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Dispute and appeals process FAQs for health care providers

 

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Dispute process and timeframes

Any health care professional who provides health care services to Aetna members can use the dispute process. In terms of our dispute process:

 

  • Practitioners are individuals or groups who are licensed or otherwise authorized by the state in which they provide health care services to perform such services. Examples include physicians, podiatrists and independent nurse practitioners.
  • Organizational providers are institutional providers and suppliers of health care services. Examples include hospitals, skilled nursing facilities, independent durable medical equipment vendors and behavioral health organizations, such as mental health or residential treatment.

 

A dispute is a disagreement regarding a claim or utilization review decision.

You may contact us within 180 days of receiving the decision. State regulations or your provider contract may allow more time.

 

Reconsiderations can be submitted online, by phone or by mail/fax. 

 

Appeals must be submitted online through our provider website on Availity,or by mail/fax, using the appropriate form on forms for health care professionals.*

 

To facilitate handling:
 

  • State the reasons you disagree with our decision
  • Have the denial letter or Explanation of Benefits (EOB) statement 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).

 

If the request does not qualify for a reconsideration as defined below, the request must be submitted as an appeal online through our provider website on Availity, or by mail/fax, using the appropriate form on forms for health care professionals.*

 

*Exceptions may exist based on your state’s regulations.

1-800-624-0756 (TTY: 711) for HMO-based benefits plans
1-888-632-3862 (TTY: 711) for indemnity and PPO-based benefits plans

For the mailing address, see the denial letter or Explanation of Benefits (EOB) statement.

A reconsideration is a formal review of a previous claim reimbursement or coding decision, or a claim that requires reprocessing where the denial is not based on medical necessity or non-inpatient services denied for not receiving prior authorization.

An appeal is a written request by a practitioner/organizational provider to change:
 

  • An adverse reconsideration decision
  • An adverse initial claim decision based on medical necessity or experimental/investigational coverage criteria
  • A denial for non-inpatient hospital services that were denied for not receiving prior approval
  • An adverse initial utilization review decision

Claims decisions are all decisions made during the claims adjudication process: For example, decisions related to the provider contract, our claims payment policies or a processing error.

 

Utilization review decisions are decisions made during the precertification, concurrent or retrospective review processes for services that require precertification. For these types of issues, the practitioner and organizational provider appeal process applies only 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.

When you are requesting a review for medical necessity of the service, you should provide medical records.

No. According to our policies, we only allow one level of appeal for practitioners or providers.

You may request an expedited appeal. Expedited appeals are available when precertification of urgent or ongoing services has been denied and a delay in decision making might seriously jeopardize the life or health of the member or otherwise jeopardize the member’s’ ability to regain maximum function.

 

We will resolve expedited appeals within 36 hours of receipt for a two level appeal process or 72 hours for a one level appeal process or within state mandated guidelines. Please note that the member appeals process applies to expedited appeals. Post-service appeals are not eligible for expedited handling. Refer to the member health plan benefits FAQs for more details.

No. However, there may be a charge if you decide to pursue an independent external review process.

State law supersedes our process for disputes and appeals when they apply to the member’s plan. We follow all state laws and regulations. State mandates requiring different time periods will take precedence, except as previously noted.

 

Appeals relating to Aetna Medicare plans and most self-insured plan sponsors are an exception. Generally, state laws do not apply to these plans.

A member may designate a practitioner or organizational provider as an "authorized representative" to file an appeal on his or her behalf for claims involving pre-service, urgent care or inpatient urgent concurrent review. The practitioner or organizational provider must be the member's primary physician or a health care professional with knowledge of the member’s medical condition. The member appeal process applies to pre-service appeals.

Yes. The appeal request must clearly indicate that you are acting on the member’s behalf and you must complete and have the member sign and date the Authorized Representative Request form. Return the form with the appeal request to authorize you to appeal on the member's behalf in order to access member appeal rights.

 

Get the Authorized Representative Request form (PDF)

 

Reconsiderations versus appeals

You may contact us within 180 days of receiving the decision. State regulations or your provider contract may allow more time.

 

Reconsiderations can be submitted online, by phone or by mail/fax.

 

Appeals must be submitted online through our provider website on Availity, or by mail/fax, using the appropriate form on forms for health care professionals.*

 

To facilitate handling:
 

  • State the reasons you disagree with our decision
  • Have the denial letter or Explanation of Benefits (EOB) statement 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).

 

*Exceptions may exist based on your state’s regulations.

1-800-624-0756 (TTY: 711) for HMO-based plans and Medicare Advantage plans
1-888-632-3862 (TTY: 711) for all other plans

The address is on the denial letter or Explanation of Benefits (EOB) statement in question.

We will route your request to the appropriate team.

The request will be routed to the appropriate area. If the request did not include the appeal form, we will notify you that it needs one in order to be handled as an appeal.

 

Appeals must be submitted online through our provider website on Availity, or by mail/fax, using the appropriate form on forms for health care professionals.*

 

*Exceptions may exist based on your state’s regulations.

No.  In your appeal, let us know that you submitted information on your reconsideration. Also add any information you want us to consider in the appeal. 

An appeal response letter will indicate, typically in the subject line, if it was handled as an appeal.

 

If we respond to your reconsideration with a letter, the letter will indicate where to file an appeal.  That will be your clue that it was handled as a reconsideration.

No.  We want to give you the opportunity to provide additional information before requesting an appeal.

 

2017 policy changes

We are making changes to the Provider/Practitioner Complaint and Appeal process.  These changes include:
 

  • Changing the levels of practitioner appeals allowed from 2 to 1.
  • Requiring submission of the Aetna Provider Complaint and Appeal Form for all provider written complaints and all appeals.  This requires all appeals to be submitted in writing.

Get a Provider Complaint and Appeal form (PDF)

For medical providers, changes are effective March 1, 2017.

 

For dental providers, changes are effective May 21, 2017.

Medical providers were notified via Office Links in December and also received an email communication February 22, 2017.

 

Dental providers were notified mid-February 2017.

The changes affect all Aetna commercial medical and dental plans, including consumer business. The changes also affect Aetna Medicare plans for participating providers appeal requests.

All providers must now use the form to submit appeals in writing. The change to the levels of appeal affects only non-facility providers (facilities already have only one level of appeal).

This change affects appeals for providers acting on their own behalf.  It does NOT affect the member appeal process.  Therefore, it does not affect expedited, urgent or pre-service issues which are treated as member appeals.

We are changing the appeals process to be consistent with the facility appeals process. Facilities receive one level of appeal; we are changing the practitioner’s process to match.

 

Requiring the use of the Aetna Provider Complaint and Appeal Form will ensure that we have all the information necessary to accurately process appeals and minimize delays.

No.

The Provider Call Center will direct callers to use the form to submit an appeal.

Appeals require supporting documentation, and we cannot accommodate attachments for electronic submissions. We accept appeals via fax or mail. 

Submit a Complaint and Appeal Form, as well as any medical records or other documents that will support the request, to the address provided on the adverse determination notification.  This notification could be a claim EPP, a denial letter from Clinical Claim Review or rework, or a verbal notification from the Provider Call Center.

The response process is not changing. We will notify the provider in writing.

Call the Provider Service Center to:
 

  • Confirm that we received an appeal
  • Check on the status of an appeal
  • Ask questions about an appeal decision
  • Speak to a network representative

Service Center numbers:
 

Legal notices

Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates (Aetna).

Health benefits and health insurance plans contain exclusions and limitations.

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