Medical - Practitioner/organizational provider dispute process quick reference guide
Use this quick reference guide to determine when and where to submit disputes. For a more detailed explanation of the levels of review for claims and utilization review issues, please see the provider dispute process document.
Issue types
Claims issuesrelate to all decisions made during the claims adjudication process (for example, related to the provider contract, our claims payment policies, processing error, etc.), as well as decisions made as a predetermination of services not requiring precertification.
Utilization review issuesrelate 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.
Application of state laws and regulations
To the extent that our policy varies from the applicable laws and/or regulations of an individual state, the requirements of the state regulation apply and supersede our policy, except with respect to 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 any particular law.
Claims issues for reimbursement or coding decisions
Within 180 calendar days of 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. Visit www.aetna.com/provider and select “Medical.”
Level 1 Appeal
Within 60 calendar days of receiving 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 receiving 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
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 receiving 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
