Dispute level
Our process for disputes and appeals
Health care providers can use the Aetna dispute and appeal process if they do not agree with a claim or utilization review decision.
The process includes:
- Peer to Peer Review - Aetna offers providers an opportunity to present additional information and discuss their cases with a peer-to-peer reviewer, as part of the utilization review coverage determination process. The timing of the review is prior to an appeal and incorporates state, federal, CMS and NCQA requirements.
- Reconsiderations: Formal reviews of claims reimbursements or coding decisions, or claims that require reprocessing.
- Appeals: Requests to change a reconsideration decision, an initial utilization review decision, or an initial claim decision based on medical necessity or experimental/investigational coverage criteria.
To help us resolve the dispute, we'll need:
- A completed copy of the appropriate form
- The reasons why you disagree with our decision
- A copy of the denial letter or Explanation of Benefits letter
- The original claim
- Documents that support your position (for example, medical records and office notes)
Have dispute process questions?
Or contact our Provider Service Center (staffed 8 a.m. - 5 p.m. local time):
- 1-800-624-0756 ${tty} for HMO-based benefits plans
- 1-888-632-3862 ${tty} for indemnity and PPO-based benefits plans
Timeframes for reconsiderations and appeals
|
|
Doctor / provider submission timeline |
Aetna response timeframe |
Contacts |
|---|---|---|---|
|
Reconsideration |
Within 180 calendar days of the initial claim decision. |
Within 45 business days of receiving the request, depending on the matter in question, and if review by a specialty unit is needed. |
Submit online and check the status through your secure provider website. Write: See mailing addresses below. Call: See phone numbers above. |
|
Appeals |
Within 60 calendar days of the previous decision.* |
Within 60 business days of receiving the request. If additional information is needed, within 60 calendar days of receiving that information. |
Call: See phone numbers above.
Write: Medicare contracted appeals use: Medicare Provider Appeals PO Box 14835 Lexington, KY 40512 Fax 860-900-7995
Medicare non contracted appeals use: Medicare Non Contracted Provider Appeals PO Box 14067 Lexington, KY 40512 Fax 724-741-4953
Non Medicare appeals use: Aetna Provider Resolution Team PO Box 14020 Lexington, KY 40512 Fax 859-455-8650 |
Dispute level |
Reconsideration |
|---|---|
Doctor / provider submission timeline |
Within 180 calendar days of the initial claim decision. |
Aetna response timeframe |
Within 45 business days of receiving the request, depending on the matter in question, and if review by a specialty unit is needed. |
Contacts |
Submit online and check the status through your secure provider website. Write: See mailing addresses below. Call: See phone numbers above. |
Dispute level |
Appeals |
Doctor / provider submission timeline |
Within 60 calendar days of the previous decision.* |
Aetna response timeframe |
Within 60 business days of receiving the request. If additional information is needed, within 60 calendar days of receiving that information. |
Contacts |
Call: See phone numbers above.
Write: Medicare contracted appeals use: Medicare Provider Appeals PO Box 14835 Lexington, KY 40512 Fax 860-900-7995
Medicare non contracted appeals use: Medicare Non Contracted Provider Appeals PO Box 14067 Lexington, KY 40512 Fax 724-741-4953
Non Medicare appeals use: Aetna Provider Resolution Team PO Box 14020 Lexington, KY 40512 Fax 859-455-8650 |
*The timeframe is 180 calendar days for appeals involving utilization review issues or claims issues based on medical necessity or experimental/investigational coverage criteria.
Mailing addresses for reconsiderations
|
State |
Address |
|---|---|
|
AL, AK, AR, AZ, CA, FL, GA, HI, ID, LA, MS, NC, NM, NV, OR, SC, UT, TN, WA |
Aetna Provider Resolution Team PO Box 14079 Lexington, KY 40512-4079 |
|
CO, CT, DC, DE, IA, IL, IN, KS, KY, MA, MD, ME, Ml, MN, MO, MT, NE, ND, NH, NJ, NY, OH, OK, PA, RI, SD, TX, VA, VT, WI, WV, WY |
Aetna Provider Resolution Team PO Box 981106 El Paso, TX 79998-1106 |
State |
AL, AK, AR, AZ, CA, FL, GA, HI, ID, LA, MS, NC, NM, NV, OR, SC, UT, TN, WA |
|---|---|
Address |
Aetna Provider Resolution Team PO Box 14079 Lexington, KY 40512-4079 |
State |
CO, CT, DC, DE, IA, IL, IN, KS, KY, MA, MD, ME, Ml, MN, MO, MT, NE, ND, NH, NJ, NY, OH, OK, PA, RI, SD, TX, VA, VT, WI, WV, WY |
Address |
Aetna Provider Resolution Team PO Box 981106 El Paso, TX 79998-1106 |
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Legal notices
Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates (Aetna).
Health benefits and health insurance plans contain exclusions and limitations.