Pre-service dispute options
Here’s how to dispute a denial for care your patient hasn’t received yet.
First, see if a peer-to-peer review is available
What’s a peer-to-peer review?
A peer-to-peer review is an informal clinical discussion between you, the requesting provider, and an Aetna® Medical Director. It’s part of the utilization management process we use to make coverage decisions and follows state, federal and NCQA requirements.
These reviews aren’t always available and may depend on the plan. If you’ve received an adverse determination, file a pre-service appeal instead.
During this review, you can:
- Ask questions about why a request was denied
- Share or discuss clinical information that wasn’t previously reviewed
When to request one
- After you receive a pre-service medical necessity denial
- When you have new or clarifying clinical information
- Before you file a formal pre-service appeal
To request a peer-to-peer review, call Aetna Provider Services.
Still need to dispute a denial? File a pre-service appeal.
What’s a pre-service appeal?
A pre-service appeal is a formal request to reconsider a utilization management denial for care your patient hasn’t received yet. We review the appeal based on the member’s covered benefits and plan limits.
When to file this appeal
- If a peer-to-peer review isn’t available
- If a peer-to-peer review didn’t overturn the denial
- If you’ve already received an adverse determination
For medical necessity denials, be sure to include supporting clinical documentation. Keep in mind that you generally have one level of appeal.
When to request an expedited pre-service appeal
- Precertification for urgent or ongoing services has been denied, and
- Waiting for a standard decision could seriously jeopardize the member’s life, health or ability to regain maximum function
You’ll receive a decision within 72 hours — or sooner if required by state law. We follow member appeal requirements when processing all expedited appeals, including those requested by providers.
Post-service dispute options
There are two ways to dispute a claim decision for care your patient has already received: a reconsideration or an appeal.
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 outpatient 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. It covers reconsideration decisions and initial utilization review or clinical claim decisions.
Appeals apply when a decision was based on medical necessity, a payment policy or 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
Sent us an appeal that should be a reconsideration? We'll route it to the right place.
How the reconsideration process works
File your reconsideration within 180 calendar days of the initial claim decision.
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.*
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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?
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Response times depend 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.
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- 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 doesn’t qualify for reconsideration, file within 180 days for Medicare and commercial plans or 65 days if you’re a non-contracted Medicare provider. (Post-service appeals can’t be expedited. Check the member's 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.)
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Send us this information, unless you’ve 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 you’re 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.
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We'll send a decision by mail or fax within 60 calendar days of receiving your appeal or any additional information we request.
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Contact us using the same method you used to file your appeal or use this contact information:
Helpful resources
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Check eligibility, get prior authorization, file appeals and manage other tasks.
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Find forms for claims, payment, billing, Medicare, pharmacy and more.
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Check medical, dental or pharmacy clinical policy bulletins.
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.