What is the Appeal Process for Aetna?

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As an Aetna Medicare member, you will be able to file an appeal if your request is rejected. However, not all Aetna members really know what the appeal is and how it works. In fact, appeal is really important for those who are using medicare or healthcare in a facility.

If you are also an Aetna member and want to file an appeal, you definitely have to understand the appeal process step-by-step. If you do not know yet about the appeal process, you will find out everything related to Aetna’s appeal process in our post below!

What is Aetna’s Appeal Process?

It is known that the appeal process in Aetna is a formal way of asking them to review and change a coverage decision that Aetna made. In short, appeal is a written request performed by a practitioner or organizational provider to change some things.

The appeal process actually involves the healthcare providers to use the Aetna appeal process if they do not agree with a claim or utilization review decision. The healthcare providers will change a bunch of things within the appeal process, here are they:

  1. An adverse reconsideration decision.
  2. An adverse initial claim decision that is based on medical necessity or investigational/ experimental coverage criteria.
  3. A denial for non-inpatient hospital services denied for not accepting previous approval.
  4. An adverse initial utilization review decision.

In this case, claims decisions are all decisions that are made during the claims adjudication process. For instance, decisions that are related to the provider contract, a processing error or our claims payment policies.

Furthermore, the term ‘Utilization review decisions’ refers to decisions that are made during the precertification, concurrent or retrospective review processes for services which require precertification.

For those types of issues, the appeal process of healthcare providers will only apply to appeals received subsequent to the services being rendered. Moreover, the member appeal process will apply to appeals that are related to pre-service or concurrent medical necessity decisions.

How Is the Appeal Process for Aetna?

The appeal process for Aetna will pass some stages to complete, here are they:

  1. Peer to Peer Review

In the first stage, Aetna will offer healthcare providers an opportunity to present additional information and discuss their cases with a peer-to-peer reviewer. The peer to peer review can be mentioned as part of the utilization review coverage determination process.

The timing of this review is prior to an appeal and incorporates federal, states, CMS and NCQA requirements.

  1. Reconsideration

The second step is about reconsiderations that include coding decisions, formal reviews of claims reimbursements or claims which require reprocessing. Here’s a list of mailing addresses for reconsideration:

Address 1

  • Address: Aetna P.O. Box 14079 Lexington, KY 40512-4079
  • States: AL, AK, AR, AZ, CA, FL, GA, HI, ID, LA, MS, NC, NM, NV, OR, SC, UT, TN, WA

Address 2

  • Address: Aetna P.O. Box 981106 El Paso, TX 79998-1106
  • State: CO, CT, DC, DE, IA, IL, IN, KS, KY, MA, MD, ME, MI, MN, MO, MT, NE, ND, NH, NJ, NY, OH, OK, PA,  RI, SD, TX, VA, VT, WI, WV, WY
  1. Appeals

The last step is to file an appeal as request to change a reconsideration decision, an initial claim decision, an initial utilization review decision based on medical necessity or experimental/ investigational coverage criteria.

We will also show you in detail the utilization review issues or claim issues that are based on medical necessity or cosmetic or experimental/ investigational coverage criteria. Let’s see them below!

Dispute Level Practitioner/ Organizational Provider Submission Timeframe Aetna Response Timeframe Contact Information
Level 1 Appeal Within 180 calendar days of utilization review decision or an initial claim decision. Within 30 business days of receiving the additional requested information, within 30 business days of receiving the request if additional information is needed. For HMO based benefits plan and WA Primary Choice plan, call at 1-800-624-0756

 

For indemnity and PPO based benefits plans, call at 1-888-632-3862

 

Mail to Aetna Provider Resolution Team P.O. Box 14020 Lexington, KY 40512

Level 2 Appeal (available only to practitioners) Within 60 calendar days of the level 1 appeal decision Within 30 business days of receiving the additional requested information, within 30 business days of receiving the request if additional information is needed. For HMO based benefits plan and WA Primary Choice plan, call at 1-800-624-0756

 

For indemnity and PPO based benefits plans, call at 1-888-632-3862

 

Mail to Aetna Provider Resolution Team P.O. Box 14020 Lexington, KY 40512

How to Submit An Appeal for Aetna?

To file an appeal for Aetna, you have to submit a Complaint and Appeal Form that you can find here. Aside from a Complaint and Appeal Form, you can also submit any medical records or other documents which will support the request to the address available on the adverse determination notification.

Well, this notification would be a claim EPP, a verbal notification from Provider Call Center or also denial letter from Clinical Claim Review or rework. Of course, all the appeal processes will need supporting documentation.

If you do not provide the additional documents, they cannot accommodate attachments for electronic submissions. They definitely accept appeals via mail or fax.

After you submit an appeal, you can also check on the status of an appeal by calling the Provider Service Center. In addition to checking on the status of an appeal, you can also confirm that they received an appeal, ask questions about an appeal decision and talk to a network representative.

The forms that you should submit to file an appeal and dispute include:

  • Authorized Representative request
  • Medicare Member Authorization Appeals
  • Medicare Non-contracted Provider Appeal Process
  • Medicare Member Payment Appeals
  • Medicare Practitioner/Provider Complaint and Appeal request
  • Member Complaint and Appeal form
  • Practitioner and Provider Complaint and Appeal request

For more information, an appeal response letter will typically indicate in the subject line if it was handled as an appeal. If  they respond to your reconsideration with a letter, it will indicate where to submit an appeal. Certainly, it will be your clue  where it was handled as a reconsideration.

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