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:
- Reconsiderations: Formal reviews of claims reimbursements or coding decisions, or claims that require reprocessing.
- Level 1 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.
- Level 2 appeals: Requests to change a Level 1 appeal decision.
To help us resolve the dispute, we'll need:
- 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)
Have dispute process questions?
Or contact our Provider Service Center (staffed 8 a.m. – 5 p.m. local time):
- 1-800-624-0756 for HMO-based benefits plans and WA Primary ChoiceSM plans
- 1-888-632-3862 for indemnity and PPO-based benefits plans
Timeframes for reconsiderations and appeals
|
Dispute level |
Doctor/Provider submission timeframe |
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. |
|
Level 1 and Level 2* appeals |
Within 60 calendar days of the previous decision.** |
Within 60 calendar 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. |
*Level 2 appeals are generally available only to practitioners.
**The timeframe is 180 calendar days for Level 1 appeals involving utilization review issues or claims issues based on medical necessity or experimental/investigational coverage criteria.
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 |
|
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 Provider Resolution Team |
