Claim Denials
How to appeal a denied claim
If 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
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.
Plans that provide for one appeal
- If we had to approve your claim before you got care, we will decide within 30 days of getting your appeal.
- For other claims, we’ll decide within 60 days.
Plans that provide for two appeals
- If we had to approve your claim before you got care, we will decide within 15 days of getting your appeal.
- For other claims, we’ll decide within 30 days.
- In either case, if you do not agree with our decision, you can ask for a second review. You have 60 days from the date that you get the appeal decision letter to let us know. You can call Member Services at the phone number listed on your member ID card, or write to us.
Urgent care claims
We make decisions for urgent care claims more quickly. If your doctor feels that a delay will put your health, your life or your recovery at serious risk or cause you severe pain, that’s an urgent care claim. You or your doctor may ask for an "expedited" appeal. Call the toll-free number on your Member ID card or the number on the claim denial letter.
- If your plan has one level of appeal, we’ll tell you our decision no later than 72 hours after we get your request for review.
- If your plan has two levels of appeal, we’ll tell you our decision no later than 36 hours after we get your request for review.
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.
