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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 AM to 5 PM local time):

 

 

Timeframes for reconsiderations and appeals

 

Dispute level

Provider submission timeline

Aetna response timeframe

Contacts

Reconsideration

Within 180 calendar days of the initial claim decision.

Within 45 business days of receiving the request, depending on the matter in question, and if review by a specialty unit is needed.

Submit online and check the status through your secure provider website.
 

Write: Use mailing addresses below.
 

Call: Use phone numbers above.

Appeals: Non Medicare

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

Call: Use phone numbers above.

 

Write:

Aetna Provider Resolution Team

PO Box 14020

Lexington, KY 40512

Fax: 859-455-8650

Appeals: Medicare Contracted Providers

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

Call: Use phone numbers above.

 

Write:

Medicare Contracted

 

Appeals use:

Medicare Provider Appeals

PO Box 14835

Lexington, KY 40512

Fax: 860-900-7995

Appeals: Medicare Non-Contracted Providers

Within 65 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: Use phone numbers above.

 

Write:

Medicare Non Contracted Provider Appeals

PO Box 14067

Lexington, KY 40512

Fax: 724-741-4953

Dispute level

Reconsideration

Provider submission timeline

Within 180 calendar days of the initial claim decision.

Aetna response timeframe

Within 45 business days of receiving the request, depending on the matter in question, and if review by a specialty unit is needed.

Contacts

Submit online and check the status through your secure provider website.
 

Write: Use mailing addresses below.
 

Call: Use phone numbers above.

Dispute level

Appeals: Non Medicare

Provider submission timeline

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: Use phone numbers above.

 

Write:

Aetna Provider Resolution Team

PO Box 14020

Lexington, KY 40512

Fax: 859-455-8650

Dispute level

Appeals: Medicare Contracted Providers

Provider submission timeline

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: Use phone numbers above.

 

Write:

Medicare Contracted

 

Appeals use:

Medicare Provider Appeals

PO Box 14835

Lexington, KY 40512

Fax: 860-900-7995

Dispute level

Appeals: Medicare Non-Contracted Providers

Provider submission timeline

Within 65 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: Use phone numbers above.

 

Write:

Medicare Non Contracted Provider Appeals

PO Box 14067

Lexington, KY 40512

Fax: 724-741-4953

 
 

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

 

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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