Disputes & Appeals Overview
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 for HMO-based benefits plans
- 1-888-632-3862 for indemnity and PPO-based benefits plans
Timeframes for reconsiderations and appeals
| Dispute Level | Doctor/Provider submission timeframe | Aetna response timeframe | Contacts |
|---|---|---|---|
| Reconsideration | Within 180 calendar days of the initial claim decision | Within 3-5 business days of receiving the request. Within 30 business days of receiving the request if review by a specialty unit is needed. |
Call: See phone numbers above. Write: See mailing addresses below. Submit online through your secure provider website. |
| Appeals | Within 60 calendar days of the previous decision.* | Within 60 calendar days of receiving the request. If additional information is needed, within 60 calendar days of receiving that information. | Call: See phone numbers above. Write: Aetna Provider Resolution Team PO Box 14020 Lexington, KY 40512. |
*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, MI, 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 |
Policy changes
We have made changes to the complaint and appeal process for practitioners:
- There is now only one level of appeal, rather than two levels.
- All appeals must be submitted in writing, using the Aetna Provider Complaint and Appeal form.
These changes do NOT affect member appeals. Expedited, urgent, and pre-service appeals are considered member appeals and are not affected.
Timing and scope of changes
As of March 1, 2017, the change affected all Aetna medical plans, including Aetna Medicare plans. Non-participating Aetna Medicare providers’ disputes about rate issues and contractual denials also are affected as of the March 1 date.
The change also affects all Aetna dental plans. For these plans, changes went into effect May 21, 2017.
Questions?
For more information, see the Policy Changes section of our FAQ.
Read more about the changes to practitioner complaints and appeals
