Understanding denials, appeals and the coverage dispute process

Americans make over a billion visits to doctors annually.* Most of the time, you, your doctor and your health plan agree on the treatment plan and payment. Sometimes, your providers may recommend services that are not covered under your health plan. When this happens, you will receive an alert from your health insurer that your coverage request has been “denied.”

When this happens, we give you and your providers a voice. Through multiple review stages and resolution options, we strive to deliver efficient ways to address concerns for all members.

What a health care denial means

You might receive a letter from your health plan that coverage for a service or medication has been denied. This can happen:

• Before a service is provided. This happens during prior authorization.
• After a service is provided. This is a claims denial.

If you feel that a service should be covered, there are a number of actions you can take. In the health insurance industry, this is called the dispute process. Aetna® has a responsibility to provide appeals and resolutions according to our members’ health plans as well as state and federal guidelines.

Claims and prior authorizations are processed differently, so their dispute processes vary as well. 

Pre-servicePrior authorization disputes

If you or your health care provider disagree with a prior authorization decision, Aetna can review more information or documentation.

We may also hold a discussion between your doctor and a peer-to-peer reviewer. This is an Aetna clinician or other representative with the appropriate training and clinical expertise. This happens before an appeal and complies with state, federal, Centers for Medicare & Medicaid Services (CMS) and National Committee for Quality Assurance (NCQA) requirements.

During peer-to-peer reviews, the treating physician should be prepared to discuss clinical information about the patient's condition that supports the medical necessity of the requested service.

If an agreement is not reached during the peer-to-peer review, a member or health care provider can then file an appeal. Appeals on behalf of a patient require patient consent. There may also be requirements specific to your plan.

Documentation submitted for reviews or appeals should include clinical records that show medical necessity. This may include:

• Detailed patient history
• Physical examination findings
• Diagnostic test results
• Treatment plans
• Responses to previous treatments

For complex cases, supporting evidence from peer-reviewed literature may strengthen the case.

If a prior authorization is denied following a peer-to-peer review, most members have the right to request an external review. Usually, prior authorization external reviews can be requested if the denial is based on medical necessity or experimental/investigational status, and if the financial responsibility exceeds an amount determined by the plan.

If Aetna denies coverage for certain services, the external review program allows members to have their case reviewed by independent doctors outside of Aetna. These doctors make decisions based on medical evidence and your health plan's rules.

The external review decision is typically made within 30 calendar days, or faster when a physician confirms that a delay would jeopardize the member's health.

Post-serviceClaims coverage and dispute process

After you receive a medical service, the claim submitted for payment is reviewed by your health plan. Health plans are either private insurance companies, state or federal government programs (like Medicare) or both.

Health plans review claims to determine the next step.

• If a medical treatment or service is approved and covered, the health plan will pay it based on the member’s benefits, the provider’s contract terms and the network rates.
• If a medical treatment or service is not covered or denied, the health plan cannot pay the claim. When that happens at Aetna, we provide an explanation of benefits to explain why the claim was denied and information about your rights to submit an appeal.

Claim denials are sent to both members and health care providers using an explanation of benefits or similar communication. When claims are approved, explanation of benefits also show what is paid by the insurance company and what the member owes.

Claim resubmission/reconsideration

If a claim is denied or the provider doesn’t believe the insurer has paid enough, the claim can be resubmitted with additional documentation. When resubmitting a claim, you or your doctor can ask Aetna to review it again based on the rules in your health plan.

Claim denials based on clinical reasons, such as a service or drug considered experimental or investigational, may go directly to the appeal process.

Claims appeals process

During this process, you or your doctor can send in new information to help with the review of your claim. Clinicians or claims specialists review the additional materials along with:

• The original claim
• The denial letter or explanation of benefits
• The physician or member’s disagreement rationale
• Often, an appeals form

Certain denials can be processed through external, independent reviewers for certain eligible members.

Health insurance disputes and appealsTransforming our approach

We have specialized teams that review appeals and requests for reconsiderations. This helps reduce denials and simplifies the appeals process for members and providers.

We continue to improve our dispute processes using:

• Specialized member service representatives
• Electronic claims submission
• Automation, when appropriate – we never automate denials based on medical necessity
• Secure member websites

Our continuous improvement mindset keeps us focused on what matters most: creating seamless experiences for both members and health care providers at every touchpoint.