As a specialty of Acupuncture, Aetna actually has NO acupuncturist network in Virginia (VA), Washington DC area.
Aetna only has one acupuncture discount rate network through ASH, i.e. American Specialty Health Acupuncture network. So, it means any acupuncturist has to accept a discount fee schedule if he/she join the ASH network when treating a patient who has Aetna insurance.
But, sometime, if the patient has Aetna Acupuncture benefit, Aetna may pay the acupuncture provider at a out-of-network fee schedule (see, save money) –i.e., according to the rule, Aetna should have an acupuncturist network (but has NONE), then Aetna could pay the provider treating its HMO/EPO patient, –Aetna may refuse to pay, because no acupuncturist is in-network. Sometime Aetna may pay the treatment for PPO patients who have acupuncture benefit (as an out-of network, 50%-70%, patient need pay more, such as high deductible due to out-of-network, high percentage of coinsurance, 30-50%), which Aetna may also refuse to pay…….the reasons—medical unnecessary, or acupuncture benefit only for acupuncture anesthesia—that means it should be done when surgery by is done by an MD—not by an acupuncturist.
Aetna insurance is not very clear about the acupuncture network issues, acupuncture benefit definition, HMO, EPO, PPO, etc. , and payment.
Appeal? No one will say that “my processing was wrong” in Aetna insurance office. The representatives seem to always have many reasons to refuse any appeal.