABA Medical Necessity Guide may be updated and are,
therefore, subject to change.
Medical necessity determinations in connection with coverage decisions are made
on a case-by-case basis. In the event that a member disagrees with a coverage
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an independent external appeal in accordance with applicable federal or state
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ASAM TERMS AND CONDITIONS
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Licensee's use and interpretation of the American Society of Addiction
Medicine’s ASAM Criteria for Addictive, Substance-Related, and Co-Occurring
Conditions does not imply that the American Society of Addiction Medicine has
either participated in or concurs with the disposition of a claim for benefits.
This excerpt is provided for use in connection with the review of a claim for
benefits and may not be reproduced or used for any other purpose.
Copyright 2015 by the American Society of Addiction Medicine. Reprinted with
permission. No third party may copy this document in whole or in part in any
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PRECERTIFICATION LISTS
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your agreement and acceptance by selecting the button below labeled "I Accept".
* The term precertification here means the utilization review process to
determine whether the requested service, procedure, prescription drug or
medical device meets the company's clinical criteria for coverage. It does
not mean precertification as defined by Texas law, as a reliable
representation of payment of care or services to fully insured HMO and PPO
members.
* Applies to: Aetna Choice® POS, Aetna Choice POS II, Aetna Medicare℠ Plan
(PPO), Aetna Medicare Plan (HMO), all Aetna HealthFund® products, Aetna
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Access Aetna Select℠, Elect Choice, HMO, Managed Choice POS, Open Choice®,
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* All services deemed "never effective" are excluded from coverage. Aetna
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professional standards of safety and effectiveness in the United States for
diagnosis, care or treatment. Visit the secure website, available through
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Tool," "Clinical Policy Code Search."
* The five character codes included in the Aetna Precertification Code Search
Tool are obtained from Current Procedural Terminology (CPT®), copyright 2022
by the American Medical Association (AMA). CPT is developed by the AMA as a
listing of descriptive terms and five character identifying codes and
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unit values, relative value guides, conversion factors or scales are included
in any part of CPT. Any use of CPT outside of Aetna Precertification Code
Search Tool should refer to the most Current Procedural Terminology which
contains the complete and most current listing of CPT codes and descriptive
terms. Applicable FARS/DFARS apply.
LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ("CPT®")
* CPT only Copyright 2022 American Medical Association. All Rights Reserved.
CPT is a registered trademark of the American Medical Association. You, your
employees and agents are authorized to use CPT only as contained in Aetna
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You acknowledge that AMA holds all copyright, trademark and other rights in
CPT. Any use not authorized herein is prohibited, including by way of
illustration and not by way of limitation, making copies of CPT for resale
and/or license, transferring copies of CPT to any party not bound by this
agreement, creating any modified or derivative work of CPT, or making any
commercial use of CPT. License to sue CPT for any use not authorized herein
must be obtained through the American Medical Association, CPT Intellectual
Property Services, 515 N. State Street, Chicago, Illinois 60610. Applications
are available at the American Medical Association Web site,
www.ama-assn.org/go/cpt.
U.S. Government Rights
* This product includes CPT which is commercial technical data and/or computer
data bases and/or commercial computer software and/or commercial computer
software documentation, as applicable which were developed exclusively at
private expense by the American Medical Association, 515 North State Street,
Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce,
release, perform, display, or disclose these technical data and/or computer
data bases and/or computer software and/or computer software documentation
are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2)
(June 1995) and/or subject to the restrictions of DFARS 227.7202-1(a) (June
1995) and DFARS 227.7202-3(a) (June 1995), as applicable for U.S. Department
of Defense procurements and the limited rights restrictions of FAR 52.227-14
(June 1987) and/or subject to the restricted rights provisions of FAR
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* CPT is provided "as is" without warranty of any kind, either expressed or
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merchantability and fitness for a particular purpose. No fee schedules, basic
unit, relative values or related listings are included in CPT. The American
Medical Association (AMA) does not directly or indirectly practice medicine
or dispense medical services. The responsibility for the content of this
product is with Aetna, Inc. and no endorsement by the AMA is intended or
implied. The AMA disclaims responsibility for any consequences or liability
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* This Agreement will terminate upon notice if you violate its terms. The AMA
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Accept".
* The information contained on this website and the products outlined here may
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Arizona residents, members, employers and brokers must contact Aetna directly
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* This information is neither an offer of coverage nor medical advice. It is
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constitute a contract. In case of a conflict between your plan documents and
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DENTAL CLINICAL POLICY BULLETINS
By clicking on “I accept”, I acknowledge and accept that:
* Aetna Dental Clinical Policy Bulletins (DCPBs) are developed to assist in
administering plan benefits and do not constitute dental advice. Treating
providers are solely responsible for dental advice and treatment of members.
Members should discuss any Dental Clinical Policy Bulletin (DCPB) related to
their coverage or condition with their treating provider.
* While the Dental Clinical Policy Bulletins (DCPBs) are developed to assist in
administering plan benefits, they do not constitute a description of plan
benefits. The Dental Clinical Policy Bulletins (DCPBs) describe Aetna's
current determinations of whether certain services or supplies are medically
necessary, based upon a review of available clinical information. Each
benefit plan defines which services are covered, which are excluded, and
which are subject to dollar caps or other limits. Members and their providers
will need to consult the member's benefit plan to determine if there are any
exclusions or other benefit limitations applicable to this service or supply.
Aetna's conclusion that a particular service or supply is medically necessary
does not constitute a representation or warranty that this service or supply
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coverage. Some plans exclude coverage for services or supplies that Aetna
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and a member's plan of benefits, the benefits plan will govern. In addition,
coverage may be mandated by applicable legal requirements of a State or the
Federal government.
* Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly
updated and are therefore subject to change.
* Since Dental Clinical Policy Bulletins (DCPBs) can be highly technical and
are designed to be used by our professional staff in making clinical
determinations in connection with coverage decisions, members should review
these Bulletins with their providers so they may fully understand our
policies.
* Under certain plans, if more than one service can be used to treat a covered
person's dental condition, Aetna may decide to authorize coverage only for a
less costly covered service provided that certain terms are met.
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* Aetna Clinical Policy Bulletins (CPBs) are developed to assist in
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Members should discuss any Clinical Policy Bulletin (CPB) related to their
coverage or condition with their treating provider.
* While the Clinical Policy Bulletins (CPBs) are developed to assist in
administering plan benefits, they do not constitute a description of plan
benefits. The Clinical Policy Bulletins (CPBs) express Aetna's determination
of whether certain services or supplies are medically necessary, experimental
and investigational, or cosmetic. Aetna has reached these conclusions based
upon a review of currently available clinical information (including clinical
outcome studies in the peer-reviewed published medical literature, regulatory
status of the technology, evidence-based guidelines of public health and
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relevant clinical areas, and other relevant factors).
* Aetna makes no representations and accepts no liability with respect to the
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a specific provider, product, process or service by name, trademark,
manufacturer, constitute Aetna's opinion and are made without any intent to
defame. Aetna expressly reserves the right to revise these conclusions as
clinical information changes, and welcomes further relevant information
including correction of any factual error.
* CPBs include references to standard HIPAA compliant code sets to assist with
search functions and to facilitate billing and payment for covered services.
New and revised codes are added to the CPBs as they are updated. When
billing, you must use the most appropriate code as of the effective date of
the submission. Unlisted, unspecified and nonspecific codes should be
avoided.
* Each benefit plan defines which services are covered, which are excluded, and
which are subject to dollar caps or other limits. Members and their providers
will need to consult the member's benefit plan to determine if there are any
exclusions or other benefit limitations applicable to this service or supply.
The conclusion that a particular service or supply is medically necessary
does not constitute a representation or warranty that this service or supply
is covered (i.e., will be paid for by Aetna) for a particular member. The
member's benefit plan determines coverage. Some plans exclude coverage for
services or supplies that Aetna considers medically necessary. If there is a
discrepancy between a Clinical Policy Bulletin (CPB) and a member's plan of
benefits, the benefits plan will govern.
* In addition, coverage may be mandated by applicable legal requirements of a
State, the Federal government or CMS for Medicare and Medicaid members.
See CMS's Medicare Coverage Center
* Please note also that Clinical Policy Bulletins (CPBs) are regularly updated
and are therefore subject to change.
* Since Clinical Policy Bulletins (CPBs) can be highly technical and are
designed to be used by our professional staff in making clinical
determinations in connection with coverage decisions, members should review
these Bulletins with their providers so they may fully understand our
policies.
* While Clinical Policy Bulletins (CPBs) define Aetna's clinical policy,
medical necessity determinations in connection with coverage decisions are
made on a case by case basis. In the event that a member disagrees with a
coverage determination, Aetna provides its members with the right to appeal
the decision. In addition, a member may have an opportunity for an
independent external review of coverage denials based on medical necessity or
regarding the experimental and investigational status when the service or
supply in question for which the member is financially responsible is $500 or
greater. However, applicable state mandates will take precedence with respect
to fully insured plans and self-funded non-ERISA (e.g., government, school
boards, church) plans.
See Aetna's External Review Program
* The five character codes included in the Aetna Clinical Policy Bulletins
(CPBs) are obtained from Current Procedural Terminology (CPT®), copyright
2015 by the American Medical Association (AMA). CPT is developed by the AMA
as a listing of descriptive terms and five character identifying codes and
modifiers for reporting medical services and procedures performed by
physicians.
* The responsibility for the content of Aetna Clinical Policy Bulletins (CPBs)
is with Aetna and no endorsement by the AMA is intended or should be implied.
The AMA disclaims responsibility for any consequences or liability
attributable or related to any use, nonuse or interpretation of information
contained in Aetna Clinical Policy Bulletins (CPBs). No fee schedules, basic
unit values, relative value guides, conversion factors or scales are included
in any part of CPT. Any use of CPT outside of Aetna Clinical Policy Bulletins
(CPBs) should refer to the most current Current Procedural Terminology which
contains the complete and most current listing of CPT codes and descriptive
terms. Applicable FARS/DFARS apply.
LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ("CPT®")
CPT only copyright 2015 American Medical Association. All Rights Reserved. CPT
is a registered trademark of the American Medical Association.
You, your employees and agents are authorized to use CPT only as contained in
Aetna Clinical Policy Bulletins (CPBs) solely for your own personal use in
directly participating in healthcare programs administered by Aetna, Inc. You
acknowledge that AMA holds all copyright, trademark and other rights in CPT.
Any use not authorized herein is prohibited, including by way of illustration
and not by way of limitation, making copies of CPT for resale and/or license,
transferring copies of CPT to any party not bound by this agreement, creating
any modified or derivative work of CPT, or making any commercial use of CPT.
License to use CPT for any use not authorized herein must be obtained through
the American Medical Association, CPT Intellectual Property Services, 515 N.
State Street, Chicago, Illinois 60610. Applications are available at the
American Medical Association Web site, www.ama-assn.org/go/cpt.
Go to the American Medical Association Web site
U.S. Government Rights
This product includes CPT which is commercial technical data and/or computer
data bases and/or commercial computer software and/or commercial computer
software documentation, as applicable which were developed exclusively at
private expense by the American Medical Association, 515 North State Street,
Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce,
release, perform, display, or disclose these technical data and/or computer data
bases and/or computer software and/or computer software documentation are
subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (June
1995) and/or subject to the restrictions of DFARS 227.7202-1(a) (June 1995) and
DFARS 227.7202-3(a) (June 1995), as applicable for U.S. Department of Defense
procurements and the limited rights restrictions of FAR 52.227-14 (June 1987)
and/or subject to the restricted rights provisions of FAR 52.227-14 (June 1987)
and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR
Supplements, for non-Department of Defense Federal procurements.
Disclaimer of Warranties and Liabilities.
CPT is provided "as is" without warranty of any kind, either expressed or
implied, including but not limited to the implied warranties of merchantability
and fitness for a particular purpose. No fee schedules, basic unit, relative
values or related listings are included in CPT. The American Medical Association
(AMA) does not directly or indirectly practice medicine or dispense medical
services. The responsibility for the content of this product is with Aetna, Inc.
and no endorsement by the AMA is intended or implied. The AMA disclaims
responsibility for any consequences or liability attributable to or related to
any use, non-use, or interpretation of information contained or not contained in
this product.
This Agreement will terminate upon notice if you violate its terms. The AMA is a
third party beneficiary to this Agreement.
Should the foregoing terms and conditions be acceptable to you, please indicate
your agreement and acceptance by selecting the button labeled "I Accept".
The information contained on this website and the products outlined here may not
reflect product design or product availability in Arizona. Therefore, Arizona
residents, members, employers and brokers must contact Aetna directly or their
employers for information regarding Aetna products and services.
This information is neither an offer of coverage nor medical advice. It is only
a partial, general description of plan or program benefits and does not
constitute a contract. In case of a conflict between your plan documents and
this information, the plan documents will govern.
I accept
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