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    Dispute & appeal process: state exceptions to filing standard

     

    In the absence of an exception below, Aetna's 180-day dispute filing standard will apply. The exceptions below apply to requests regarding members covered under fully insured plans only.

     

    Exception by state for time allowed to file an initial claim-payment dispute

    State

    To whom does the exception apply?

    Time allowed to file an initial claim-payment dispute

    Arizona (AZ)

    All providers — participating and nonparticipating

    1 year

    California (CA) HMO

    All providers -- participating and nonparticipating, when the request relates to an HMO member and the date of service is on/after 1/1/04

    365 days

    California (CA) Traditional

    All providers -- participating and nonparticipating, when the request relates to a traditional member and the appeal is received on/after 6/29/09

    180 days

    Colorado (CO)

    All providers — participating and nonparticipating

    12 months

    Florida (FL)

    All participating or nonparticipating licensed physicians or physician assistants (or practitioners licensed under FL Ch. 458), osteopathic physicians, chiropractors, podiatrists or dentists

    12 months (does not apply to faciliate)

    Georgia (GA)

    All providers — participating and nonparticipating

    24 months from date of service or discharge

    Indiana (IN)

    All providers -- participating and nonparticipating, effective with claims paid on or after 7/1/06

    2 years (from claim payment date)

    Kentucky (KY)

    Participating providers only

    2 years

    Maryland (MD)

    All providers — participating and nonparticipating

    365 days

    New Jersey (NJ)

    All providers treating fully-insured NJ contracted members and submitting their dispute using the "Health Care Provider Application to Appeal a Claims Determination Form" will be eligible for review by New Jersey's Program for Independent Claims Payment Arbitration (PICPA).

    90 calendar days from the notice of the disputed claim determination

    New Jersey (NJ)

    No health care provider treating fully-insured NJ contracted members shall seek reimbursement from a payer or covered person for underpayment of a claim later than 18 months from the date the first payment on the claim was made. After 90 calendar days from the notice of the disputed claim determination the provider shall not be eligible for PICPA (see above).

    18 months from the date the first payment of a claim was made

    North Carolina (NC)

    All providers — participating and nonparticipating

    2 years from the original claim payment

    Ohio (OH)

    All providers — participating and nonparticipating

    2 years

    Oklahoma (OK)

    All providers — participating and nonparticipating

    2 years

    Oregon (OR)

    All providers — participating and nonparticipating

    18 months from the claim denial or payment date, upon written requests (or 30 months if COB issues)

    Rhode Island (RI)

    All providers — participating and nonparticipating

    18 months.

    In situations where a claim was denied for not being filed timely, the provider has 180 calendar days from the date the denial was received from another carrier as long as the claim was submitted within 180 calendar days of the date of service to the other carrier.

    Tennessee (TN)

    All providers — participating and nonparticipating

    18 months

    Utah (UT)

    All providers — participating and nonparticipating

    24 months if the improper payment was due to a coordination of benefits error.

     

    36 months if the improper payment was due to a recovery by Medicaid, Medicare, the Children's Health Insurance program or any other state or federal health care program.

     

    12 months if the improper payment was due to any other reason.

    Washington (WA)

    All listed providers -- participating and nonparticipating, effective 1/1/06

    24 months from the claim denial or payment date, upon written requests (or 30 months if COB issues)

    State

    Arizona (AZ)

    To whom does the exception apply?

    All providers — participating and nonparticipating

    Time allowed to file an initial claim-payment dispute

    1 year

    State

    California (CA) HMO

    To whom does the exception apply?

    All providers -- participating and nonparticipating, when the request relates to an HMO member and the date of service is on/after 1/1/04

    Time allowed to file an initial claim-payment dispute

    365 days

    State

    California (CA) Traditional

    To whom does the exception apply?

    All providers -- participating and nonparticipating, when the request relates to a traditional member and the appeal is received on/after 6/29/09

    Time allowed to file an initial claim-payment dispute

    180 days

    State

    Colorado (CO)

    To whom does the exception apply?

    All providers — participating and nonparticipating

    Time allowed to file an initial claim-payment dispute

    12 months

    State

    Florida (FL)

    To whom does the exception apply?

    All participating or nonparticipating licensed physicians or physician assistants (or practitioners licensed under FL Ch. 458), osteopathic physicians, chiropractors, podiatrists or dentists

    Time allowed to file an initial claim-payment dispute

    12 months (does not apply to faciliate)

    State

    Georgia (GA)

    To whom does the exception apply?

    All providers — participating and nonparticipating

    Time allowed to file an initial claim-payment dispute

    24 months from date of service or discharge

    State

    Indiana (IN)

    To whom does the exception apply?

    All providers -- participating and nonparticipating, effective with claims paid on or after 7/1/06

    Time allowed to file an initial claim-payment dispute

    2 years (from claim payment date)

    State

    Kentucky (KY)

    To whom does the exception apply?

    Participating providers only

    Time allowed to file an initial claim-payment dispute

    2 years

    State

    Maryland (MD)

    To whom does the exception apply?

    All providers — participating and nonparticipating

    Time allowed to file an initial claim-payment dispute

    365 days

    State

    New Jersey (NJ)

    To whom does the exception apply?

    All providers treating fully-insured NJ contracted members and submitting their dispute using the "Health Care Provider Application to Appeal a Claims Determination Form" will be eligible for review by New Jersey's Program for Independent Claims Payment Arbitration (PICPA).

    Time allowed to file an initial claim-payment dispute

    90 calendar days from the notice of the disputed claim determination

    State

    New Jersey (NJ)

    To whom does the exception apply?

    No health care provider treating fully-insured NJ contracted members shall seek reimbursement from a payer or covered person for underpayment of a claim later than 18 months from the date the first payment on the claim was made. After 90 calendar days from the notice of the disputed claim determination the provider shall not be eligible for PICPA (see above).

    Time allowed to file an initial claim-payment dispute

    18 months from the date the first payment of a claim was made

    State

    North Carolina (NC)

    To whom does the exception apply?

    All providers — participating and nonparticipating

    Time allowed to file an initial claim-payment dispute

    2 years from the original claim payment

    State

    Ohio (OH)

    To whom does the exception apply?

    All providers — participating and nonparticipating

    Time allowed to file an initial claim-payment dispute

    2 years

    State

    Oklahoma (OK)

    To whom does the exception apply?

    All providers — participating and nonparticipating

    Time allowed to file an initial claim-payment dispute

    2 years

    State

    Oregon (OR)

    To whom does the exception apply?

    All providers — participating and nonparticipating

    Time allowed to file an initial claim-payment dispute

    18 months from the claim denial or payment date, upon written requests (or 30 months if COB issues)

    State

    Rhode Island (RI)

    To whom does the exception apply?

    All providers — participating and nonparticipating

    Time allowed to file an initial claim-payment dispute

    18 months.

    In situations where a claim was denied for not being filed timely, the provider has 180 calendar days from the date the denial was received from another carrier as long as the claim was submitted within 180 calendar days of the date of service to the other carrier.

    State

    Tennessee (TN)

    To whom does the exception apply?

    All providers — participating and nonparticipating

    Time allowed to file an initial claim-payment dispute

    18 months

    State

    Utah (UT)

    To whom does the exception apply?

    All providers — participating and nonparticipating

    Time allowed to file an initial claim-payment dispute

    24 months if the improper payment was due to a coordination of benefits error.

     

    36 months if the improper payment was due to a recovery by Medicaid, Medicare, the Children's Health Insurance program or any other state or federal health care program.

     

    12 months if the improper payment was due to any other reason.

    State

    Washington (WA)

    To whom does the exception apply?

    All listed providers -- participating and nonparticipating, effective 1/1/06

    Time allowed to file an initial claim-payment dispute

    24 months from the claim denial or payment date, upon written requests (or 30 months if COB issues)
     

    Exception by state for time allowed to file and pursue a dispute

    State

    To whom does the exception apply?

    Time allowed to file and pursue a dispute

    Texas (TX)

    All participating providers and nonparticipating providers who are paid on a participating basis (examples include an emergency situation, a network inadequacy issue, a nonparticipating provider who is pre­approved by Aetna or a hospital-based physician who is a nonparticipating provider but provides services at a participating facility)

    4 years for claims and non-claims issues — (complaints are handled as appeals in TX)

     

    TAC 21.2809

     

    A preferred provider that received an underpayment in relation to an audit must notify Aetna within 270 days per Texas law to qualify to receive a penalty for the underpaid amount.

    State

    Texas (TX)

    To whom does the exception apply?

    All participating providers and nonparticipating providers who are paid on a participating basis (examples include an emergency situation, a network inadequacy issue, a nonparticipating provider who is pre­approved by Aetna or a hospital-based physician who is a nonparticipating provider but provides services at a participating facility)

    Time allowed to file and pursue a dispute

    4 years for claims and non-claims issues — (complaints are handled as appeals in TX)

     

    TAC 21.2809

     

    A preferred provider that received an underpayment in relation to an audit must notify Aetna within 270 days per Texas law to qualify to receive a penalty for the underpaid amount.
     

    Related links

     

    Dispute process: Questions and answers

     

    Dispute process: Overview 

    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.