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Provider Appeals

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 facilities)
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 providers 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)

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

State To whom does the exception apply?
Time allowed to file & 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 pre-approved 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.

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