Doctor Visits, Hospital Visits, and Referrals

This section provides information needed when you, your spouse, or your child must visit the doctor or hospital, or are referred to a specialist.

Doctor Visits (for You, Your Spouse, or Your Child)

If you are sick or have hurt yourself, it is best to go to a 'preferred provider'. If you do not visit a 'preferred provider' it is possible that you will be charged more than the 'reasonable and customary charge' which will increase the amount you will have to pay. You can find names of preferred providers at the Aetna Insurance home page. Please remember that even if you visit a preferred provider, you will still be charged the deductible of $50. A deductible is a charge that you must pay before the insurance company will pay its portion of your costs.
If you have an emergency for which you need immediate attention, go to the emergency room of the hospital or call 911 for an ambulance. (You will be charged the $50 deductible.)
If you must go to the hospital, it is best if you choose one of the hospitals that are included in the network for this plan (consult www.aetnaushc.com/docfind). Hospitals in the network cost less than those outside of the network.

The local Dearborn hospital in the network is the Henry Ford Health Systems.

Please consult the insurance brochure for additional information about network providers.

In many cases, the doctor/hospital will bill the insurance company directly. If so, either you will not receive a bill at all or you will be billed for the portion of the services that the insurance company does not cover, such as the deductible.

For an inpatient non-emergency hospital admission, when you will be in the hospital for 18 hours or longer, you must notify the insurance company at least three (3) working days prior to admission in order to obtain Pre-Certification for the hospitalization. Either you, your doctor or the hospital must call the insurance company at 800.239.9697. The insurance company will ask you why you are planning to go into the hospital and will certify your visit over the phone.
For an inpatient emergency admission, you must notify the insurance company by phone within one (1) working day of admission to the hospital. Either you, your representative, your doctor, or the hospital must call the insurance company at 800.239.9697.
Pre-Certification or Notification for hospitalization is required by the insurance company. If you do not follow this procedure, the first $200 of the hospital bill will be your responsibility.

Any time that a physician refers you to another specialist, you will receive a note from the referring doctor. It is a good idea to make a copy of this referral note and keep it for your records because the insurance company might ask to see it.

Last reviewed: 11/07