Disputes and appeals process

As a health care provider, you may not agree with a claim or utilization review decision. This page explains how to dispute or appeal a decision.

Need to dispute or appeal a decision? Let’s go through your options.

Peer-to-peer discussion: You can share more information and discuss your case with a peer-to-peer reviewer as part of the utilization review coverage decision process. This discussion happens before the appeal and follows state, federal, CMS and NCQA requirements. To request a peer-to-peer call, contact customer service. The appeal request form shouldn’t be used to request a peer-to-peer call.
Reconsideration: This is a formal review of a claim reimbursement or coding decision, or for claims that need to be processed again.
Appeal: This is for requests to change a reconsideration decision or our initial utilization review or claim decision based on medical need or experimental/investigational coverage criteria. To request a peer-to-peer review as part of the appeal, send the appeal request form with a note asking for a peer-to-peer review. A peer clinician will review the appeal.

Next steps: What we need from you

To help us close the dispute, send us:

A completed dispute and appeal form. You can find forms for Medicaid, Medicare and non-Medicare plans on our forms for health care professionals page.
A copy of the denial letter or explanation of benefits letter
The original claim
The reasons why you disagree with our decision
Documents to support your reason, such as medical records or office notes

Have questions?

Check our dispute process FAQS . You can also call our provider service center. We’re here for you 8 AM to 5 PM, local time.

Medicare medical and dental plans:
1-800-624-0756 ${tty}

Non-Medicare plans (includes individual & family plans):
1-888-632-3862 ${tty}

Time frames for reconsiderations and appeals

This chart lists general filing and review time frames. Some states may have different time frames.

Check state exceptions to these time frames

Dispute type	When do I have to file?	When will Aetna® make a decision?	How do I file a dispute or appeal, or check on my request?
Reconsideration	Within 180 calendar days of the initial claim decision.	Within 45 business days of receiving the request. (Timing depends on the request or if our specialty unit needs to review.)	Online: Use the Availity provider website to file your request and check status. Call: Medicare medical and dental plans: 1-800-624-0756 ${tty} Non-Medicare plans: 1-888-632-3862 ${tty} Want to mail a reconsideration? Find the mailing address for your state.*
Appeals: Non-Medicare providers	Within 60 calendar days* of the previous decision.	Within 60 business days of receiving the request. (If we need more information, within 60 calendar days of getting that information.	Call: 1-888-632-3862 ${tty} Write: Aetna Provider Resolution Team PO Box 14020 Lexington, KY 40512 Fax: 1-859-455-8650
Appeals: Medicare-contracted providers	Within 60 calendar days* of the previous decision.	Within 60 business days of receiving the request. (If we need more information, within 60 calendar days of getting that information.	Call: 1-800-624-0756 ${tty} Write: Medicare provider appeals PO Box 14835 Lexington, KY 40512 Fax: 1-860-900-7995
Appeals: Medicare non-contracted providers	Within 65 calendar days of the previous decision.	Within 60 business days of receiving the request. (If we need more information, within 60 calendar days of getting that information.	Call: 1-800-624-0756 ${tty} Write: Medicare non-contracted provider appeals PO Box 14067 Lexington, KY 40512 Fax: 1-724-741-4953

Dispute type	Reconsideration
When do I have to file?	Within 180 calendar days of the initial claim decision.
When will Aetna® make a decision?	Within 45 business days of receiving the request. (Timing depends on the request or if our specialty unit needs to review.)
How do I file a dispute or appeal, or check on my request?	Online: Use the Availity provider website to file your request and check status. Call: Medicare medical and dental plans: 1-800-624-0756 ${tty} Non-Medicare plans: 1-888-632-3862 ${tty} Want to mail a reconsideration? Find the mailing address for your state.*
Dispute type	Appeals: Non-Medicare providers
When do I have to file?	Within 60 calendar days* of the previous decision.
When will Aetna® make a decision?	Within 60 business days of receiving the request. (If we need more information, within 60 calendar days of getting that information.
How do I file a dispute or appeal, or check on my request?	Call: 1-888-632-3862 ${tty} Write: Aetna Provider Resolution Team PO Box 14020 Lexington, KY 40512 Fax: 1-859-455-8650
Dispute type	Appeals: Medicare-contracted providers
When do I have to file?	Within 60 calendar days* of the previous decision.
When will Aetna® make a decision?	Within 60 business days of receiving the request. (If we need more information, within 60 calendar days of getting that information.
How do I file a dispute or appeal, or check on my request?	Call: 1-800-624-0756 ${tty} Write: Medicare provider appeals PO Box 14835 Lexington, KY 40512 Fax: 1-860-900-7995
Dispute type	Appeals: Medicare non-contracted providers
When do I have to file?	Within 65 calendar days of the previous decision.
When will Aetna® make a decision?	Within 60 business days of receiving the request. (If we need more information, within 60 calendar days of getting that information.
How do I file a dispute or appeal, or check on my request?	Call: 1-800-624-0756 ${tty} Write: Medicare non-contracted provider appeals PO Box 14067 Lexington, KY 40512 Fax: 1-724-741-4953

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