Provider Appeals

Dispute & Appeal Process:
State exceptions to filing standard

In the absence of an exception below, Aetna's 180-day dispute filing standard will apply. The exceptions below apply to requests regarding members covered under fully insured plans only.

State

Abbrv.

Exception Applies To

Time Allowed to File an Initial Claim Payment Dispute

Arizona

AZ

All providers -- participating and nonparticipating

1 year

California HMO

CA

All providers -- participating and nonparticipating, when the request relates to an HMO member and the date of service is on/after 1-1-04

365 days

California Traditional

CA

All providers -- participating and nonparticipating, when the request relates to a traditional member and the appeal is received on/after 6/29/09

180 days

Colorado

CO

All providers -- participating and nonparticipating

12 months

Florida

FL

All participating or nonparticipating licensed physicians or physician assistants (or practitioners licensed under FL Ch. 458), osteopathic physicians, chiropractors, podiatrists or dentists

12 months (does not apply to facilities)

Georgia

GA

All providers -- participating and nonparticipating

24 months from date of service or discharge

Indiana

IN

All providers -- participating and nonparticipating, effective with claims paid on or after 7/1/06

2 years (from claim payment date)

Kentucky

KY

participating providers only

2 years

Maryland

MD

All providers -- participating and nonparticipating

365 days

New Jersey

NJ

All providers treating fully-insured NJ contracted members and submitting their dispute using the "Health Care Provider Application to Appeal a Claims Determination Form" will be eligible for review by New Jersey’s Program for Independent Claims Payment Arbitration (PICPA).

90 calendar days from the notice of the disputed claim determination

New Jersey

NJ

No health care provider treating fully-insured NJ contracted members shall seek reimbursement from a payer or covered person for underpayment of a claim later than 18 months from the date the first payment on the claim was made. After 90 calendar days from the notice of the disputed claim determination the provider shall not be eligible for PICPA (see above).

18 months from the date the first payment of a claim was made

North Carolina

NC

All providers -- participating and nonparticipating

2 years from the original claim payment

Ohio

OH

All providers -- participating and nonparticipating

2 years

Oklahoma

OK

All providers -- participating and nonparticipating

2 years

Oregon

OR

All providers -- participating and nonparticipating providers

24 months from the claim denial or payment date, upon written requests (or 30 months if COB issues)

Rhode Island

RI

All providers -- participating and nonparticipating

18 months

Tennessee

TN

All providers -- participating and nonparticipating

18 months

Utah

UT

All providers -- participating and nonparticipating

24 months if the improper payment was due to a coordination of benefits error.

36 months if the improper payment was due to a recovery by Medicaid, Medicare, the Children's Health Insurance program or any other state or federal health care program.

12 months if the improper payment was due to any other reason.

Washington

WA

All listed providers -- participating and nonparticipating, effective 1/1/06

24 months from the claim denial or payment date, upon written requests (or 30 months if COB issues)

State

Abbrv.

Exception Applies To

Time Allowed to File & Pursue a Dispute

Texas

TX

All participating providers and nonparticipating providers who are paid on a participating basis (examples include an emergency situation, a network inadequacy issue, a nonparticipating provider who is pre-approved by Aetna or a hospital-based physician who is a nonparticipating provider but provides services at a participating facility)

4 years for claims and non-claims issues -- (complaints are handled as appeals in TX)

TAC 21.2809

A preferred provider that received an underpayment in relation to an audit must notify Aetna within 180 days per Tx law to qualify to receive a penalty for the underpaid amount.

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