In Maryland:

Medical Referrals:

You'll need referrals for some services
Some benefits plans require you to ask your physician or PCP to request a referral for most eligible health services that are not provided by your physician or PCP. In order to receive an immediate response, we recommend that your physician or PCP submit the referral request electronically. If you don't have a referral when you need one, we won't pay the health care provider.

You don't need a referral for a network Ob/Gyn or for emergency services. If you're pregnant, your Ob/Gyn handles your pregnancy care. If needed, this will include referrals issued according to our policies and procedures.

Standing referrals
We will issue you a standing (or long-term) referral to a network specialist if all the following applies:

• Your PCP and the specialist decide you need continuing care from the specialist
• You have a life-threatening, worsening, long-lasting, or disabling condition or disease that needs specialized care
• The specialist is an expert in treating your condition or disease

Special exception for providers not in the network
You may ask your physician or PCP to request a referral to a specialist (physician or non-physician) who is not part of our provider network. Your physician or PCP may do this if you've been diagnosed with a condition or disease that requires specialized health care services or medical care from a provider we don't have in our network, or if we can't provide access to a provider in our network without unreasonable travel or delay. The specialist must have the training and expertise to provide health care services for this condition or disease.

If your physician or PCP gets precertification before treatment begins with a nonparticipating provider, you will pay the amount that applies to participating providers listed on your schedule of benefits. This means we will calculate any deductible, copayment amount or coinsurance as having been provided in the network. If it is an urgent request, we will make a decision on your physician or PCP's precertification request within a time frame appropriate for your medical condition and within 2 business days after receipt of the information necessary to make the determination. We will make a decision on your physician or PCP's non-urgent precertification request within two business days of the receipt of the request. If your physician or PCP refers you to a nonparticipating provider without getting precertification, then you will pay the amount that applies to nonparticipating providers.

What to do if you disagree with us
Please tell us if you are not satisfied with a response you received from us or with how we do business. Call Member Services at the number on your ID card to file a verbal complaint or to ask for the address to mail a written complaint.

You or your health care provider, acting on your behalf, have a right to file an appeal with us regarding our denial of your referral request. In most cases, you must ask for a review of our decision within 180 days after you receive this denial. Some plans allow for longer times, and are specified in the plan brochure.

You may file an appeal by submitting a complete, written explanation of your grievance together with any supporting documentation to: Appeals Resolution Team, PO Box 14463 Lexington, KY 40512. If additional information is needed, we will notify you and/or the provider within 5 business days of our receipt of the appeal. A decision will be made on the appeal and you and your provider will be notified of the decision within 30 calendar days after the date on which the appeal is filed. For appeal requests regarding the medical need of a service, we will notify you and/or the provider orally, with written notice sent within 5 working days. If the situation requires an expedited review, we will notify you and/or the provider orally within 24 hours of the expedited request. We will send written notice of the decision within 1 day of the oral notice.

If you are in an Aetna DMO® plan, your DMO Primary Care Dentist (PCD) will refer you to a specialty dentist when needed
If you need specialty dental care, your PCD will give you a referral to a specialist who participates in the Aetna network. A “referral” is a written request for you to see another dentist. Some dentists can send the referral electronically to your specialist. There's no paper involved. Talk to your dentist to understand why you should see a specialist.

• When your PCD determines that your treatment should be provided by a specialist dentist, you'll receive a written or electronic referral. The referral will be good for 90 days, as long as you remain covered under the plan.
• Go over the referral with your PCD. Make sure you understand what types of services have been recommended and why.
• When you visit the specialist dentist, bring the referral (or check in advance to verify that they have received the electronic referral).
• You cannot request a referral from your PCD after you have received services from a specialist dentist.
• If a service you need isn't available from a network provider, your PCD may refer you to an out-of-network provider. Your PCD must get precertification from Aetna and issue a special out-of-network referral for services from out-of-network providers to be covered at the network level of coverage.

Here is our timeline for responding to your request
We will respond to your request for referral to a dental specialist within 15 days after we receive all information necessary to complete our review.

What to do if you disagree with us
Please tell us if you are not satisfied with a response you received from us or with how we do business.

Call Member Services to file a verbal complaint or to ask for the address to mail a written complaint. The phone number is 1-877-238-6200. You can also send us an e-mail through our secure member website, www.aetna.com. If you're not satisfied after talking to a Member Services representative, you can ask us to send your issue to the appropriate complaint department.