Columbia University Health Services

Customer Service Representatives are available 8:30am to 5:30pm, Monday through Friday (ET), for any questions.

1. Bills must be submitted to the following address within 90 days from the date of treatment.
2. Payment for Covered Medical Expenses will be made directly to the hospital or Physician concerned unless bill receipts and proof of payment are submitted.
3. In the event of a disagreement over the payment of a claim, a written request to review the claim must be mailed to Aetna Student Health Claims Administrators, Inc. within 60 days from the date appearing on the Explanation of Benefits.

Complaint and Appeals Procedure

New York State mandates that the following information be provided to all insured:

The complaints and appeals process is designed to address coverage issues, complaints and problems. If you have a coverage issue or other problem, contact Aetna Student Health . A representative will address your concern. If you are dissatisfied with the outcome of the initial contact, the decision may be appealed.

You may also submit a request, in writing, along with all pertinent correspondence, to:

Aetna Student Health Claims Administrators, Inc.
P.O. Box 15708
Boston , MA 02215-0014

For purposes of the following section, the term “you” pertains to the Covered Person, including students as well as covered dependents.

Internal Appeals Procedure
An Appeal is defined as a written request for review of a decision that has been denied in whole or in part, after consideration of any relevant information: a request for claim payment, certification, eligibility, referral, etc.

Aetna has established a procedure for resolving appeals. If you have an appeal, please follow this procedure:

First Level Appeals Procedure

• An Appeal must be submitted to Aetna within 180 days of the date Aetna provides notice of denial. The address is on your ID Card. The Appeal may be submitted by you, or by a representative as designated by you.
• You may submit an oral grievance in connection with:
• A denial of, or failure to pay for, a referral; or
• A determination as to whether a benefit is covered under this Plan.
  

You may do this by calling Customer Services. The Customer Services telephone number is on your ID Card. If you are required to leave a recorded message, your message will be acknowledged within one business day after the call was recorded.

Aetna will summarize the nature of the grievance in writing. You will be required to sign a written acknowledgement of the grievance. Such acknowledgement will be mailed promptly to you. You must sign and return the acknowledgement, with any amendments, in order to initiate the grievance. Upon receipt of the signed acknowledgement, the process below will be followed:

• An acknowledgment letter will be sent to you within 1 day of Aetna’s receipt of an oral Appeal and within 5 days of Aetna’s receipt of a written Appeal. This letter may request additional information. If so, the additional information must be submitted to Aetna within 15 days of the date of the letter.
• You will be sent a response within 30 days of Aetna’s receipt of the Appeal. The response will be based on the information provided with, or subsequent to, the Appeal.
• If the Appeal concerns an eligibility issue, and if additional information is not submitted to Aetna after receipt of Aetna’s response, the decision is considered Aetna’s final response 45 days after receipt of the Appeal. For all other Appeals, if additional information is to be submitted to Aetna after receipt of Aetna’s response, it must be submitted within 15 days of the date of Aetna’s response letter.
• Aetna’s response will be sent within 30 days from the date of Aetna’s first response letter.
  

In any urgent or emergency situation, the Expedited Appeal procedure may be initiated by a telephone call to Customer Services. The Customer Services telephone number is on your ID Card. A verbal response to the Appeal will be given to you and to your provider within 2 days provided that all necessary information is available. Written notice of the decision will be sent within 2 business days of Aetna’s verbal response.

Second Level Appeals Procedure

If you are dissatisfied with Aetna’s grievance determination, you or a representative designated by you may submit a written appeal within 60 business days after receipt of such determination.

• An acknowledgement letter will be sent to you within 15 days of Aetna’s receipt of the written appeal. This letter may request additional information. If so, the additional information must be submitted to Aetna within 15 days of the date of the letter.
• Aetna’s final response for an urgent or emergency situation will be sent within 2 business days. For all other situations, a response will be sent within 30 business days from the date of Aetna’s receipt of all necessary information.
  

If additional time is needed to resolve an Appeal, except in an urgent or emergency situation, Aetna will provide a written notification indicating that additional time is needed, explaining why such time is needed and setting a new date for a response. The additional time will not be extended beyond another 30 days.

You must exhaust the Internal Appeals Procedure before requesting an External Appeal. However, you are not required to exhaust the Internal Appeals Procedure prior to requesting an External Appeal, if you and Aetna have agreed that the matter may proceed directly to an External Appeal.

Aetna will keep the records of your complaint for 3 years.

Right to an External Appeal

 

Under certain circumstances you have a right to an external appeal of a denial of coverage. Specifically, if Aetna has denied coverage on the basis that the service is not necessary or is an experimental or investigational treatment, you may appeal that decision to an External Appeal Agent, an independent entity certified by the State, to conduct such appeals.

Right to Appeal a Determination That a Service is Not Necessary

 

If Aetna has denied coverage on the basis that the service is not necessary you may appeal to an External Appeal Agent if you satisfy the criteria listed below:

• The service, procedure, or treatment must otherwise be a Covered Medical Expense under the Columbia Student Medical Insurance Plan; and
• You must have received a final adverse determination through the first level of the internal review process and Aetna must have upheld the denial or you and Aetna must agree in writing to waive any internal appeal.
  

Right to Appeal Determination That a Service is Experimental or Investigational

If you have been denied coverage on the basis that the service is an experimental or investigational treatment, you must satisfy the following criteria:

• The service must otherwise be a Covered Medical Expense under the Columbia Student Medical Insurance Plan; and
• You must have received a final adverse determination through the first level of the internal appeal process and Aetna must have upheld the denial or you and Aetna must agree in writing to waive any internal appeal.
  

In addition, your attending Physician must certify that you have a life-threatening or disabling condition or disease. A “life-threatening condition or disease” is one which, according to the current diagnosis of the attending Physician, has a high probability of death. A “disabling condition or disease” is any medically determinable physical or medical impairment that can be expected to result in death or that has lasted, or can be expected to last, for a continuous period of not less than 12 months which renders you unable to engage in any substantial gainful activities. In the case of a dependent child under the age of 18, a “disabling condition or disease” is any medically determinable physical or mental impairment of comparable severity.

Your attending Physician must also certify that the life-threatening or disabling condition or disease is one for which standard health services are ineffective, or medically inappropriate, or one for which there does not exist a more beneficial standard service or procedure covered under this Plan, or one for which there exists a clinical trial (as defined by law).

In addition, your attending Physician must have recommended at least one of the following:

• A service, procedure, or treatment that two documents from available medical and scientific evidence indicate is likely to be more beneficial to you than any standard Covered Medical Expense (only certain documents will be considered in support of this recommendation– your attending physician should contact the State in order to obtain current information as to what documents will be considered acceptable); or
• A clinical trial for which you are eligible (only certain clinical trials can be considered).
  

For the purposes of this section, your attending Physician must be a licensed, board certified, or board eligible Physician, qualified to practice in the area appropriate to treat your life-threatening or disabling condition or disease.

The External Appeal Process

If, through Aetna’s internal appeal process, you have received a final adverse determination upholding a denial of coverage on the basis that the service is not necessary or is an experimental or investigational treatment, you have 45 days from receipt of such notice to file a written request for an external appeal. If you and Aetna have agreed to waive any internal appeal, you have 45 days from the receipt of such waiver to file a written request for an external appeal. Aetna will provide an external appeal application with the final adverse determination issued through Aetna’s internal appeal process or its written waiver of an internal appeal.

You may also request an external appeal application from the New York State Department of Insurance at 800 400 8882. The completed application must be submitted to the New York State Department of Insurance at the address listed in the application. If you satisfy the criteria for an external appeal, the State will forward the request to a certified External Appeal Agent.

You will have the opportunity to submit additional documentation with the request. If the External Appeal Agent determines that the information you submit represents a material change from the information on which Aetna based its denial, the External Appeal Agent will share this information with Aetna in order for it to exercise its right to reconsider its decision. If Aetna chooses to exercise this right, Aetna will have 3 business days to amend or confirm its decision. Please note that in the case of an expedited appeal (described below), Aetna does not have a right to reconsider its decision.

In general, the External Appeal Agent must make a decision within 30 days of receipt of the completed application. The External Appeal Agent may request additional information from you, your physician, or Aetna. If the External Appeal Agent requests additional information, it will have 5 additional business days to make its decision. The External Appeal Agent must notify you in writing of its decision within 2 business days.

If your attending Physician certifies that a delay in providing the service that has been denied poses an imminent or serious threat to your health, you may request an expedited external appeal. In that case, the External Appeal Agent must make a decision within 3 days of receipt of the completed application. Immediately after reaching a decision, the External Appeal Agent must try to notify you and Aetna by telephone or facsimile of that decision. The External Appeal Agent must also notify you in writing of its decision.

If the External Appeal Agent overturns Aetna’s decision that a service is not necessary, or approves coverage of an experimental or investigational treatment, Aetna will provide coverage subject to the other terms and conditions of this Plan. If the External Appeal Agent approves coverage of an experimental or investigational treatment that is part of a clinical trial, Aetna will only cover the costs of services required to provide treatment to you according to the design of the trial. Aetna shall not be responsible for the costs of investigational drugs or devices, the costs of non-health care services, the costs of managing research, or costs which would not be covered under this Plan for non-experimental or non-investigational treatments provided in such clinical trial.

The External Appeal Agent’s decision is binding on both you and Aetna. The External Appeal Agent’s decision is admissible in any court proceeding.

You will be charged a fee of $50 for an external appeal. The external appeal application will instruct you on the manner in which you must submit the fee. Aetna will also waive the fee if Aetna determines that paying the fee would pose a hardship to you. If the External Appeal Agent overturns the denial of coverage, the fee shall be refunded to you.

It is your responsibility to initiate the external appeals process. You may initiate the external appeal process by filing a completed application with the New York State Department of Insurance. If the requested service has already been provided to you, your attending Physician may file an expedited appeal application on your behalf, but only if you have consented to this in writing.

Under New York State law your completed request for appeal must be filed within 45 days of either the date upon which you receive written notification from Aetna that it has upheld a denial of coverage or the date upon which you receive a written waiver of any internal appeal. Aetna has no authority to grant an extension of this deadline.

In general, the Columbia Student Medical Insurance Plan does not cover experimental or investigational treatments. However, this Columbia Student Medical Insurance Plan shall cover an experimental or investigational treatment approved by an External Appeal Agent in accordance with this section. If the External Appeal Agent approves coverage of an experimental or investigational treatment that is part of a clinical trial, Aetna will only cover the costs of services required to provide treatment to you, according to the design of the trial. Aetna shall not be responsible for the costs of investigational drugs or devices, the costs of non-health care services, the costs of managing research, or costs which would not be covered under the Columbia Student Medical Insurance Paln for non-experimental or non-investigational treatments provided in such clinical trial.