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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 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.

 

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.