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Disputes and appeals overview

Our process for disputes and appeals

 

Health care providers can use the Aetna dispute and appeal process if they do not agree with a claim or utilization review decision.

 

The process includes:

 

  • Peer to Peer Review - Aetna offers providers an opportunity to present additional information and discuss their cases with a peer-to-peer reviewer, as part of the utilization review coverage determination process. The timing of the review is prior to an appeal and incorporates state, federal, CMS and NCQA requirements.
  • Reconsiderations: Formal reviews of claims reimbursements or coding decisions, or claims that require reprocessing.
  • Appeals: Requests to change a reconsideration decision, an initial utilization review decision, or an initial claim decision based on medical necessity or experimental/investigational coverage criteria.

To help us resolve the dispute, we'll need:

 

  • A completed copy of the appropriate form
  • The reasons why you disagree with our decision
  • A copy of the denial letter or Explanation of Benefits letter
  • The original claim
  • Documents that support your position (for example, medical records and office notes)

Find dispute and appeal forms

 

 

Have dispute process questions?

 

Read our dispute process FAQs

 

Or contact our Provider Service Center (staffed 8 a.m. - 5 p.m. local time):

 

 

Timeframes for reconsiderations and appeals

Dispute level

Doctor / provider submission timeline

Aetna response timeframe

Contacts

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.

Call: See phone numbers above.

 

Write: See mailing addresses below.

 

Submit online through your secure provider website.

Appeals

Within 60 calendar days of the previous decision.*

Within 60 business days of receiving the request. If additional information is needed, within 60 calendar days of receiving that information.

Call: See phone numbers above.

 

Write: Aetna Provider Resolution Team

PO Box 14020

Lexington, KY 40512.

Dispute level

Reconsideration

Doctor / provider submission timeline

Within 180 calendar days of the initial claim decision.

Aetna response timeframe

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.

Contacts

Call: See phone numbers above.

 

Write: See mailing addresses below.

 

Submit online through your secure provider website.

Dispute level

Appeals

Doctor / provider submission timeline

Within 60 calendar days of the previous decision.*

Aetna response timeframe

Within 60 business days of receiving the request. If additional information is needed, within 60 calendar days of receiving that information.

Contacts

Call: See phone numbers above.

 

Write: Aetna Provider Resolution Team

PO Box 14020

Lexington, KY 40512.

 

*The timeframe is 180 calendar days for appeals involving utilization review issues or claims issues based on medical necessity or experimental/investigational coverage criteria.

 

See state exceptions to these timeframes

 

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 Provider Resolution Team

PO Box 14079

Lexington, KY

40512-4079

CO, CT, DC, DE, IA, IL, IN, KS, KY, MA, MD, ME, Ml, MN, MO, MT, NE, ND, NH, NJ, NY, OH, OK, PA, RI, SD, TX, VA, VT, WI, WV, WY

Aetna Provider Resolution Team

PO Box 981106

El Paso, TX

79998-1106

State

AL, AK, AR, AZ, CA, FL, GA, HI, ID, LA, MS, NC, NM, NV, OR, SC, UT, TN, WA

Address

Aetna Provider Resolution Team

PO Box 14079

Lexington, KY

40512-4079

State

CO, CT, DC, DE, IA, IL, IN, KS, KY, MA, MD, ME, Ml, MN, MO, MT, NE, ND, NH, NJ, NY, OH, OK, PA, RI, SD, TX, VA, VT, WI, WV, WY

Address

Aetna Provider Resolution Team

PO Box 981106

El Paso, TX

79998-1106

 

Policy changes

 

We have made changes to the complaint and appeal process for practitioners:

 

  • There is now only one level of appeal, rather than two levels.
  • All appeals must be submitted in writing, using the Aetna Provider Complaint and Appeal form.

These changes do NOT affect member appeals. Expedited, urgent, and pre-service appeals are considered member appeals and are not affected.

 

Get a Provider Complaint and Appeal form (PDF)

 

Timing and scope of changes

 

As of March 1, 2017, the change affected all Aetna medical plans, including Aetna Medicare plans.

 

The change also affects all Aetna dental plans. For these plans, changes went into effect May 21, 2017.

 

Questions

 

For more information, see the Policy Changes section of our FAQ.

 

Read more about the changes to practitioner complaints and appeals

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.