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Guidelines for Determining Coverage | Clinical Policy Bulletins | Medicare | Payment Policy | Dispute Process

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Medical - State Exceptions to Timely Dispute Filing Rule

In the absence of an exception below, Aetna's 180 day dispute filing standard will apply.

AZ   CA   CO   FL  GA   IA   IN   KY   MD   NJ   NC   OH   OK   RI   TN   TX   WA

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 Practitioners -- participating and nonparticipating, effective with claims paid on or after 11/1/08 12 months
Georgia GA All providers -- participating and nonparticipating 12 months
Indiana IN All providers -- participating and nonparticipating, effective with claims paid on or after 7/1/06 2 years (from claim payment date)
Iowa IA All providers -- participating and nonparticipating 2 years
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" 90 calendar days from the notice of the disputed claim determination
New Jersey NJ All providers treating fully-insured NJ contracted members that fail to submit their dispute within 90 calendar days from the notice of the disputed claim determination. Such disputes will not be eligible for review by New Jersey's Program for Independent Claims Payment Arbitration (PICPA). 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
Rhode Island RI All providers -- participating and nonparticipating 2 years
Tennessee TN All providers -- participating and nonparticipating 18 months
Washington WA All Listed providers -- participating and nonparticipating, effective 1/1/06 24 months (or 30 months for 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)
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