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.
- 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)
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
- 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. |
| 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. |
*The timeframe is 180 calendar days for 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 PO Box 14079 Lexington, KY 40512-4079 |
| 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 PO Box 981106 El Paso, TX 79998-1106 |
