What's the difference between a reconsideration and an appeal?
We offer two ways to dispute a claim decision: with a reconsideration or an appeal. We don't charge for either.
What's a reconsideration?
A reconsideration is a formal review of a previous claim decision. It covers reimbursement decisions, coding decisions and claims that need to be reprocessed.
Some claims skip reconsideration and go straight to appeal. These include:
- Adverse initial claim decisions based on medical necessity, a payment policy or experimental/investigational coverage
- Denials for non-inpatient hospital services with no precertification
- Adverse initial utilization review decisions
- Retroactive authorizations
- Medicare nonparticipating review decisions
- Some non-Medicare claims under state legislation
Filed a reconsideration that should be an appeal? We'll route it to the right place.
What's an appeal?
An appeal is a written request to change or overturn a previous decision. That includes reconsideration decisions and initial utilization review or clinical claim decisions.
Appeals apply when a decision was based on:
- Medical necessity
- A payment policy
- Experimental or investigational coverage criteria
Some situations go straight to appeal and skip reconsideration. These include:
- Adverse initial inpatient claim decisions
- Outpatient service denials for no precertification
- Adverse utilization review decisions
- Retroactive authorizations
How the reconsideration process works
File your reconsideration within 180 calendar days of the initial claim decision. Sent us an appeal by mistake? If it should be a reconsideration, we'll route it to the right place.
How to file a reconsideration
File online through the Availity® provider website.
You can also:
- Mail your request to the address on the denial letter or Explanation of Benefits (EOB).
- Use your state-specific mailing address. Find the mailing address for your state.*
What to include with your reconsideration request
Send us this information:
- Medical records, office notes and other supporting documents
- A completed dispute and appeal form or an explanation that includes:
- Reason for reviewing the initial determination
- Member ID number
- Patient name
- Tax identification number (TIN)
- Claim ID
- Date(s) of service and billed amounts
- Procedure codes and modifiers being disputed
Looking for dispute and appeal forms?
When to expect a response
Response times vary. It depends on the request and whether a specialty unit needs to review it.
In most cases, you'll receive an EOB or letter within 30 business days of us receiving the request.
How to check the status of a reconsideration
- Filed through Availity®? Log in to track your request.
- Filed by mail or fax? Call us:
- Non-Medicare plans: 1-888-632-3862 ${tty}
- Medicare medical and dental plans: 1-800-624-0756 ${tty}
How the appeals process works
File your appeal within 60 calendar days of the reconsideration decision. If the issue didn't qualify for reconsideration, file within 180 days for Medicare and commercial or 65 days for Medicare non-contracted providers.
Sent a reconsideration that should be an appeal? We'll route it to the right place.
Post-service appeals are not eligible for expedited handling. Refer to the member's health plan benefits for details.
How to file an appeal
File online through the Availity® provider website.
You can also:
File by mail or fax using the appropriate form. Find an appeal form.
State-specific exceptions may apply.
What to include with your appeal request
Send us this information, unless you have already sent it with your reconsideration:
- A clear explanation of why you disagree with the decision
- Supporting documents (medical records, office notes or remittance advice)
- The denial letter or EOB and original claim, for reference
- A completed dispute and appeal form (not required if filing through Availity)
Required for a valid appeal:
- A completed dispute and appeal form
- An explanation identifying the denied codes or payments being disputed
- Medical records and other relevant documentation
Incomplete submissions may affect how your appeal is handled.
When to expect a response
We'll send a decision by mail or fax within 60 calendar days of receiving your appeal or any additional information we request.
How to check the status of an appeal
Contact us the same way you filed or use this information:
Helpful resources
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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.