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Dispute & Appeal Process:
Quick reference guide

This quick reference guide shows you when and where to submit disputes

Issue types 

Claims issues
These issues relate to all decisions made during the claims adjudication process. For example, related to the provider contract, our claims payment policies, processing errors.

Utilization review issues
These issues relate to decisions made during the precertification, concurrent or retrospective review processes for services that require precertification. For these issues, the practitioner and 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.

Application of state laws and regulations

If our policy varies from the applicable laws or regulations of an individual state, the requirements of the state regulation supersede our policy. However, appeals relating to Aetna Medicare plans are an exception. State laws do not apply to Medicare plans. Aetna’s law department makes the final determination if there is any question regarding the applicability of any particular law.

Claims issues for reimbursement or coding decisions

Dispute Level  Practitioner/Organizational Provider Submission Timeframe Aetna Response Timeframe Contact Information 
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 (for example, clinical coding review)

Call ~ 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

Write See reconsideration mailing addresses below

Submit online through the EOB claim search tool. Log in to the secure provider website via NaviNet® to access this tool.

Level 1 Appeal  

Within 60 calendar days of the reconsideration decision

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

Call ~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

Write Aetna Provider Resolution Team P.O. Box 14020 Lexington, KY 40512

Level 2 Appeal (available only to practitioners)

Within 60 calendar days of the Level 1 appeal decision

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

Call ~ 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

Write Aetna Provider Resolution Team P.O. Box 14020 Lexington, KY 40512



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 P.O. 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 P.O. Box 981106 El Paso, TX 79998-1106



Utilization review issues or claim issues based on medical necessity or cosmetic or experimental/investigational coverage criteria 

Dispute Level  Practitioner/Organizational Provider Submission Timeframe  Aetna Response Timeframe Contact Information 
Level 1 Appeal 

Within 180 calendar days of an initial claim decision or utilization review decision

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

Call ~ 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

Write Aetna Provider Resolution Team P.O. Box 14020 Lexington, KY 40512

Level 2 Appeal (available only to practitioners)

Within 60 calendar days of the Level 1 appeal decision

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

Call ~ 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

Write Aetna Provider Resolution Team P.O. Box 14020 Lexington, KY 40512