Claim Determinations. Our claim determination procedure applies to all claims that do not relate to a medical necessity or experimental or investigational determination. For example, Our Claim determination procedure applies to contractual benefit denials. If You disagree with Our claim determination, You may submit a Grievance pursuant to the Grievance Procedures section of this Contract. For a description of the Utilization Review procedures and Appeal process for medical necessity or experimental or investigational determinations, see the Utilization Review and External Appeal sections of this Contract.
Claim Determinations. We have complete authority to review all claims for Covered Benefits under this Group Agreement. In exercising such responsibility, We shall have discretionary authority to determine whether and to what extent eligible individuals and beneficiaries are entitled to coverage and to construe any disputed or doubtful terms under this Group Agreement, the Certificate or any other document incorporated herein. We shall be deemed to have properly exercised such authority unless We abuse our discretion by acting arbitrarily and capriciously. Our review of claims may include the use of commercial software (including Claim Check) and other tools to take into account factors such as an individual’s claims history, a Provider’s billing patterns, complexity of the service or treatment, amount of time and degree of skill needed and the manner of billing.
Claim Determinations. We have authority to review all claims for Covered Benefits under this Group Agreement. In exercising such responsibility, We shall have authority to determine whether and to what extent eligible individuals and beneficiaries are entitled to coverage and to construe any disputed or doubtful terms under this Group Agreement, the Certificate or any other document incorporated herein. Our review of claims may include the use of commercial software (including Claim Check) and other tools to take into account factors such as an individual’s claims history, a Provider’s billing patterns, complexity of the service or treatment, amount of time and degree of skill needed and the manner of billing. Our determinations, interpretations, and decisions on these matters are subject to de novo review by an impartial reviewer as provided in this Group Agreement or as allowed by law. Members and beneficiaries are entitled to have their claims reviewed de novo in any court with jurisdiction and to a trial by jury. AETNA HEALTH INC. (COLORADO) GROUP AGREEMENT AMENDMENT Contract Holder Group Agreement Effective Date: January 1, 2013 The Aetna Health Inc. (HMO) Group Agreement issued to the Contract Holder is hereby amended as follows: Section 5., RESPONSIBILITIES OF THE CONTRACT HOLDER, is hereby amended to include the following:
Claim Determinations. If You disagree with Our claim determination, You may submit a Grievance pursuant to the Grievance Procedures section of this Certificate.
Claim Determinations. We have responsibility to review all claims for Covered Benefits under this Group Agreement. In exercising such responsibility, We have the right to: determine all questions of eligibility of Members; determine the amount and type of benefits payable in accordance with the terms of this Group Agreement; and interpret the provisions of this Group Agreement, including, but not limited to, the denial of certification of the medical necessity of hospital or medical treatment. We have the right to adopt reasonable: policies; procedures; rules; and interpretations; of this Group Agreement to promote orderly and efficient administration. Our determinations, interpretations, and decisions on these matters are subject to de novo review by an impartial reviewer as provided in this Group Agreement or as allowed by law. Our review of claims may include the use of commercial software (including Claim Check) and other tools to take into account factors such as an individual’s claim history, a Provider’s billing patterns, complexity of the service or treatment, amount of time and degree of skill needed and the manner of billing. HMO IL GAAMEND-2 7-05 1 AETNA HEALTH INC. (ILLINOIS) AMENDMENT TO THE GROUP AGREEMENT TERMINATION Contract Holder Group Agreement Effective Date: January 1, 2013 The “Termination” section of the Group Agreement is hereby amended to delete section 6.3 entitled “Termination by Us”. The following replaces section 6.3:
Claim Determinations. We have complete authority to review all claims for Covered Benefits under this Group Agreement. In exercising such responsibility, We shall have discretionary authority to determine whether and to what extent eligible individuals and beneficiaries are entitled to coverage and to construe any disputed or doubtful terms under this Group Agreement, the Certificate or any other document incorporated herein. Our review of claims may include the use of commercial software (including Claim Check) and other tools to take into account factors such as an individual’s claims history, a Provider’s billing patterns, complexity of the service or treatment, amount of time and degree of skill needed and the manner of billing. The Member may be eligible to appeal HMO's decision through an Independent Utilization Review Organization (IURO). Please refer to the Appeal Procedure section of the Certificate for more information on this process.
