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Kathleen R. (Aetna)

Kathleen R. received outpatient treatment at alcohol treatment center for alcohol dependence for a period of approximately five weeks. The services were rendered by a licensed physician at a licensed, accredited treatment facility. Two months before treatment began a facility representative contacted Aetna and verified availability of coverage for both inpatient and outpatient treatment, subject to a $25,000 lifetime maximum.

A claim for benefits was submitted by the facility. At first, Aetna just ignored it. When called about the claim, a representative said that the claim was denied because the facility was “not licensed", which was not true. The denial letter that followed said the claim was denied on the ground that "services were not provided by a physician". The facility faxed Aetna a copy of its license and the treating doctor’s license.

At that point, Aetna said it wanted to do a medical record review, so it requested copies of all medical records, which the facility provided. A month later, Aetna sent the facility an “Explanation of Benefits” (EOB) form, which stated, “Benefits payable $0;” "These expenses are not covered because this provider is not recognized under the plan definition of a physician."

A period of time passed before there was yet another follow-up attempt by the treatment center to get the claim paid. A call was made to an Aetna supervisor, who asked that the facility send in yet another copy of the doctor’s license, which it did. A month passed and the facility made another call to Aetna only to be told that the claim was "not processed yet". Two weeks later, Aetna asked for yet another copy of the medical records. No further action was taken on the claim.

At that point the file was referred to me. I sent Aetna an administrative appeal, which called attention to the plan provisions, the applicable law, and the medical necessity of the treatment rendered.

Result: The case was resolved satisfactorily, without the need for litigation.

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