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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 a.m. - 5 p.m. local time):

     

     

    Timeframes for reconsiderations and appeals

    Dispute level

    Doctor / provider submission timeline

    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 business 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.

    Dispute level

    Reconsideration

    Doctor / provider submission timeline

    Within 180 calendar days of the initial claim decision.

    Aetna response timeframe

    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.

    Contacts

    Call: See phone numbers above.

     

    Write: See mailing addresses below.

     

    Submit online through your secure provider website.

    Dispute level

    Appeals

    Doctor / provider submission timeline

    Within 60 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: 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.

     

    See state exceptions to these timeframes

     

    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
     

    Policy changes

     

    We have made changes to the complaint and appeal process for practitioners:

     

    • There is now only one level of appeal, rather than two levels.
    • All appeals must be submitted in writing, using the Aetna Provider Complaint and Appeal form.

    These changes do NOT affect member appeals. Expedited, urgent, and pre-service appeals are considered member appeals and are not affected.

     

    Get a Provider Complaint and Appeal form (PDF)

     

    Timing and scope of changes

     

    As of March 1, 2017, the change affected all Aetna medical plans, including Aetna Medicare plans.

     

    The change also affects all Aetna dental plans. For these plans, changes went into effect May 21, 2017.

     

    Questions

     

    For more information, see the Policy Changes section of our FAQ.

     

    Read more about the changes to practitioner complaints and appeals

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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.