Aetna Appeal Form for Providers Example

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In the world of Aetna, an appeal is described as a written request by the likes of providers and practitioners to change a few things, including an adverse reconsideration decision, an adverse initial claim decision based on medical necessity or experimental or investigational coverage criteria, a denial for non-patient hospital services that were denied for not getting prior approval, and an adverse initial utilization review decision.

Keep in mind that the claims decisions that are all decisions made during the claims adjudication process (such as decisions related to the provider contact, the claims payment policies or a processing error).

Utilization review decisions are the kinds of decisions that are made during the precertification, concurrent or retrospective review processes for every service that needs precertification. In this kind of issues, both the practitioner and provider appeal process applies only to appeals received subsequent to every service that is being rendered. Take not that the member appeal process applies to appeals that are related to pre-service or concurrent medical necessity decisions.

Talking about the Aetna appeals, there are several kinds of form that you need to know. Some of them related to providers. If you are a provider who want to appeal, here are the examples of the form that you need to fill out:

Example 1:

Practitioner and Provider Complaint and Appeal Request

NOTE: Completion of this form is mandatory. To obtain a review submit this form as well as information that will support your appeal, which may include medical records, office notes, discharge summaries, lab records and/or member history (this is not an all-inclusive list) to the address listed on your Explanation of Benefits (EOB) or other correspondence received from Aetna.

Please provide the following information.

(This information may be found on the front of the member’s ID card.)

Today’s Date Member’s ID Number Plan Type Member’s Group Number (Optional)
     Medical               Dental
Member’s First Name Member’s Last Name Member’s Birthday (MM/DD/YYYY)
Provider Name TIN/NPI Provider Group (if applicable)
Contact Name and Title
Contact Address (Where appeal/complaint resolution should be sent)
Contact Phone Contact Fax Contact Email Address

To help Aetna review and respond to your request, please provide the following information.

(This information may be found on correspondence from Aetna.)

You may use this form to appeal multiple dates of service for the same member.

Claim ID Number (s) Reference Number/Authorization Number Service Date(s)
Initial Denial Notification Date(s) Reconsideration Denial Notification Date(s)
CPT/HCPC/Service being Disputed
Explanation of Your Request (Please use additional pages if necessary.)
 

 

Note: If you are acting on the member’s behalf and have a signed authorization from the member or you are appealing a preauthorization denial and the services have yet to be rendered, use the member complaint and appeal form.

You may mail your request to:

Aetna-Provider Resolution Team

PO Box 14020

Lexington, KY 40512

Or use our National Fax Number: 859-455-8650

Example 2:

Medical Provider Complaint and Appeal Request

NOTE: You must complete this form. To obtain a review, you’ll need to submit this form. Make sure to include any information that will support your appeal. This may be medical records, office notes, discharge summaries, lab records and/or member history (this isn’t an all-inclusive list). Send this to the address listed on your Explanation of Benefits (EOB) or other correspondence received from us.

Please provide the following information.

(This information may be found on the front of the member’s ID card.)

Today’s Date Member’s ID Number Plan Type Member’s Group Number (Optional)
     Medical               Dental
Member’s First Name Member’s Last Name Member’s Birthday (MM/DD/YYYY)
Provider Name TIN/NPI Provider Group (if applicable)
Contact Name and Title
Contact Address (Where appeal/complaint resolution should be sent)
Contact Phone Contact Fax Contact Email Address

To help us review and respond to your request, please provide the following information.

(This information may be found on correspondence from Aetna.)

You may use this form to appeal multiple dates of service for the same member.

Claim ID Number (s) Reference Number/Authorization Number Service Date(s)
Initial Denial Notification Date(s) Reconsideration Denial Notification Date(s)
CPT/HCPC/Service being Disputed
Explanation of Your Request (Please use additional pages if necessary.)
 

 

Note: If you are acting on the member’s behalf and have a signed authorization from the member or you are appealing a preauthorization denial and the services have yet to be rendered, use the member complaint and appeal form.

You may mail your request to:                                    Or Fax us at: 1-860-900-7995

Medicare Provider Appeals

PO Box 14835

Lexington, KY 40512

Example 3:

AETNA BETTER HEALTH

Provider appeal form

Post Services Appeals – Dispute of the denial of services that have been previously rendered. The provider may file a formal appeal to dispute any of the following:

  • Denial days for an inpatient stay, including medical necessity Service rendered without an authorization/pre-certification
  • Claims denied for no prior authorization that have been upheld upon consideration. (Example: after submission of proof of prior authorization, claims that remain denied after Aetna Better Health’s reconsideration).
  • Services denied per finding of a review organization

The provider must initiate an appealing challenging Aetna Better Health’s action in writing by fax or mail to the Aetna Better Health Appeals Department. Provider appeals must be filled within 60 days from the d ate of notification of claim denial unless otherwise specified with the provider contact.

Mail to: Aetna Better Health                                       or Fax: 1-860-754-1757

Attn: Appeals Department

2000 Market St., Suite 850

Philadelphia, PA 19103

The documentation required for review and reconsideration is as follows:

  • Operative notes. Medical notes, Office notes, ER notes

I do not agree with Aetna Better Health’s decision, therefore I am requesting a formal appeal with Aetna Better Health.

Member Name: …………………………………………………….           Member ID #: ………….

Date(s) of Service Denied: …………………………………….           Claim Number: ………..

Date of Notice of Action: ………………………………………

Please attach any other necessary information along with your operative notes, medical notes, office notes or ER notes to enable a thorough Appeal/Grievance investigation.

……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Provider Name: ……………………………………………………………………………………………………………

Contact Person: ……………………………………………………..                          Phone Number: …………………..

Contact Person’s Address: ……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Signature of requestor: ………………………………………….                          Date: ………………………………….

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