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Claim Status Inquiry
Frequently Asked Questions (FAQs)

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.Q: What is the advantage of using the electronic Claim Status Inquiry transaction?.
.Q: What information must be supplied for a Claim Status Inquiry transaction? .
.Q: What claims can a provider inquire about? .
.Q: Are there any claims that are not supported by Claim Status Inquiry (i.e., the dental provider will receive no claims returned in the claim status response)?.
.Q: Is there some other way to determine if an electronically submitted claim was accepted or rejected after it was sent to Aetna? .
.Q: Can you explain why multiple status responses are received for one claim? .
.Q: What information will be returned on a Claim Status Inquiry?.
.Q: Do all claims that are rejected display status? Why would some not display a message (i.e. "Patient found, Provider not.").
.Q: What situations can cause the claim status response "Member was not found or Insured or subscriber not found," and what action should be taken? .
.Q: Why would the message "Response not possible System Status or Business Application Currently Not Available" display?.
.Q: Why did the message "Payer Not Responding, Please Try Again Later" display?.
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Q: What is the advantage of using the electronic Claim Status Inquiry transaction?
A: The electronic Claim Status Inquiry transaction provides the following advantages:

Claims processing information is currently available for Aetna Dental products. Those products include: Indemnity, PPO, DMO, Aetna Advantage Plus, Aetna Advantage Dental, Basic Dental, Family Preventive, Discount Dental and Pediatric Direct Access.

  • Available for both paper and electronic claim submissions
  • Transaction is available Monday through Saturday 24 hours per day and on Sundays from noon until 4 a.m.
  • Minimal wait time
  • Decreased manual processes, such as telephone calls

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Q: What information must be supplied for a Claim Status Inquiry transaction?
A: Providers are required to enter the following information:

  • Member ID or Social Security number
  • Subscriber’s last name
  • Patient relationship to the employee
  • Patient first and last name
  • Patient date of birth
  • Patient gender
  • Provider billing tax identification number and/or provider PIN
  • Date of service range

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Q: What claims can a provider inquire about?
A: Claim Status Inquiry supports the following claims:

  • Providers can inquire and receive claim status responses for claims accepted and rejected by Aetna that are submitted either electronically or on paper.
  • PPO and Indemnity claims processed after April 7, 2001, and HMO claims processed after July 2001.

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Q: Are there any claims that are not supported by Claim Status Inquiry (i.e., the dental provider will receive no claims returned in the claim status response)?
A: The following claims are not supported by the Claims Status Inquiry transaction:

  • Some claims for certain benefit plans processed on an older Aetna claim system
  • Claims that were originally sent to Prudential HealthCare and were forwarded to Aetna for processing
  • Claims that were originally sent to Prudential HealthCare and paid by Prudential HealthCare

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Q: Is there some other way to determine if an electronically submitted claim was accepted or rejected after it was sent to Aetna?
A: The provider should check the batch claim status reports returned by their vendors to determine if the claim was accepted or rejected by either the vendor or by Aetna.

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Q: Can you explain why multiple status responses are received for one claim?
A: Reasons this will occur include:

  • The claim had to be split into multiple pieces for claim processing (i.e., two different benefit years).
  • The claim needed to be reprocessed due to an initial processing error.

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Q: What information will be returned on a Claim Status Inquiry?
A: The following information is returned on the Claim Status Inquiry response:

  • Claim number
  • Total charged amount
  • Statement from and through date
  • Status message
  • Amount paid to the provider
  • Claim adjudication date
  • Check number/EFT trace

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Q: Do all claims that are rejected display status? Why would some not display a message (i.e. "Patient found, Provider not.")
A: Claim status is available for most claims rejected by Aetna. In some instances, you may not receive status for all rejected claims. Only claims that match the incoming request will be available for inquiry. For this reason, claims rejected due to an inability to identify the provider on the claim or rejected claims that the system is otherwise unable to match to the request for status will not be available.

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Q: What situations can cause the claim status response "Member was not found or Insured or subscriber not found," and what action should be taken?
A: The member cannot be found in Aetna’s eligibility file with the member information sent by the provider. The provider should try one of the following solutions if applicable:

  • Review the information for input errors. If input errors are found, submit a new inquiry with the correct information for the member.
  • Confirm that the patient has been correctly identified as the subscriber or dependent.
  • The member information on file at the provider office may be different from what is found on Aetna’s eligibility file.
  • Use the Aetna eligibility transaction to obtain the member information on Aetna’s eligibility file. Then use the eligibility response’s member information for the Claim Status Inquiry.

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Q: Why would the message "Response not possible System Status or Business Application Currently Not Available" display?
A: An Aetna application that Claim Status Inquiry transaction requires is currently not available. This message should be reported to the vendor Help Desk in order to have the problem resolved in a timely manner.

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Q: Why did the message "Payer Not Responding, Please Try Again Later" display?
A: The Aetna application is not currently available for the Claim Status Inquiry transaction. This problem should be reported to the vendor Help Desk immediately.

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