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:

  • Reconsiderations: Formal reviews of claims reimbursements or coding decisions, or claims that require reprocessing.
  • Level 1 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.
  • Level 2 appeals: Requests to change a Level 1 appeal decision.

To help us resolve the dispute, we'll need:

  • 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?

Read our dispute process FAQs

Or contact our Provider Service Center (staffed 8 a.m. – 5 p.m. local time):

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.

Level 1 and Level 2* appeals

Within 60 calendar days of the previous decision.**

Within 30 business days of receiving the request. If additional information is needed, within 30 business days of receiving that information.

Call: See phone numbers above.

Write: Aetna Provider Resolution Team PO Box 14020 Lexington, KY 40512.

*Level 2 appeals are generally available only to practitioners.

**The timeframe is 180 calendar days for Level 1 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

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