Here to help you with your health needs

UVA Health Plan Ombuds


About

The UVA Health Plan Ombuds makes health plan information available and understandable for UVA employees. The UVA Health Plan Ombuds can:

  • Answer questions about policies and benefits
  • Listen to complaints and concerns
  • Provide information regarding complaint and appeal procedures and advise on the appropriate course of action
  • Investigate payment problems for submitted claims that employees have been unable to resolve themselves
  • Refer issues to other University offices or committees, as appropriate

Privacy Notice

When sending emails to the UVA Health Plan Ombuds:

  • Do not include your Social Security number
  • Include a telephone number
  • Be aware that email is not secure; there is some risk it could be seen by a third party

All encounters with the UVA Health Plan Ombuds are kept confidential.

About UVA Health Plan

UVA Health Plan is self-funded. UVA pays claims to physicians, hospitals, and other providers directly from employee premiums and from UVA itself.

Aetna is the plan’s third-party medical claims administrator. Aetna determines medical necessity for services. 

Participants should use Aetna network providers in order for claims to be processed as in-network.

Frequently Asked Questions

  • Why did I get a charge for a lab test that the doctor ordered during my yearly physical exam?

    While physical exams that are coded as “preventive” by your participating provider will be processed at 100%, if there are additional tests that are not coded as a “preventive” test (i.e. submitted with a medical condition such as history of high blood pressure) the tests will go towards your deductible and coinsurance as a diagnostic test, even if the test are done during your annual exam. There are specific lab tests that may be designated as preventive.

  • How can I determine costs for a procedure?

    To obtain a costs estimate for an upcoming procedure there are a few options.

    1. Visit the Aetna member portal  Once you have logged on. The Find Care & Pricing tab is located at the top of the site. Click on the tab to open, you can type procedure name within search or click through suggestions within the site. 
    2. Your provider can contact Aetna provider services phone number 888.632.3862. The provider will share diagnosis and procedure coding to obtain an accurate estimate. 
    3. Hospital billing offices can provide costs estimates too. Just obtain the diagnosis and procedure codes from your provider and contact the hospital.

    Here are area resources:  

    UVA Health Price Estimates

    Sentara Martha Jefferson Price Estimates

    Augusta Health Price Estimates

    Centra Price Estimates

    Ballad Health Price Estimates 

  • What is preventive care?

    Preventive care is given to you when you're symptom-free and have no reason to believe you might be unhealthy. Preventive care is often given as part of a routine physical or checkup. Diagnostic care is what you receive when you have symptoms or risk factors and your doctor wants to diagnose them. During a provider's visit, whether it's a physical or medical office visit, if the service is used to diagnose, monitor or treat an illness or injury, then copays, coinsurance and deductibles will apply.

  • Am I covered while traveling abroad?

    Yes, UVA Health Plan members have coverage while traveling abroad. Coverage varies depending on the length of time you are a way. See details below for less than 90 days and 90 day or more coverage. 

    Leaving the Country Less Than 90 Days

    If you or your covered UVA Health Plan family member will be out of the United States for less than 90 days, you are eligible for only emergency or urgent care, at in network benefits, while traveling out of the US. 

    Emergency Room Visits:

    For an emergency room visit, the emergency must be a sudden, unexpected onset of a medical or psychological condition with severe symptoms that could result in serious harm to you if left untreated. 

    Examples of conditions that require emergency room treatment include, but are not limited to:

    • Severe or unusual bleeding
    • Trouble breathing
    • Suspected poisoning
    • Prolonged or repeated seizures
    • Unconsciousness
    • Severe burns

    Urgent Care Visits:

    If you get sick while traveling but do not need to visit the emergency room, you may visit any Urgent care center for treatment and be eligible for In-Network coverage. In order for the Claims Administrator to approve your visit, you cannot receive care considered “routine or non-urgent.” 

    Contacting Aetna:

    Foreign travelers can:

    • Call Aetna at 800.987.9072, member services
    • Call Aetna, Special Case Precertification Unit at 855.888.9046 or 215.775.6445 

    This is a Monday – Friday line. Even if you were in the US, Aetna customer service /authorization department is not available 24/7.

    • Call the Aetna National Medical Excellence Program NME and After-Hours Precertification number: 215.775.6445

    There will be an Aetna resource on call to assist with urgent or acute care needs. 

    • Contact Aetna online through the secure email via Aetna navigator at www.aetna.com

    What You Need to Do:

    1. If you have a medical emergency, go immediately to the nearest participating or non-participating Urgent Care facility or Emergency Room, if appropriate for your condition. You may also call the Aetna Informed Health Line at 1.800.556.1555, which is available 24 hours a day, 365 days a year to participants.
    2. If you are admitted to the hospital, or need outpatient surgery to resolve the emergency, contact the Claims Administrator at Aetna, to notify them of your admission. If you are unable to make the call, have a family member, friend or the hospital call for you. If you are admitted emergently to an out of network hospital, be sure the Out-of-Network provider requests and receives “In-Network” authorization for any “follow up” outpatient services, including surgery, by contacting Aetna at 1.800.987.9072 if you are medically unable to return home.
    3. If you visit an Urgent Care Center for urgent care, contact the Claims Administrator within 48 hours or the next business day.
    4. Remember that any “follow up” care must be obtained in network or must be preauthorized by Aetna at “in network benefits”. Follow up care is defined as treatment occurring after discharge from the emergency or urgent care medical facility, or hospital admission through the emergency room. This can include outpatient surgery following an Emergency room visit, such as for surgical repair of a fracture.
    5. Pay the foreign provider and submit claims for reimbursement to the claims Administrator within 90 days of the date of service to the health insurance for review for possible reimbursement. The UVA Health Plan Ombudsman can assist with submission of foreign claims.

    Leaving the Country 90 Days or More

    If you or your covered UVA Health Plan family member will be out of the United States for 90 days or more, you should enroll in the foreign country enrollment program by completing a Foreign Country Enrollment Form and sending the completed form back to the UVA Health Plan Ombudsman before you leave the US.

    With this foreign country enrollment, you will be covered for eligible routine and emergency services but will need to pay the foreign providers directly and then you should submit your foreign claims to the Claims Administrator within 90 days for reimbursement. Please be sure that you contact Aetna customer service for preauthorization of scheduled inpatient admissions/surgery or as soon as possible following emergency admissions. 

    Contact the UVA Health Plan Ombudsman for a prescription medication vacation override with AetnaRx if you need any prescriptions beyond a 90 day supply or an early “vacation” override refill.

    Contact Aetna for any foreign inpatient admissions, surgery, emergency room services or complex radiology situations as soon as possible. 

    Pay the foreign provider and submit claims for reimbursement to the claims Administrator within 90 days. The UVA Health Plan Ombudsman can assist with submission of foreign claims.

    Contacting Aetna:

    Foreign travelers can:

    • Call Aetna at 1.800.987.9072, member services
    • Call Aetna, Special Case Precertification Unit at 855.888.9046 or 215.775.6445 

    This is a Monday – Friday line. Even if you were in the US, Aetna customer service /authorization department is not available 24/7.

    • Call the Aetna National Medical Excellence Program NME and After-Hours Precertification number: 215.775.6445

    There will be an Aetna resource on call to assist with urgent or acute care needs. 

    • Contact Aetna online through the secure email via Aetna navigator at www.aetna.com