In compliance with the laws of New Jersey and federal
laws and regulations, we are pleased to provide you withthe following notice about your plan coverage.

Questions?
Here’s how to reach us. You can either:• Go to your personal member website at Aetna.com• Forgot your user name or password? Call us at Member
Services using the toll-free number on your ID card
Note: Don’t have internet access? Ask us for a copy ofthis document and a printed list of doctors and otherproviders.

Search our network for doctors, hospitals andother health care providers
It’s important to know which doctors are in our network.
That’s because some health plans only provide coveragefor doctors, hospitals and other health care providers ifthey are in our network. Some plans provide coveragefor outside of the network. But you pay less when you
visit doctors in the network.

Here’s how you can find out if your health careprovider is in our network• Go to Aetna.com, your personal member website, andlog in. Follow the path to find a doctor and enter yourdoctor’s name in the search field.
• Call us at the toll-free number on your Aetna member
ID card at 1-888-87-Aetna (TTY: 711) or
1-888-872-3862 (TTY: 711).
If you would like a printed list of doctors, call us at the
toll-free number on your Aetna member ID card.
Our online directory is more than just a list of doctors’
names and addresses. It also includes information about:• Where the doctor attended medical school• Board certification status• Language spoken• Hospital affiliations• GenderYou can even get driving directions. If you don’t haveinternet access, call us to ask about this information.

How Aetna compensates your health careproviderAll the physicians are independent practicing physicians
who are neither employed — nor exclusively contracted— with Aetna. Individual physicians and other providers
are in the network by either directly contracting with us
and/or affiliating with a group or organization that
contracts with us.
In-network providers are compensated in various ways:• Per individual service or case, at contracted rates (afee-for-service basis)• Per hospital, per day at contracted rates (a per diembasis)• A prepaid amount per member, per month (a capitationbasis)• Through integrated delivery systems (IDSs),
independent practice associations (IPAs), physician
hospital organizations (PHOs), physician medicalgroups (PMGs), behavioral health organizations, orother similar provider organizations or groups. We paythese organizations directly. Then, they may reimburse
the physician, provider organization or facility, directly
or indirectly, for covered services. In sucharrangements, the group or organization has a financial
incentive to control the cost of care.
• Behavioral health network providers participate througha behavioral health organization. Aetna pays theseorganizations on a capitation basis. The organization
reimburses the physician, provider organization or
facility on either a fee-for-service or a per-diem basis,for covered services.
One purpose of managed care is to manage the cost ofhealth care. Incentives in compensation arrangementswith physicians and health care providers are one
method by which Aetna attempts to achieve this goal.
If you need more information about how we pay primarycare physicians or any other provider in our network,
please contact us by:• Phone: use the toll-free number on your member ID
card• Mail: Aetna Health Inc., 9 Entin Road, Parsippany,
NJ 07054

03.28.323.1-NJ D (3/22)
1Doctors, chiropractors and podiatrists must
inform you of certain financial interests

Note: You do not have to get precertification for
emergency services.

Some doctors make referrals to other health careproviders. They may refer you to doctors or facilities inwhich they have a significant financial interest. Whilethey are allowed to do that, they must tell you about theirfinancial interest at the time of the referral. If you wantmore information about this, contact your physician,chiropractor or podiatrist. If you believe that you are notreceiving the information to which you are entitled,
contact the Division of Consumer Affairs in the New
Jersey Department of Law and Public Safety at
1-973-504-6200 or 1-800-242-5846.

First, we check to see that you are still a member. And
we make sure the service is considered medicallynecessary for your condition. Second, we make sure theservice and place requested to perform the service arecost effective. We may suggest a different treatment orplace of service that is just as effective but costs less.
Third, we look to see if you qualify for one of our casemanagement programs. If so, one of our nurses may
contact you.

Physician board certification
As of 2022, 78% of our in-network physicians are board
certified. If you would like to know if a specific physician
is board certified, or is currently accepting new patients,
call us at the toll-free number on your member ID card.

Appointment waiting times
We expect members who need an appointment with
their primary care physician (PCP) to be seen in a timely
manner, as described below.
• Urgent care: same day or within 24 hours• Nonurgent symptomatic care: within 3 days
• Nonurgent routine care: within 7 days
• Nonurgent preventive care: within 8 weeks

Precertification: getting approvals for services
Sometimes we will pay for care only if we have given an
approval before you get it. We call that “precertification.”
You usually only need precertification for more serious
care, like surgery or being admitted to a hospital.
When you get care from a doctor in the Aetna® network,
your doctor gets precertification from us. But if you getyour care outside our network, you must call us forprecertification when that’s required.
Your plan documents list all the services that require you
to get precertification. If you don't get precertification,
you will have to pay for all, or a larger share, of the costfor the service. Even with precertification, you will usually
pay more when you use out-of-network doctors.
To be covered, you must get the precertification before
you receive the care. To begin the process, call thetoll-free number on your member ID card.

What we look for when reviewing a request

Note: Have you reached any plan dollar limits or visit
maximums for a particular service? If so, even if you get
precertification for that service, it may not be covered.
Your costs when you go outside of the network
You may be enrolled under a point-of-service plan,
which means the plan covers health care services whenprovided by a doctor who participates in the Aetna
network (also referred to as "in-network" benefits). The
plan also covers health care services when provided by adoctor who does not participate in the Aetna network(also referred to as "out-of-network benefits"). If you areadmitted to a network health care facility by an
out-of-network provider, care you receive from anadmitting or attending out-of-network provider while you
are there will be covered under the plan at theout-of-network level of benefits. You will be responsible
for applicable out-of-network copayments, coinsurance
and deductibles.

Over-age dependents
If you are a parent of an over-age dependent who isactively covered under a New Jersey-issued grouphealth contract, your dependent may be eligible forcoverage to age 31 if you meet the eligibility requirement
and elect coverage. For more information, pleasecontact your employer, refer to your plan documents, orcall us at the toll-free number on your Aetna member ID
card.

Organ and tissue donation
Each year, we’re required to send you informational
materials about organ and tissue donation andregistration. This is required,* as your health benefits
plan is written in New Jersey.
For information on how to make an anatomical gift,including information on the registration of a gift in the

Aetna is the brand name used for products and services provided by one or more of the Aetna group ofcompanies, including Aetna Life Insurance Company and its affiliates (Aetna).

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Donate Life New Jersey registry, please use the following
contact information, depending on where you live.
Northern or central New Jersey residents:• Mail:New Jersey Sharing Network
691 Central Avenue,
New Providence, NJ 07974• Phone: 1-800-742-7365• Email: Info@NJSharingNetwork.org• Web: NJSharingNetwork.org
Southern New Jersey residents:• Mail:Gift of Life Donor Program
401 N. 3rd Street
Philadelphia, PA 19123• Phone: 1-800-Donors-1 or 1-800-366-6771• Email: Info@Donors1.org• Website: Donors1.org
Residents in other states:• Website:
OrganDonor.Gov/Awareness/Organizations/LocalOPO.html

What to do if you disagree with us
Complaints, appeals and external reviews
We have procedures for you to use if you are dissatisfied
with a decision that we made or with our operations.The
procedure you need to follow will depend on the type ofissue or problem you have.

shown in this document.
Under certain circumstances, the time frames may be
extended. The written notice will provide important
information that will help you in making an appeal of theadverse benefit determination, if you wish to do so.
Urgent care or pre-service claim appeal
If your claim is an urgent claim or a pre-service claim,
your provider may appeal for you without having to fillout an appeal form. We will answer urgent utilization
review claim appeals within 36 hours for level one andtwo appeals and within [24-72 hours] for an initialdetermination. We will answer utilization review
pre-service claims within 15 calendar days. We willanswer utilization review pre-service claim appeals
within 10 calendar days for level one appeals and within
15 calendar days for level two appeals. There are no
extensions for urgent care utilization review claims.
Extensions for pre-service claim utilization are 15 days.
The additional information request timeframe for urgent
care utilization review claims is [24-72 hours]. The
additional information request timeframe for pre-service
claim utilization review is 15 days. Responses toadditional information requests are required within 48
hours for urgent care utilization claims and within 45
days for pre-service utilization claims.
A concurrent claim appeal will be addressed according
to what type of service and claim it involves. We willanswer urgent concurrent care claims within 24 hours if
received at least 24 hours before the previously
approved health care services end. Non-urgent
concurrent care utilization claim review timeframes are
15 calendar days.

Adverse benefit determinations
Adverse benefit determinations are decisions that result
in denial, reduction, or termination of a benefit or theamount paid for it. It also means a decision not to provide
a benefit or service. Adverse benefit determinations canbe made for utilization review and denials — wedetermine that the service or supply is not medicallynecessary, is an experimental or investigational
procedure, or is for dental or cosmetic purposes.
All adverse benefit determinations to deny or limit anadmission, service, procedure or extension of stay will bemade by a physician. You will receive written notice of an
adverse benefit determination within the time frames*This notice is sent in compliance with Chapter 220 of the New Jersey Laws of 2017.

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The chart below summarizes some information about how different types of claims are handled.

Time frames for notification of an adverse benefit determination
Type of claim

Response time from receipt of claim

Urgent care claim

As soon as possible but not later than 72 hours

A claim for medical care or treatment for which a delay
could seriously jeopardize the life or health of themember, the ability of the member to regain maximum
function or subject the member to severe pain thatcannot be adequately managed without the requestedcare or treatment
Concurrent care claim extension
A request to extend a course of treatment that waspreviously pre-authorized by Aetna
Concurrent care claim reduction or termination
A decision to reduce or terminate a course of treatment
previously pre-authorized by us (we will not denycoverage based on medical necessity for previously
approved services, unless the approval was based onmaterial misrepresentation or fraudulent information
submitted by the covered person or provider)
Preservice claim• If an urgent care claim, as soon as possible but notlater than 24 hours• If a nonurgent care claim, within 15 calendar days
With enough advance notice to allow the member toappealWithin 15 calendar days

A claim for a benefit that requires pre-authorization of
the benefit before getting medical care
Postservice claim

Within 30 calendar days

A claim for a benefit that is not a preservice claim

4Time frames for responding to an adverse benefit determination appeal(starts when we receive the appeal)Type of claim

Level-one appeal

Level-two appeal

Urgent care claim

Within 36 hours (review will be
provided by Aetna personnel who
were not involved in making theadverse benefit determination)

Within 36 hours (review will be
provided by the Aetna Appeals
Committee)

Treated like an urgent care claim(within 36 hours) or a preservice
claim (within 10 calendar days),depending on the circumstances

Treated like an urgent care claim(within 36 hours) or a preservice
claim (within 15 calendar days),depending on the circumstances

Within 10 calendar days (review will
be provided by Aetna personnel
who were not involved in making
the adverse benefit determination)

Within 15 calendar days (review will
be provided by the Aetna Appeals
Committee)

Within 10 calendar days (review will
be provided by Aetna personnel
who were not involved in making
the adverse benefit determination)

Within 20 business days (review will
be provided by the Aetna Appeals
Committee)

A claim for medical care ortreatment where a delay could
seriously jeopardize the themember's life, health, or ability toregain maximum function, or
subject the member to severe painthat cannot be adequately
managed without the requestedcare or treatment
Concurrent care claim extension
A request to extend, or a decision
to reduce, a previously approved
course of treatment
Preservice claim
A claim for a benefit that requires
approval of the benefit before
getting medical care
Postservice claim
Any claim for a benefit that is not apreservice claim

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(A) Complaints

A complaint is an expression of dissatisfaction about thequality of care or our operation.
If you are not satisfied with the administrative services
you have received from Aetna or want to complain abouta participating provider, please call or write to us. You’ll
need to:• Give us a detailed description of the matter• Send copies of any records or documents that you
think may help or be relevant to the matter
We will review the information and send you a written
response within 30 calendar days of our receipt of thecomplaint. We may take longer to send you a response if
we need more information and this information cannot
be obtained within the original 30 days. The response will
let you know what you will need to do to seek anadditional review.
(B) Appeals of adverse benefit determinations
An appeal is a request to Aetna to reconsider an adverse
benefit determination. The appeal procedure for anadverse benefit determination has two levels.
We will send written notice of an adverse benefit
determination. The notice will:• Tell you why we made our decision• Explain the next steps you must take if you want toappeal• Identify your rights to receive additional informationthat may be relevant to your appeal
Important: You must make your appeal by phone or inwriting within 180 calendar days from the date of thenotice.
If you are dissatisfied with a utilization management
adverse benefit determination, you (or a provider acting
on your behalf and with your consent) will have theopportunity to appeal.
We provide two levels of appeal of the adverse benefit
determination. You must complete the two levels ofreview before you pursue an appeal to an independentutilization review organization (IURO).
If you decide to appeal to the second level, the request
must be made in writing within 60 calendar days fromthe date of our notice. The level-one appeal result will
include information about how to make a level-two
appeal. Within 10 business days of our receipt of alevel-two appeal, we will acknowledge the appeal inwriting.
The level-one appeal review will be conducted by aphysician who was neither the original reviewer, nor asubordinate of the original reviewer.
For a level-two appeal, we will conduct a same or similar
specialty review for appeals involving clinical issues. In
no event, however, will the consulting practitioner or
professional have been involved in the utilization
management determination at issue.
We maintain a formal level-two internal utilization
management appeal process. In this process, any
member (or provider acting on behalf of a member withthe member’s consent) who is dissatisfied with theresults of a level-one appeal, will have the opportunity to
pursue the appeal before a panel of physicians and/or
other health care professionals selected by Aetna. The
panel will not include anyone who was involved in any ofthe previous utilization management decisions. The
member (and/or an authorized representative) may
attend the level-two appeal hearing, question the Aetna
representatives, and present her or his case.
(C) Exhaustion of process
You are not required to use up internal appeals before
you complain to the Department of Banking andInsurance. The department’s ability to investigate acomplaint will not be limited by any exhaustion.
If we fail to comply with any of the deadlines forcompletion of the level-one appeal or level-two appeal,
or if we, for any reason, expressly waive our rights to aninternal review of any appeal, then you and/or yourprovider have the option to proceed directly to theexternal appeals process described in the External
Appeal Process section.
(D) External appeal process
A covered person or a provider, acting with the consent
of the covered person, has the right to contest autilization management (UM) denial through internal andexternal appeals.
In an internal appeal, the covered person (or theprovider, with the consent of the covered person)
submits a request to the insurance company to reverse a
UM denial, i.e. a denial of a claim or an authorization thatis based on a lack of medical necessity. The request
should explain why the covered person and/or provider
believe the denial was inappropriate.
An external appeal is a request to an independent

6

utilization review organization (IURO) to reverse a UM
denial, generally following an unsuccessful internal
appeal or appeals.
An IURO is an organization of medical professionals thatis not part of or affiliated with an insurance company. In
New Jersey, the Department of Banking and Insurance
contracts with IUROs to review internal appeals andrender decisions on external appeal requests submitted
by persons covered by fully-insured health benefits plansissued in New Jersey.
Covered persons should state in both their internal andexternal appeal requests whether they want their appeal
processed on an expedited basis and the reasons they
believe expedited treatment is warranted.
A request for an external appeal must typically be filed
within four months of receipt of the decision on theinternal appeal. The covered person or provider shouldelectronically file the request for external appeal byproviding the information requested at:https://njihcap.maximus.com/
Persons who are unable to submit a request for an
external appeal electronically can download and print
the appeal from the Maximus website above. Persons
may also contact Maximus and ask that an appeal form
be sent to them by regular mail and/or by fax. The
completed appeal form may be returned to Maximus by
fax at: 585-425-5296;(1) Or Mail: Maximus Federal – NJ IHCAP, 3750 Monroe
Avenue, Suite 705, Pittsford, New York 14534
Questions about the application process can bedirected to Maximus Federal by calling
888-866-6205 or e-mailing Stateappealseast@
maximus.com.
(2) The covered person or provider should include withthe request for an IURO appeal:(3) All information submitted to the Insurance company(4) Any additional information the covered person orprovider wants considered by the IURO
(5) The insurance company’s initial UM denial(6) The insurance company’s decision(s) on the internal
appeal(s).
(7) The fee for filing an appeal is $25.The filing fee will
be waived if you submit evidence of participation in
one of the following: Pharmaceutical Assistance to

the Aged and Disabled, NJ FamilyCare (Medicaid),
General Assistance, SSI, or New Jersey
Unemployment Assistance.
(8) When the Department of Banking and Insurance
receives the appeal, together with the executed
release and the appropriate fee, it will immediately
assign the appeal to an IURO.
(9) When the IURO receives the request for appeal fromthe Department of Banking and Insurance, it willconduct a preliminary review of the appeal andaccept it for processing, if they determine that:• The individual was, or is, a member of Aetna• The service that is the subject of the complaint orappeal reasonably appears to be a covered
benefit under the Certificate of Coverage• The member has fully complied with both thelevel-one and level-two appeal processes• The member has provided all information requiredby the IURO and the Department of Banking andInsurance to make the preliminary determination,
including the appeal form and a copy of any
information we provided regarding our decision todeny, reduce, or terminate the covered benefit, afully executed release to obtain any necessary
medical records from us, and any other relevant
health care provider(10) When the IURO receives the request for appeal
from the Department of Banking and Insurance, itwill conduct a preliminary review of the appeal andaccept it for processing, if it determines that:• The individual was or is a member of Aetna• The service that is the subject of the complaint orappeal reasonably appears to be a covered
benefit under the Certificate of Coverage• The member has fully complied with both thelevel-one and level-two appeal processes• The member has provided all information requiredby the IURO and the Department of Banking andInsurance to make the preliminary determination,
including the appeal form and a copy of any

7

information we provided regarding our decision todeny, reduce, or terminate the covered benefit, afully executed release to obtain any necessary
medical records from us, and any other relevant
health care provider(11) Within five business days of receipt of the requestfrom the Department of Banking and Insurance, the
IURO will complete the preliminary review and notify
the member (and/or provider), in writing, of whether
the appeal has been accepted for processing. If theappeal is not accepted, the reason(s) will be
included in the written notice. The IURO will
additionally notify the individual (and/or provider) of
her or his right to submit in writing, within fivebusiness days of the receipt of acceptance of theappeal, any additional information to be consideredin the IURO’s review.
(12) When the IURO accepts the appeal for processing,it will conduct a full review to determine whether, asa result of our utilization management
determination, the member was deprived of
medically necessary covered benefits. In reaching
this determination, the IURO will take into
consideration all pertinent medical records,
consulting physician reports, and other documents
submitted by the parties; any applicable, generally
accepted practice guidelines developed by thefederal government and national or professional
medical societies, boards and associations; and any
applicable clinical protocols and/or practiceguidelines we have developed.
(13) The full review referenced in this document will
initially be conducted by a either a registered nurse
or a physician who is licensed to practice in New
Jersey. When necessary, the IURO will refer allcases for review to a consultant physician in thesame specialty or area of practice who would
generally manage the type of treatment that is the
subject of the appeal. All final recommendations of
the IURO will be approved by the medical director of
the IURO.
(14) The IURO will complete its review and issue its
recommended decision as soon as possible (but not
to exceed 45 days from the receipt of all

documentation necessary to complete the review) inaccordance with the medical urgency of the case.
The IURO may, however, extend its review for areasonable period of time as may be necessary due
to circumstances beyond its control. If that happens,then, the IURO shall, prior to the conclusion of thepreliminary review, provide written notice to themember, to the Department of Banking andInsurance, and to Aetna, explaining both the statusof its review and the specific reasons for the delay.
(15) If the IURO determines that the member was
deprived of medically necessary covered benefits,
the IURO will recommend to the member, Aetna,
and the New Jersey Department of Health andSenior Services what appropriate, covered healthcare services the member should receive.
(16) Once the review is complete, we will abide by thedecision of the IURO.
(17) The filing fee will be refunded to you (or the healthcare provider) if the IURO reverses our final internal
adverse benefit determination.
(18) We pay the costs of the IURO’s preliminary review
and full review, regardless of the outcome.
(E) Record retention
We will keep all records about your complaints andappeals for at least seven years.
(F) Fees and costs
Except as described in numbers 10 and 11 of the "External
appeal process" section in this document, for an external
appeal, Aetna is not responsible for any legal fees or any
other fees you incur if you pursue a complaint or appeal.
(G) Addresses and phone numbers• Aetna mail:Aetna Complaints and Appeals
PO Box 14596
Lexington, KY 40512• Aetna phone: 1-888-982-3862 (TTY: 711) or the
toll-free number on the member ID card
• New Jersey state government mail:New Jersey Department of Banking and Insurance
Office of Managed Care
PO Box 329 (Courier: 20 West State Street)8Trenton, NJ 08625-0329• New Jersey state government phone: 1-888-393-1062
Independent consumer satisfaction surveys
You may request independent consumer satisfaction
results and an analysis of quality outcomes of healthcare services of managed care plans in New Jersey. Fora copy of the guide, contact New Jersey state
government via any of the ways below.
• Mail:New Jersey Department of Banking and Insurance
PO Box 325
Trenton, NJ 08625-0325(Courier: 20 West State Street)• Phone: 1-888-393-1062• Website:State.NJ.US/dobi/division_consumers/insurance/h
ealth.htm (select “NJ HMO and PPO Performance
Report”)
New Jersey Quitnet and New Jersey Quitline
Tobacco products pose a serious health threat in New
Jersey, and cost the health insurance industry millions ofdollars annually. The New Jersey Department of Healthand Senior Services provides two free services to
consumers to help kick the tobacco habit:
1. New Jersey Quitline at 1-866-NJ-Stops or
1-866-657-8677
This organization provides individualized
telephone-based counseling and referral programsfor people who want to quit smoking.
2. New Jersey Quitnet at NJQuitline.org This
organization provides online, personalized supportand referrals.

9

Aetna complies with applicable Federal civil rights laws and does not unlawfully discriminate, exclude or treat people
differently based on their race, color, national origin, sex, age, or disability.
We provide free aids/services to people with disabilities and to people who need language assistance.
If you need a qualified interpreter, written information in other formats, translation or other services, call the number on
your ID card.
If you believe we have failed to provide these services or otherwise discriminated based on a protected class noted
above, you can also file a grievance with the Civil Rights Coordinator by contacting:
Civil Rights Coordinator,
P.O. Box 14462, Lexington, KY 40512 (CA HMO customers: PO Box 24030 Fresno, CA 93779),
1-800-648-7817, TTY: 711, Fax: 859-425-3379 (CA HMO customers: 860-262-7705), CRCoordinator@aetna.com.
You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights
Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or at: U.S. Department of Health andHuman Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, or at
1-800-368-1019, 800-537-7697 (TDD).

©2022 Aetna Inc.
03.28.323.1-NJ D (3/22)
10©2022 Aetna Inc.
03.28.323.1-NJ D (3/22)
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