Dispute & Appeal Process

Health care professionals and organizational health care providers can dispute adverse decisions. The information below explains when and how to submit a dispute. It applies to all our medical benefits plans. (Please note that state requirements take precedence when they differ from our policy.)

Aetna has a formal process that allows participating and non-participating dentists to file an appeal. Learn more about Aetna's Provider Appeal Process.

Aetna has a formal process for Medicare Advantage Plan provider payment dispute resolution for non-contracted providers.  (PDF, 70 KB)

Aetna has a formal process for Medicare Advantage Plan provider payment appeal resolution for non-contracted providers.  (PDF, 137 KB)

Got Questions? 

See our answers regarding the insurance dispute process.

Definitions

The following definitions apply in an insurance dispute: 

Practitioners:
An individual who is licensed or otherwise authorized by the State to provide health care services. Examples include doctors, podiatrists and independent nurse practitioners.

Organizational providers: 
Institutional providers and suppliers of health care services including behavioral health care organizations. Examples of organizational providers include, but are not limited to: hospitals, nursing homes; skilled nursing facilities (SNF), home care agencies, free standing surgical centers, birthing centers, urgent care centers, pain management centers, ambulance services, pharmacy, hospice, infusion centers, blood banks, diagnostic testing centers, diabetic treatment centers, residential treatment facilities, MRI centers, independent durable medical equipment vendors, orthotics facilities, oncology treatment centers, optical facilities, and sleep diagnostic center.

Behavioral health organizations include, but are not limited to mental health and chemical dependency hospitals, residential treatment facilities, partial hospital programs, intensive outpatient programs and clinics. Behavioral health organizations can be freestanding or hospital-based.

Additionally, in networks where the Medicare product is offered, the organizational providers must include: laboratories, comprehensive outpatient rehabilitation facilities, outpatient physical therapy and speech pathology providers, and providers of end-stage renal disease services.

Dispute: 
A disagreement regarding a claim or utilization review decision.

Reconsideration: 
A formal review of a previous claim payment decision as a result of an organizational provider/practitioner inquiry. If an organizational provider/practitioner’s issue is eligible for the reconsideration, it takes place prior to the appeal process. Examples include, but are not limited to: 

• Provider contract issues
• Claim payment policies
• Processing error

Level 1 appeal: 
An oral or written request by a practitioner/provider to change:

• An adverse reconsideration decision
• An adverse initial claim decision based on medical necessity or experimental/investigational coverage criteria
• An initial precertification/patient management review decision

Practitioners and organizational providers may request Level 1 appeals. After the first level of appeal, the internal Aetna appeal process for organizational providers is exhausted.

Claims issues:
Issues relate to all decisions made during the claims adjudication process, including those that result in an overpayment, (for example, related to the provider contract, our claims payment policies, processing error, etc.).

Utilization review: 
Issues relate to decisions made during the precertification, concurrent or retrospective review processes for services that require precertification. For these types of issues, the practitioner/organizational provider appeal process only applies to appeals received subsequent to the services being rendered. The member appeal process applies to appeals related to pre-service or concurrent medical necessity decisions.

Level 2 appeal: 
An oral or written request by a practitioner to change a Level 1 appeal decision.

The dispute process 

Dispute
A practitioner or organizational provider may submit a dispute in one of three ways: 

1. Write to the P.O. box listed on the Explanation of Benefits (EOB) statement, denial letter or overpayment letter related to the issue being disputed. 
2. Call our Provider Service Center at:
   -- 1-800-624-0756 for HMO-based benefits plans and WA Primary Choice plans
   -- 1-888-632-3862 for indemnity and PPO-based benefits plans
3. Submit online through the EOB claim search tool – log in to the secure provider website via  NaviNet®to access this tool.

You have 180 days from the date of the initial decision to submit a dispute. However, you may have more time if state regulations or your organizaional provider contract allows more time.

To facilitate the handling of an issue, you should:

• State the reasons you disagree with our decision.
• Have the denial letter, EOB statement or overpayment letter and the original claim available for reference.
• Provide appropriate documentation to support your payment dispute (for example, a remittance advice from a Medicare carrier; medical records; office notes, etc.).

Claims payment disputes related to reimbursement or coding are subject to our reconsideration process. Initial adverse claims decisions based on medical necessity or experimental or investigational coverage criteria are handled as Level 1 appeals and reviewed by clinicians. Utilization review disputes are handled as Level 1 appeals and reviewed by clinicians as well.

Reconsideration

If you would like to dispute a claim payment decision, contact us to have the decision reconsidered. This is the first step in disputing a claim payment decision.

A provider service center representative will research the handling of the claim in question. We will generally resolve claims payment issues related to contract application within three to five business days. If the decision is in your favor, we will recalculate and reprocess the claim for any services affected by the decision.

It may be necessary to forward claims payment issues involving reimbursement or coding reviews to a specialty unit for investigation and resolution. We will issue a response within 30 business days if no additional information is required, or within 30 business days of when the specialty unit receives any additional requested information. If the decision is in your favor, we will recalculate and reprocess the claim for any services affected by the decision.

Following reconsideration, if the decision is not in your favor, you may initiate a Level 1 appeal. We will provide instructions on how and when to file an appeal when we issue the reconsideration decision.

Level 1 appeal
You may request a Level 1 appeal, either verbally or in writing, if you are not satisfied with:

• The reconsideration decision (for claims disputes)
• An initial claim decisions based on medical necessity or experimental/investigational coverage criteria
• An initial precertification/patient management review decision

We will notify you of our Level 1 decision in writing within 30 business days of our receipt of the appeal, unless we need additional information. If we need additional information, we will send the Level 1 appeal decision within 30 business days of receipt of the additional requested information.

If the Level 1 appeal decision is in your favor, we will recalculate and reprocess the claim for any services affected by the decision. If the Level 1 appeal decision upholds our original position, we will send a written response.

• For practitioners, the notice will include information about their right to request a review of the adverse determination as a Level 2 appeal.
• For organizational providers, the notice will include our final determination.

Level 2 appeal
If practitioners are not satisfied with the Level 1 appeal decision, they may request a Level 2 appeal, either verbally or in writing, within 60 calendar days from the date of the Level 1 appeal decision. Organizational providers are not eligible for a Level 2 appeal, except as required by state regulations.

For appeals of a utilization review, medical necessity or experimental/investigational coverage criteria, a reviewer not associated with the Level 1 appeal will examine the Level 2 appeal. We will notify you of our Level 2 appeal decision within 30 business days of our receipt of the appeal, unless we need additional information. If we need additional information, we will send the Level 2 appeal decision within 30 business days of receipt of the additional requested information.

If the Level 2 appeal decision is in your favor, we will recalculate and reprocess the claim for any services affected by the decision. If the Level 2 appeal decision upholds our original position, we will send a final resolution letter.

Post-appeal review process
If you have exhausted our appeal processes, there may be an opportunity for additional review by an external organization. There is no fee for using our appeal process. However, if you pursue an independent external review process, you may be charged.

Medical necessity external review
Physicians can also obtain an independent review of disputed medical necessity issues when a plan member has access to external review under our external review policy or applicable law. The final resolution letter indicates if an organizational provider has access to external review.

Under this process, an Aetna-contracted independent review organization (IRO) will perform an external third-party binding review of eligible medical necessity and experimental or investigational coverage denials. State mandates related to external review will take precedence.

We will process practitioner appeals related to pre-service, concurrent or urgent medical necessity review decisions as member appeals, and they may be subject to the member external review process.

Eligible practitioners may request external review when all of the following criteria are met:

1. Internal appeals are exhausted.
2. The coverage denial involves more than $500.
3. The coverage denial is based on lack of medical necessity, or it is determined that the service at issue is experimental or investigational.
4. The member has not previously or concurrently requested an external review of
   the coverage denial.

Learn more about our member medical necessity external review process.

State laws and regulations
To the extent that our policy varies from the applicable laws or regulations of an individual state, the requirements of the state regulation apply and supersede our policy.

State law does not supersede our policy in appeals relating to Aetna Medicare plans. State laws do not apply to Medicare plans. Aetna’s law department makes the final determination when there is any question as to the applicability of a law.

Questions
If you have questions about our appeal process, please contact our provider service center:

• 1-800-624-0756 for HMO-based benefits plans and WA Primary Choice plans
• 1-888-632-3862 for indemnity and PPO-based benefits plans

State-specific forms

Arizona Definitions and Requirements for Provider Grievances 
Health Care Provider Rights - Timely Pay  (PDF, 73 KB)

Timely Pay and Grievance Law - Regulatory Bulletin 2006-02  (PDF, 63 KB)

California 
Aetna's practitioner/provider dispute resolution policy for California HMO business  (PDF, 81 KB)

New Jersey 
New Jersey Provider Appeal Procedure  (PDF, 21 KB)

New Jersey Department of Banking and Insurance Health Care Provider Application to Appeal a Claim Determination  (PDF, 54 KB)