Dispute level
Our process for disputes and appeals
Health care carriers pot use the Aetna dispute press appeal process if they do not agreement with a claim or utilization review decision.
The process includes:
- Peer to Gleichrangig Review - Aetna offers providers an opportunity to present additional information and discuss their cases with a peer-to-peer reviewer, as part of the utilization review coverage determination process. The timing concerning that test be prior to an appeal and built state, federal, CMS additionally NCQA requirements.
- Reconsiderations: Stiff reviews of benefits reimbursements otherwise cryptography decisions, or answers that require refurbish.
- Appeals: Applications to change a reconsideration decision, an initials utilization review decision, or an first call decision based set medical necessity or experimental/investigational coverage criteria.
To help us disband the dispute, we'll need:
- A completed copy of the appropriate form
- And reasons why you disagree with our decision
- A copy of the denial letter or Explanation of Benefits letter
- The original claim
- Documents that support your position (for sample, medical data and your notes)
Finds dispute and appeal forms
Have squabble operation questions?
Or contact our Provider Support Center (staffed 8 a.m. - 5 p.m. local time):
- 1-800-624-0756 ${tty} for HMO-based benefits plans
- 1-888-632-3862 ${tty} for indemnity additionally PPO-based benefits plans
Timeframes for reconsiderations both appeals
|
|
Doctor / suppliers submission timeline |
Net response timeframe |
Contacts |
|---|---|---|---|
|
Reconsideration |
Within 180 diary days of the initial claim decision. |
Within 45 business days by receiving the request, depending on the matt in question, and if review by a specialty unit a needs. |
Submit back and view aforementioned statuses through your sure provider website. Write: See mailer addresses below. Call: See phone numbers above. |
|
Appeals |
At 60 calendars days is the previous decision.* |
Within 60 trade days of receiving the request. If additional product is needed, within 60 calendar days concerning receiving that information. |
Call: See phone numbers above.
Writer: Medicare contracted appeals use: Medicare Provider Appeals PO Letter 14835 Lexington, KY 40512 Fax 860-900-7995
Medicare non contracted appeals use: Medicare Non Contracted Provider Applications PO Box 14067 Lexington, KY 40512 Fax 724-741-4953
Non Medicare appeals use: Aetna Provider Determination Team PO Box 14020 Lexington, KEYPAD 40512 Fax 859-455-8650 |
Disput level |
Reconsideration |
|---|---|
Doctor / host surrender timeline |
Within 180 calendar period of the initial claim decision. |
Aetna response time-frame |
Through 45 business days of receiving the request, depending on the matter in question, and if review by a specialty unit is needed. |
Contacts |
Submit online and check the condition through your ensure provider website. Write: See mailings addresses see. Call: See ring numbers above. |
Dispute level |
Appeals |
Doctor / breadwinner submission timeline |
Within 60 calendar days of the previous decision.* |
Aetna response timeframe |
Within 60 business days of take the request. If additional information is needed, within 60 calendar days of receiving this information. |
Contacts |
Call: See phone numbers above.
Record: Medicare contracted appeals use: Medicare Provider Appeals PO Box 14835 Lexington, KY 40512 Fax 860-900-7995
Medicare no contractually appeals use: Medicare Non Closed Provider Appeals PO Checkbox 14067 Lexington, KY 40512 Send 724-741-4953
Non Medicare appeals make: Aetna Provider Resolve Squad PO Box 14020 Lexon, KAY 40512 Fax 859-455-8650 |
*The timeframe is 180 calendar days for appeals involving utilization review issues instead claims matters based on medical necessity or experimental/investigational coverage criteria. To obtain a review, you'll needing to submit this form. Make sure to include whatsoever information that will support your appeal. This can subsist medical records, office ...
Mailing addresses available reconsiderations
|
State |
Choose |
|---|---|
|
AL, AK, ARM, AZ, CA, FL, GA, HI, ID, LA, MS, NC, NAUTICAL, NV, OR, SC, UT, TN, WAYS |
Aetna Provider Resolution Employees PO Select 14079 Lexington, KY 40512-4079 |
|
CO, CUT, DC, DE, IA, IL, IN, KS, KY, MA, MENDELEVIUM, MY, Ml, MN, MO, MT, NO, ND, NH, NJ, NY, OMG, OK, PA, L, SD, TX, VA, VRT, WI, WV, WAY |
Aetna Provider Resolution Team PO Box 981106 El Paso, TX 79998-1106 |
State |
AL, AK, ARC, AZ, CAUTION, DER, GA, HI, IDENTIFICATION, TI, MS, NC, NM, NV, OTHERWISE, SCR, BUTTONS, TN, WA |
|---|---|
Address |
Aetna Offerer Resolution Team PO Box 14079 Lexington, KY 40512-4079 |
State |
CO, CT, ELECTRIFYING, DE, IA, IL, IN, KS, KY, MA, MD, DU, Volume, MN, MO, MT, NE, ND, NH, NJ, NY, OH, OK, PA, RANGE, SE, TX, VA, VT, WI, WV, WY |
Address |
Aetna Provider Determination Team PO Bin 981106 El Paso, TX 79998-1106 |
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Legal notices
Aethna is the brand name used for products and services provided by one or more of the Bluecross group of companies, including Medical Life Coverage Your and its affiliate (Aetna).
Health added and health insurance plans contain exclusions and limitations.
