Fraud & Abuse

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justify-content-center "> <button aria-label="Close" class="cmp-utilitynav-item__btn-close">Close</button> </li> </ul> </li> </ul> </nav> </div> </section> </div> </div> <div class="cmp-header-overlay d-none"> </div> </div> </div> </div> </header> <main> <div class="content_section" id="content__main"> <div class="herobanner"><div class="herobanner herobanner--noimagehero component--left " data-cmp-is-async="herobanner"> <div class="herobanner__main pageheader--wrapper "> <div> <div class="container"> <div class="row"> <div class="textonly__wrapper col"> <h1 class="title__hero page__title__hero">Fraud, waste and abuse (FWA)</h1> <div class="textonly__text body__copy"> <div class="intro__copy"> <p>Health care fraud affects all of us — from small businesses to corporations, insurers, doctors and members. It impacts the quality of health care and results in higher costs.</p> </div> </div> </div> </div> </div> </div> </div> <div class="container pageheader--callout"> <div class="row"> </div> </div> </div> </div> <div class="breadcrumb"> </div> <div class="responsivegrid"> <div> <div class="container "> <div class="row"> <div class="aem-Grid aem-Grid--12 aem-Grid--default--12 aem-Grid--xs--12 "> <div class="text aem-GridColumn--default--none aem-GridColumn--offset--xs--0 aem-GridColumn aem-GridColumn--default--7 aem-GridColumn--xs--none aem-GridColumn--offset--default--0 aem-GridColumn--xs--12"><div class="rte-component-wraper component--default "> <h2><span class="title__block">Zero-tolerance approach to fraud</span></h2> <p> </p> <p>Our Special Investigations Unit (SIU) is helping to lead the fight against fraud. How? We investigate all types of fraud. We work to protect you. Your health care costs go down when we reduce fraud, waste and abuse.</p> </div> </div> <div class="separator aem-GridColumn aem-GridColumn--default--12"><span class="keyline tb-margin-small "> </span> </div> <div class="accordioncore accordion aem-GridColumn--default--none aem-GridColumn--offset--xs--0 aem-GridColumn aem-GridColumn--default--7 aem-GridColumn--xs--none aem-GridColumn--xs--12 aem-GridColumn--offset--default--1"> <div class="accordian no--container component--responsive" data-cmp-is-async="accordion"> <div class="row"> <div class="accordian__main col-12 "> <h2 class="accordian-heading title__block">What is fraud, waste and abuse?</h2> <div class="accordian__wrapper"> <div class="accordian__element " data-cmp-hook-accordion="item"> <div class="accordian__title title--secondary "> <h3 class="accordian__heading-item core"> <button id="link_content_section_responsivegrid_responsivegrid_accordioncore_copy_c_1" class="accordian__button" type="button" aria-controls="1698789616_1_element" aria-expanded="false">Fraud</button> </h3> </div> <div data-cmp-hook-accordion="panel" id="1698789616_1_element" class="accordian__elemcontent core__elemcontent" aria-labelledby="link_content_section_responsivegrid_responsivegrid_accordioncore_copy_c_1"><div class="accordioncontent"><div class="content_wrapper"> <div class="aem-Grid aem-Grid--12 aem-Grid--default--12 "> <div class="text aem-GridColumn--default--none aem-GridColumn aem-GridColumn--default--12 aem-GridColumn--offset--default--0"><div class="rte-component-wraper component--default "> <p>Fraud happens when someone submits false information to get money or a benefit.</p> <p> </p> <p>Examples include:</p> <p> </p> <ul> <li>Billing for services, procedures, prescriptions and/or supplies that were never provided</li> <li>Knowingly altering claim forms, medical records, or receipts to receive a higher payment</li> <li>Offering treatment while promising you won’t have to pay the balance due after insurance pays</li> </ul> </div> </div> </div> </div></div> </div> </div> </div> </div> </div> </div> </div> <div class="separator aem-GridColumn aem-GridColumn--default--12"><span class="keyline tb-margin-extra-small "> </span> </div> <div class="accordioncore accordion aem-GridColumn--default--none aem-GridColumn--offset--xs--0 aem-GridColumn aem-GridColumn--default--7 aem-GridColumn--xs--none aem-GridColumn--xs--12 aem-GridColumn--offset--default--1"> <div class="accordian no--container component--responsive" data-cmp-is-async="accordion"> <div class="row"> <div class="accordian__main col-12 "> <div class="accordian__wrapper"> <div class="accordian__element " data-cmp-hook-accordion="item"> <div class="accordian__title title--secondary "> <h3 class="accordian__heading-item core"> <button id="link_content_section_responsivegrid_responsivegrid_accordioncore_copy_c_1805128201_1" class="accordian__button" type="button" aria-controls="840986005_1_element" aria-expanded="false">Waste</button> </h3> </div> <div data-cmp-hook-accordion="panel" id="840986005_1_element" class="accordian__elemcontent core__elemcontent" aria-labelledby="link_content_section_responsivegrid_responsivegrid_accordioncore_copy_c_1805128201_1"><div class="accordioncontent"><div class="content_wrapper"> <div class="aem-Grid aem-Grid--12 aem-Grid--default--12 "> <div class="text aem-GridColumn--default--none aem-GridColumn aem-GridColumn--default--12 aem-GridColumn--offset--default--0"><div class="rte-component-wraper component--default "> <p>Waste happens when someone overuses health services.</p> <p> </p> <p>Examples include:</p> <p> </p> <ul> <li>Conducting more than needed office visits or writing extra prescriptions</li> <li>Prescribing more medicine than necessary for treating a condition</li> <li>Ordering lab tests</li> </ul> </div> </div> </div> </div></div> </div> </div> </div> </div> </div> </div> </div> <div class="separator aem-GridColumn aem-GridColumn--default--12"><span class="keyline tb-margin-extra-small "> </span> </div> <div class="accordioncore accordion aem-GridColumn--default--none aem-GridColumn--offset--xs--0 aem-GridColumn aem-GridColumn--default--7 aem-GridColumn--xs--none aem-GridColumn--xs--12 aem-GridColumn--offset--default--1"> <div class="accordian no--container component--responsive" data-cmp-is-async="accordion"> <div class="row"> <div class="accordian__main col-12 "> <div class="accordian__wrapper"> <div class="accordian__element " data-cmp-hook-accordion="item"> <div class="accordian__title title--secondary "> <h3 class="accordian__heading-item core"> <button id="link_content_section_responsivegrid_responsivegrid_accordioncore_copy_c_1854462382_1" class="accordian__button" type="button" aria-controls="167003408_1_element" aria-expanded="false">Waste</button> </h3> </div> <div data-cmp-hook-accordion="panel" id="167003408_1_element" class="accordian__elemcontent core__elemcontent" aria-labelledby="link_content_section_responsivegrid_responsivegrid_accordioncore_copy_c_1854462382_1"><div class="accordioncontent"><div class="content_wrapper"> <div class="aem-Grid aem-Grid--12 aem-Grid--default--12 "> <div class="text aem-GridColumn--default--none aem-GridColumn aem-GridColumn--default--12 aem-GridColumn--offset--default--0"><div class="rte-component-wraper component--default "> <p>Abuse happens when someone doesn’t follow best medical practices, leading to costs and treatments that aren't needed.</p> <p> </p> <p>Examples include:</p> <p> </p> <ul> <li>Billing for unnecessary medical services</li> <li>Billing for brand name drugs when generics are available</li> <li>Charging extra for services or supplies</li> </ul> </div> </div> </div> </div></div> </div> </div> </div> </div> </div> </div> </div> <div class="separator aem-GridColumn aem-GridColumn--default--12"><span class="keyline tb-margin-small "> </span> </div> <div class="inline-cta 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Some subtypes have five tiers of coverage. Others have four tiers, three tiers or two tiers. This search will use the five-tier subtype. It will show you whether a drug is covered or not covered, but the tier information may not be the same as it is for your specific plan. 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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.</p> <p>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.</p> <p>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.</p> <p>Please note also that the ABA Medical Necessity Guide may be updated and are, therefore, subject to change.</p> <p>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, member may be eligible for the right to an internal appeal and/or an independent external appeal in accordance with applicable federal or state law.</p> </div> </div> </div> <div class="component__cta "> <a href="#" class="modalContinueBtn btn--primary type__btn--primary ">I Accept</a> </div> </div> </div> </div> </div> </div> <div class="interstitial section"><div class="aetna-modal" data-cmp-is="modal"> <div class="modal__box " id="exit-cvs-caremark" role="dialog" title="Aetna® is proud to be part of the CVS® family." tabindex="-1" aria-labelledby="modal-heading-28807244"> <div class="modal__inner"> <button type="button" aria-label="Close" class="modal__close"></button> <div class="modal__content">  <h2 id="modal-heading-28807244" class="title__block ">Aetna® is proud to be part of the CVS® family.</h2> <div class="component__main"> <div class="text"><div class="rte-component-wraper component--default "> <p>You are now being directed to CVS Caremark<sup>®</sup> site.</p> </div> </div> </div> <div class="component__cta "> <a href="#" class="modalContinueBtn btn--primary type__btn--primary ">Continue</a> </div> </div> </div> </div> </div> </div> <div class="interstitial section"><div class="aetna-modal" data-cmp-is="modal"> <div class="modal__box modal--blocked " id="asam-modal" role="dialog" title="ASAM Terms and conditions" tabindex="-1" aria-labelledby="modal-heading-1817940071"> <div class="modal__inner"> <button type="button" aria-label="Close" class="modal__close"></button> <div class="modal__content">  <h2 id="modal-heading-1817940071" class="title__block ">ASAM Terms and conditions</h2> <div class="component__main"> <div class="text"><div class="rte-component-wraper component--default "> <p>By clicking on “I accept”, I acknowledge and accept that:</p> <p> </p> </div> </div> <div class="text"><div class="rte-component-wraper component--default "> <p>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.</p> <p> </p> <p>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.</p> <p> </p> <p>Copyright 2015 by the American Society of Addiction Medicine. 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No third party may copy this document in whole or in part in any format or medium without the prior written consent of ASAM.</p> </div> </div> </div> <div class="component__cta "> <a href="#" class="modalContinueBtn btn--primary type__btn--primary ">I accept</a> </div> </div> </div> </div> </div> </div> <div class="interstitial section"><div class="aetna-modal" data-cmp-is="modal"> <div class="modal__box modal--blocked " id="cpt-modal" role="dialog" title="Precertification lists" tabindex="-1" aria-labelledby="modal-heading-1737369633"> <div class="modal__inner"> <button type="button" aria-label="Close" class="modal__close"></button> <div class="modal__content">  <h2 id="modal-heading-1737369633" class="title__block ">Precertification lists</h2> <div class="component__main"> <div class="text"><div class="rte-component-wraper component--default "> <p>By clicking on “I accept”, I acknowledge and accept that:</p> <p> </p> </div> </div> <div class="text"><div class="rte-component-wraper component--default "> <p>Should the following terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button below labeled "I Accept".</p> <p> </p> <ul> <li>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.</li> <li>Applies to: Aetna Choice<sup>®</sup> POS, Aetna Choice POS II, Aetna Medicare<sup>℠</sup> Plan (PPO), Aetna Medicare Plan (HMO), all Aetna HealthFund<sup>®</sup> products, Aetna Health Network Only<sup>℠</sup>, Aetna Health Network Option<sup>℠</sup>, Aetna Open Access<sup>®</sup> Elect Choice<sup>®</sup>, Aetna Open Access HMO, Aetna Open Access Managed Choice<sup>®</sup>, Open Access Aetna Select<sup>℠</sup>, Elect Choice, HMO, Managed Choice POS, Open Choice<sup>®</sup>, Quality Point-of-Service<sup>®</sup> (QPOS<sup>®</sup>), and Aetna Select<sup>℠</sup> benefits plans and all products that may include the Aexcel<sup>®</sup>, Choose and Save<sup>℠</sup>, Aetna Performance Network or Savings Plus networks. Not all plans are offered in all service areas.</li> <li>All services deemed "never effective" are excluded from coverage. Aetna defines a service as "never effective" when it is not recognized according to professional standards of safety and effectiveness in the United States for diagnosis, care or treatment. Visit the secure website, available through www.aetna.com, for more information. Click on "Claims," "CPT/HCPCS Coding Tool," "Clinical Policy Code Search."</li> <li>The five character codes included in the Aetna Precertification Code Search Tool are obtained from Current Procedural Terminology (CPT<sup>®</sup>), copyright 2023 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.</li> <li>The responsibility for the content of Aetna Precertification Code Search Tool 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 Precertification Code Search Tool. 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 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.</li> </ul> <p> </p> <h3><strong>LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ("CPT<sup>®</sup>")</strong></h3> <p> </p> <ul> <li>CPT only Copyright 2023 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 Precertification Code Search Tool solely for your own personal use in directly participating in health care 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 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.</li> </ul> <p> </p> <h3><strong>U.S. Government Rights</strong></h3> <p> </p> <ul> <li>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.</li> </ul> <p> </p> <h3><strong>Disclaimer of Warranties and Liabilities.</strong></h3> <p> </p> <ul> <li>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.</li> <li>This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.</li> <li>Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button labeled "I Accept".</li> <li>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.</li> <li>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.</li> </ul> </div> </div> </div> <div class="component__cta "> <a href="#" class="modalContinueBtn btn--primary type__btn--primary ">I accept</a> </div> </div> </div> </div> </div> </div> <div class="interstitial section"><div class="aetna-modal" data-cmp-is="modal"> <div class="modal__box modal--blocked " id="dcpb-modal" role="dialog" title="Dental clinical policy bulletins" tabindex="-1" aria-labelledby="modal-heading-1767983030"> <div class="modal__inner"> <button type="button" aria-label="Close" class="modal__close"></button> <div class="modal__content">  <h2 id="modal-heading-1767983030" class="title__block ">Dental clinical policy bulletins</h2> <div class="component__main"> <div class="text"><div class="rte-component-wraper component--default "> <p>By clicking on “I accept”, I acknowledge and accept that:</p> <p> </p> </div> </div> <div class="text"><div class="rte-component-wraper component--default "> <ul> <li>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.</li> <li>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 is covered (i.e., will be paid for by Aetna). Your benefits plan determines coverage. Some plans exclude coverage for services or supplies that Aetna considers medically necessary. If there is a discrepancy between this policy 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.</li> <li>Please note also that Dental Clinical Policy Bulletins (DCPBs) are regularly updated and are therefore subject to change.</li> <li>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.</li> <li>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.</li> </ul> </div> </div> </div> <div class="component__cta "> <a href="#" class="modalContinueBtn btn--primary type__btn--primary ">I accept</a> </div> </div> </div> </div> </div> </div> <div class="interstitial section"><div class="aetna-modal" data-cmp-is="modal"> <div class="modal__box modal--blocked " id="mcpbs-modal" role="dialog" title="Medical clinical policy bulletins" tabindex="-1" aria-labelledby="modal-heading-1142802819"> <div class="modal__inner"> <button type="button" aria-label="Close" class="modal__close"></button> <div class="modal__content">  <h2 id="modal-heading-1142802819" class="title__block ">Medical clinical policy bulletins</h2> <div class="component__main"> <div class="text"><div class="rte-component-wraper component--default "> <p>By clicking on “I accept”, I acknowledge and accept that:</p> <p> </p> </div> </div> <div class="text"><div class="rte-component-wraper component--default " data-linklocationGeneral="discoverable"> <p>Should the following terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button below labeled "I Accept".</p> <p> </p> <ul> <li>Aetna Clinical Policy Bulletins (CPBs) are developed to assist in administering plan benefits and do not constitute medical advice. Treating providers are solely responsible for medical advice and treatment of members. Members should discuss any Clinical Policy Bulletin (CPB) related to their coverage or condition with their treating provider.</li> <li>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, investigational, unproven, 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 health research agencies, evidence-based guidelines and positions of leading national health professional organizations, views of physicians practicing in relevant clinical areas, and other relevant factors).</li> <li>Aetna makes no representations and accepts no liability with respect to the content of any external information cited or relied upon in the Clinical Policy Bulletins (CPBs). The discussion, analysis, conclusions and positions reflected in the Clinical Policy Bulletins (CPBs), including any reference to 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.</li> <li>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.</li> <li>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.</li> <li>In addition, coverage may be mandated by applicable legal requirements of a State, the Federal government or CMS for Medicare and Medicaid members. </li> </ul> <p><a href="https://www.cms.gov/Center/special-topic/medicare-coverage-center.html" target="_blank" class="link__text" data-analytics-name="See CMS's Medicare Coverage Center" data-modal="exit" data-linktype="Regular">See CMS's Medicare Coverage Center</a></p> <p> </p> <ul> <li>Please note also that Clinical Policy Bulletins (CPBs) are regularly updated and are therefore subject to change.</li> <li>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. Under certain circumstances, your physician may request a peer to peer review if they have a question or wish to discuss a medical necessity precertification determination made by our medical director in accordance with Aetna’s Clinical Policy Bulletin.</li> <li>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.</li> </ul> <p><a href="/individuals-families/member-rights-resources/claims-coverage/aetna-external-review-program.html" target="_self" class="link__text" data-analytics-name="See Aetna's External Review Program" data-modal="Please Select" data-linktype="Regular">See Aetna's External Review Program</a></p> <p> </p> <ul> <li>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.</li> <li>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.</li> </ul> <p> </p> <h3>LICENSE FOR USE OF CURRENT PROCEDURAL TERMINOLOGY, FOURTH EDITION ("CPT®")</h3> <p> </p> <p>CPT only copyright 2015 American Medical Association. All Rights Reserved. CPT is a registered trademark of the American Medical Association.</p> <p> </p> <p>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.</p> <p> </p> <p>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.</p> <p> </p> <p><a href="http://www.ama-assn.org/go/cpt" target="_blank" class="link__text" data-analytics-name="Go to the American Medical Association Web site" data-modal="exit" data-linktype="Regular">Go to the American Medical Association Web site</a></p> <p> </p> <h3><strong>U.S. Government Rights</strong></h3> <p> </p> <p>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.</p> <p> </p> <h3><strong>Disclaimer of Warranties and Liabilities.</strong></h3> <p> </p> <p>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.</p> <p> </p> <p>This Agreement will terminate upon notice if you violate its terms. The AMA is a third party beneficiary to this Agreement.</p> <p> </p> <p>Should the foregoing terms and conditions be acceptable to you, please indicate your agreement and acceptance by selecting the button labeled "I Accept".</p> <p> </p> <p>The information contained on this website and the products outlined here may not reflect product design or product availability in Arizona. 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8337713686 8337713688 8337713691 8337713690 8337712462 8332200349 8446195664 8882107634 8882108618 8882138508 8882145871 8882133137 8882134076 8445219010 8337713707 8449475338 8449475340 8337713705 8337713706 8337713707 8449475335 8449475340 8449475338 8337713743 8337713751 8337713755 8337713763 8337713757 8337713760 8337713759 8882034676 8882035554 8449873336 8449873338 8449873339 8449873340 8449943108 8449943109 8449943110 8449943111 8449943112 8449943113 8449943114 8449943115 8449943116 8449943117 8557905985 8633458146 8664443331 8667513437 8667513530 8882024526 8882029055 8882029495 8446917720 8446917730 8445121366 8445121367 8445121368 8445121379 8445440055 8445440624 8445440625 8445440626 8445440627 8445440729 8445581343 8445581344 8445581345 8445641332 8445641341 8445641344 8447212085 8447212252 8447305502 8447305537 8447305558 8447305579 8447350518 8447350519 8447350952 8447350953 8447350954 8447541206 8447541207 8447541210 8445440055 8445440624 8445440625 8445210707 8445210708 8445210722 8445210905 8445211400 8445211440 8445211441 8445211443 8445212050 8445212090 8445212332 8445212977 8445213040 8445213380 8445213443 8445213553 8445213681 8445213744 8445213891 8445214080 8445214374 8337713755 8445219425 8445214499 8445214544 8445217575 8337713907 8337713910 8337713917 8337713923 8337713927 8337713929 8337713936 8337713938 8337713942 8447248844 8447248855 8447248866 8447248870 8447248877 8447248890 8447248899 8447249020 8447249050 8447249516 8447249595 8447249779 8447249910 8447249960 8447249980 8447249990 8447244826 8447244833 8447245040 8447245070 8447245090 8447245520 8447245775 8447245855 8447245858 8447246748 8447247020 8447247050 8447247060 8447247171 8447247790 8447241075 8447241076 8447240376 8447240442 8447240456 8447240706 8447241097 8447241099 8447241123 8447241134 8447240017 8447241077 8447241078 8447240377 8447240519 8447240585 8447240707 8447241101 8447241110 8447241124 8447240100 8447240136 8447241079 8447241081 8447240381 8447240601 8447240615 8447240708 8447241115 8447241116 8447241125 8447240356 8447240361 8447241082 8447241083 8447240385 8447240620 8447240652 8447240709 8447241117 8447241119 8447241131 8447240446 8447240613 8447240303 8447240375 8447240424 8447240690 8447240691 8447240713 8447241121 8447241122 8447241133 8447240656 8447240688 8449475373 8447240870 8447240874 8447240871 8332388685 8335697700 8337713706 8337713707 8337713757 8337713759 8337713760 8337713763 8337713887 8337713894 8337713895 8445210722 8445211443 8445212332 8445212682 8446917720 8446917730 8449475349 8449475360 8449943116 8449943117 8552980184 8557905985 8633458146 8664443331 8667513437 8667513530 8882024526 8882029055 8882029495 8337717075 8445212977 8337714056 8337713888 8337713889 8337713813 8337713815 8337713870 8337713879 8337713833 8337713836 8337713851 8337713852 8337713830 8337713831 8337713805 8337713811 8337713826 8337713827 8337713837 8337713843 8337713848 8337713818 8337713820 8337713821 8337713825 8337713823 8337713832 8337713850 8337713853 8337713855 8337713856 8337713858 8337713860 8337713865 8337713868 8337713876 8337713903 8449475346 8449475342 8449475344 8449475351 8449475348 8449475350 8449475353 8449475355 8449475361 8449475362 8449475357 8449475359 8449475365 8449475367 8449475369 8449475371 8449322686 8334933115 8449322687 8337714058 8337714060 8337714064 8337714149 8337714150 8337714151' data-cookie='ReferrerPhoneNumber'></span>" window.AETH.GlobalVariablesMap["hours"] = "7 days a week, 8 AM to 8 PM" window.AETH.GlobalVariablesMap["medsupenroll"] = "<span class='gvphonebycookie' data-cmp-is='globalvariable/phone' data-tag='tfn' data-default='8003588749' data-restriction='' data-cookie=''></span>" window.AETH.GlobalVariablesMap["medsupphours"] = "Monday to Friday, 8 AM to 8 PM ET" window.AETH.GlobalVariablesMap["orderKitPlanKitName"] = "<span class='gvphonebycookie' data-cmp-is='globalvariable/request' data-tag='planKit' data-default='' data-restriction='' data-cookie=''></span>" window.AETH.GlobalVariablesMap["orderKitProjectCode"] = "<span class='gvphonebycookie' data-cmp-is='globalvariable/request' data-tag='projectCode' data-default='' data-restriction='' data-cookie=''></span>" window.AETH.GlobalVariablesMap["orderKitZipcode"] = "<span class='gvphonebycookie' data-cmp-is='globalvariable/request' data-tag='Zip' data-default='' data-restriction='' data-cookie=''></span>" window.AETH.GlobalVariablesMap["planType"] = "HMO/PPO" window.AETH.GlobalVariablesMap["ProviderDirectoryPlanName"] = "Aetna Medicare Plan (HMO) (PPO)" window.AETH.GlobalVariablesMap["RSVPdynamicPhone"] = "<span class='gvphonebycookie' data-cmp-is='globalvariable/phone' data-tag='tfn' data-default='8332519949' data-restriction='8009723599 8449850088 8449850093 8337718220 8337712466 8337713113 8337715544 8337717117 8337712474 8337712479 8002237099 8002528290 8332236974 8332245604 8332245606 8332245607 8332245608 8332245644 8332245655 8332245731 8332245742 8332245748 8332245749 8332245752 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