Service Without Borders: Aetna’s new servicing framwork program

Aetna has redesigned their internal workflow to increase efficiency and provide members with a better customer service experience. See highlights of this redesign below:

  • Issues resolved faster, the first time. Aetna Customer Service Representatives will use lifelines that give them real-time access to support areas.
  • Those representatives will also educate and guide members on the benefits of Aetna’s digital tools and programs.
  • Aetna Customer Service Representatives are now empowered to make claim decisions* in certain situations while giving guidance on how to make the best use of plan benefits.  For example:
    • They will be able to allow payment at the in-network benefit level for an out-of-network provider for the first visit.
    • If a participating provider orders a covered service, they will honor it at the network benefit level (with proper limits for extremely expensive services).
    • If a benefit was misquoted (par/no par), an Aetna Customer Service Representative can send the claim for payment.
    • Aetna Customer Service Representatives will even be able to retroactively approve two associated visits in the past three months to an out-of-network provider with documented clinical decision (network deficiency). This helps to resolve issues earlier.

*Members will automatically be provided this service model. Self-funded plan sponsors have the option to opt-out of this service. Aetna assumes Self-funded plan sponsors are participating unless they choose to opt-out by 7/17/17. 


Aetna Servicing Framework Program


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