Guidance on submitting Ingenix settlement claims

March 28, 2014, is the deadline for eligible psychologists to submit claims.

You may be eligible to participate in a class action lawsuit settlement if you provided out-of-network health care services to Aetna Plan members during the period from June 2003 to August 2013. March 28, 2014, is the deadline for eligible psychologists and other class members to submit their claims under the settlement. 

Guidance on submitting claims in the Aetna class action lawsuit settlement 

On Dec. 7, 2013, Aetna Inc. agreed to a proposed $120 million settlement of a class action lawsuit filed by psychologists, other health care providers and patients in federal court in New Jersey. The APA Practice Organization has been collaborating actively with the New Jersey Psychological Association, a named plaintiff in this lawsuit, since 2009.

Aetna and its subsidiaries (except recently acquired Coventry Health) have agreed to settle this lawsuit for $120 million to avoid further litigation. Sixty million dollars will be paid out of a general settlement fund and an additional $60 million is available to pay those who submit valid claims. 

Here is an overview of who qualifies to participate in the settlement and how you can submit valid claims to the settlement fund:

1. Who may participate in the settlement?

There are two classes of settlement participants: 

  1. provider class members — out-of-network1 psychologists and other health care providers (individual or practice) who provided covered services to Aetna subscribers during the period of June 3, 2003, through Aug. 30, 2013; and 
  2. subscriber class members —individuals who were covered under Aetna and received covered services or supplies from an out-of-network provider.
2. When are claims due?

Completed claim forms must be postmarked no later than March 28, 2014. Any claims postmarked after that date may not be accepted.

Claims should be mailed to:

Aetna UCR Litigation — Provider
c/o Berdon Claims Administration LLC
P.O. Box 15000
Jericho, NY 11853-0001

Claims may not be submitted electronically. 

The settlement will not become final until it is approved at the fairness hearing scheduled for March 18, 2014. We expect that the court will approve the settlement so you are encouraged not to wait for final approval before submitting your claim. Otherwise, you risk missing the March 28 deadline.

3. I provided covered services to Aetna members as an out-of-network provider. How do I submit a claim for settlement funds?

As an eligible provider, you have two options for submitting a claim. However, you must choose one of the two options as described on the first page of the provider claim form; you may not submit a claim under both options.

(a) Option 1 — Simplified Provider Claim

This simplified claim form requests basic information, such as your contact information, as well as those years between June 3, 2003 and Aug. 30, 2013, when you provided and billed for covered out-of-network services to patients insured under Aetna. You do not need to provide supporting documentation under this option.

If you choose this option and your claim is deemed eligible under the settlement fund, you may receive up to $40 for each year that you provided covered services as an out-of-network provider and received reimbursement less than the billed amount for that service.

For this option, you would complete Section A of the provider claim form (PDF, 151KB; see pp. 11-12) and the certification section (page 14).

(b) Option 2 — Provider Claim

This option is only available to those out-of-network providers who (1) received an assignment2 from an Aetna insured and (2) sent the Aetna insured a balance bill3 but did not receive full payment for the covered service.

If you choose this option and your claim is deemed eligible under the settlement fund, you may receive up to 5 percent of the allowed amount4 on each valid claim submitted for which you can provide necessary supporting documentation. Your claim represents the total amount of balance bills and must exceed $750 for individual out-of-network providers (or $1,000 for out-of-network provider groups). Any claim less than these amounts will be ineligible for payment under this option and not receive payment. However, such claim may be eligible for payment under Option 1. So if your balance billed amounts are below these limits, we recommend that you file under Option 1.

Under Option 2, you will need to provide supporting documentation in addition to the following information requested in the claims chart (page 13) included in the claims form:

  • CPT code or description of the covered service provided.
  • Date of service.
  • Name of patient/Aetna Plan member.
  • Original billed amount and allowed amount.
  • Attestation of member assignment.
  • Any payments received for said service and payment source.
  • Amount of balance bill sent to Aetna Plan member and whether payment of balance bill was received.

Valid, supporting documentation includes documentation evidencing that the Aetna Plan member assigned his/her claim to you as the provider; documentation of a balance bill sent to the Aetna Plan member prior to Aug. 30, 2013; and documentation showing that the balance bill was not paid, in whole or in part.

For this option, you would need to complete sections A and B as well as the certification section of the provider claim form (see pp. 11-14 in the above link). If you need additional data tables for the claim form, the chart is available on the settlement administrator’s website (PDF, 43KB). 

4. What if I do not have all of the necessary information to submit a claim under either provider option?

To assist providers and subscribers interested in submitting claims, Aetna has made certain claims information for the relevant time period available to the settlement administrator. You may request your claims information from the settlement administrator to use in completing your settlement claim form. The Claims information request authorization form (page 15) must be used to obtain the relevant claims information. You should select the provider option on the form and provide your tax ID number and contact information. The authorization form asks for a notice number. If you do not have that number, write “not available” in the space provided.

5. What if the claims information from the settlement administrator is incomplete or incorrect?

Since Aetna did not necessarily provide complete records to the settlement administrator, it is possible that the information you receive may not be complete or correct. Make your changes and corrections on the report you requested and received from the settlement administrator. You should use the data tables listed under Section B of the claim form to update or add omitted information if you are submitting a claim under Option 2. Be sure to print your name and tax ID number at the top of each sheet. It is important that you send proper documentation for all changes and updates for your claim to be valid. 

6. I plan to submit a claim. When can I expect to receive payment under the settlement?

The settlement must be approved as final by the court. The final settlement hearing is set for March 18, 2014. The settlement funds will be distributed on a pro-rata basis so all valid claims will be paid at the same time. All claims are first reviewed and evaluated and then claimants with deficient claims are given a chance to correct them. Since Aetna insures millions of people, it is anticipated that a very large number of claims will be submitted, so this review process may take a substantial amount of time. (On the previous Ingenix settlement — with United — it took well over one year between the deadline for submitting claims and psychologists’ receipt of payment checks.) After the court approves the distribution, payments will be made to eligible claimants based on the settlement administrator’s findings.

7. What happens if I do not submit a claim?

If you do not submit a claim form, you will not receive payment from the settlement fund and you give up your rights to sue Aetna over the claims covered by this settlement.

If you want to be excluded from this settlement so that you can sue Aetna individually over claims covered by this settlement, you must submit a signed request for exclusion by mail to the settlement administrator. Your request for exclusion must include your name, address and federal Social Security Number or Tax ID number and a statement that you wish to be excluded from the settlement class. Your request for exclusion must be mailed to the settlement administrator:

Aetna UCR Litigation — Exclusions
c/o Berdon Claims Administration LLC
P.O. Box 15000
Jericho, NY 11853-0001

Your request for exclusion must be postmarked no later than Feb. 26, 2014. You should note that exclusion from this settlement renders you ineligible from receiving payment under the settlement fund.

8. Whom do I contact if I have questions about the settlement or submitting a claim?

APA Practice Organization members may contact the APA Practice Office of Legal & Regulatory Affairs at (800) 374-2723, ext. 5886 or by email with any questions.

You may also obtain copies of the settlement notice and claims documents as well as responses to frequently asked questions (FAQs) from the settlement administrator:

Mail
Aetna UCR Litigation 
c/o Berdon Claims Administration LLC
P.O. Box 15000
Jericho, NY 11853-0001
Email

Phone
(800) 600-3079

Fax
(516) 393-0031


1Those who did not have a valid written contract with Aetna to provide covered services to its insureds.

2“Assignment” is defined under the settlement agreement as the election by an Aetna plan member permitting an out-of-network provider to bill and receive reimbursement from Aetna directly.

3“Balance bill” is defined under the settlement agreement as the demand for payment from an out-of-network provider to an Aetna Plan member for the difference between the billed amount and the allowed amount. This excludes any bill for denied claims, co-insurance or deductibles.

4“Allowed amount” is defined under the settlement agreement as the amount Aetna determined to be eligible for reimbursement for a plan member’s covered services billed by an out-of-network provider before application of co-insurance, deductibles or coordination of benefits coverage under another plan.