Accessing Care
When you're enrolled in KingCareSM, you may receive network benefits or out-of-network benefits. The level of coverage depends on the provider you see.
To receive network benefits:
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you must choose an Aetna network provider;
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for certain procedures and services, your network provider obtains preauthorization from Aetna;
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your provider files your claims, and Aetna reimburses the provider;
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you receive an explanation of benefits (EOB) from Aetna, informing you of applicable deductibles, coinsurance and copays, and indicating your share of the cost; and
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you receive a bill from your provider, and you pay the provider the amount indicated on the EOB.
To receive out-of-network benefits:
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you choose an out-of-network provider;
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you must obtain preauthorization from Aetna for certain procedures and services (For more information, see "Preauthorization");
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you pay the bill in full and file a claim for reimbursement from Aetna;
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Aetna reimburses you based on the out-of-network benefit at reasonable and customary rates (For important details about reasonable and customary charges, see "Reasonable and Customary (R&C) Charges"); and
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you're responsible for paying any amount in excess of the R&C rates.
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