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Claim denials

How to appeal a denial claim

lf we deny a claim and you do not agree, you can ask for a review. This is called an appeal. There are two ways to do this:

 

  • Call Member Services at the phone number on your member ID card
  • To submit your request in writing you can print and mail the following form:

Member complaint and appeal form (PDF)

 

You may appeal on your own. You also may authorize someone to appeal for you. This is called an authorized representative.

How long do I have to ask for an appeal

You have 180 days from when you get the notice of the denied claim, unless your plan brochure (or Summary Plan Description) gives you a longer period of time.

What should the request include

  • The group name (usually your employer or organization that sponsors your plan)
  • Your name
  • Your member ID number (found on your medical ID card)
  • Any comments, documents, records and other information you would like us to consider. If there are documents you need for your claim, call the Member Services phone number listed on your member ID card. We will send them to you free of charge.

How long will it be before Aetna makes a decision?

How soon we respond may vary. It depends on a state law, whether your appeal is urgent or your plan offers one or two levels of appeal.

What is an external review?

What if your claim is still denied after your appeals? You may be able to have a third party (independent party) review your denied claim. This is called an external review.

The Affordable Care Act (ACA) created new rules for health plans. Now health plans that are subject to the law must include an external review process.

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.