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.
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