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Aetna’s Provider Appeal Process

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.To Dispute a Payment Denial.
.To Dispute a Clinical Decision .
.To Dispute a UCR Denial.
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Aetna has a formal process that allows participating and non-participating dentists to file an appeal when they:

  • Do not agree with a payment decision (claims); or
  • Do not agree with a clinical (utilization management) decision that pertains to one of their Aetna patients; or
  • Do not agree with the Usual and Customary Reimbursement (UCR) allowance.

Dentists have two levels of appeals available (subject to individual state laws/regulations).

All appeals must be filed within 180 days from the receipt of the adverse determination, unless otherwise required by contract or state requirement.

A dentist may file an appeal on behalf of an Aetna member if the member designates the provider as his or her authorized representative. In these instances, Aetna’s Member Appeals Process will be followed.

The following is designed to give dentists step-by-step instructions to follow to appeal a claims denial, a clinical decision or a Usual and Customary determination.

To Dispute a Payment Denial
Aetna offers several options by which to dispute a payment decision (either in part or full):
  • By telephone (subject to individual state laws/regulations)
  • By mail
  • By fax

Initial Steps

To dispute a claim denial by telephone, call the following number:

  • 1-800-451-7715
  • Have a copy of the dentist Explanation of Benefits (EOB), formerly known as Explanation of Provider Payment (EPP), statement and the original claim for reference.

To dispute a claim denial by mail or fax, you must submit the following information:

  • A copy of the EOB
  • A copy of the original claim
  • Any supporting documentation you believe will assist Aetna in its review, including a cover letter, a brief description of the situation, and any pertinent information.
  • Fax to 1-860-262-7603
  • Send this information to:
    Aetna Dental
    Complaints, Appeals and Grievances
    P.O. Box 14080
    Lexington, KY 40512-4080
  • Once all necessary information is received, Aetna will re-evaluate the initial determination. A verbal or written response will be provided within 30 business days of receipt. State mandates allowing a longer time period for a provider appeal will take precedence.
  • If the dispute is decided in the dentist’s favor, Aetna will recalculate and reprocess the claim for any services affected by the decision.

Level I Appeals

  • If the dispute is not decided in the dentist’s favor, it will automatically be elevated by Aetna to “Level I” appeal status. A Level I appeal is an oral or written request that asks Aetna to change the adverse decision.
  • Dentists will be notified of Aetna’s determination of the Level I appeal in writing within 30 business days of Aetna’s receipt of the appeal.
  • If the Level I appeal is decided in the dentist’s favor, Aetna will recalculate and reprocess the claim for any services affected by the decision.
  • If the Level I decision upholds Aetna’s original position, dentists will receive a letter that includes: the decision; a description of the documentation that supports the decision; and a notice of the right to request review of the adverse determination as a “Level II” appeal; or notice that specifies the outcome with no further opportunity to appeal.

Level II Appeals (subject to individual state laws/regulations)

  • If a dentist is not satisfied with the resolution of the Level I appeal, they may file a Level II appeal. This appeal must be filed within 60 days of the date of the Level I appeal decision. State mandates allowing a longer time period for a provider appeal will take precedence.
  • Aetna will provide a written response of the Level II appeal within 30 business days of receipt of the appeal.
  • If the Level II claim dispute is decided in the dentist’s favor, Aetna will recalculate and reprocess the claim for any services affected by the decision.
  • If the Level II decision upholds Aetna’s original position, the dentist will receive a final resolution letter that includes: the decision and a description of the documentation that supports the decision.

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To Dispute a Clinical Decision
A clinical appeal is a request to change an adverse initial determination for care or services that were denied by Aetna. A dentist may dispute a clinical denial on a member’s behalf with written authorization by the member.

Initial Steps

Aetna offers providers several options by which to dispute a clinical decision:

  • By telephone (subject to individual state laws/regulations)
  • By mail
  • By fax

To dispute a clinical denial by telephone, call the following number:

  • 1-800-451-7715
  • Have a copy of the dentist Explanation of Benefits (EOB), formerly known as Explanation of Provider Payment (EPP), statement and the original claim for reference.

To dispute denial by mail or fax, the dentist should submit the following information:

  • A copy of the EOB
  • A copy of the original request for services
  • A copy of the original denial letter
  • Any supporting documentation the dentist believes will assist Aetna in its review, including a cover letter and brief description of the situation. Providers should include their Aetna provider identification number with their documentation. The dentist also must state in writing that they are disputing this decision on behalf of the member.
  • Fax to 1-860-262-7603
  • Send this information to:
    Aetna Dental
    Complaints, Appeals and Grievances
    P.O. Box 14080
    Lexington, KY 40512-4080
  • All clinical disputes will be reviewed by an Aetna dental consultant who was not involved in the initial determination.
  • A verbal or written response will be provided by Aetna within 30 business days of receipt of the appeal
  • If denial is decided in the dentist’s favor, Aetna will notify the dentist of the new decision and issue an updated EOB on behalf of the member.

Level I Appeals

  • If the dispute is not decided in dentist’s favor, it will automatically be elevated by Aetna to “Level I” appeal status. A Level I appeal is an oral or written request that asks Aetna to change the adverse decision.
  • The Dentists will be notified of Aetna’s determination of the Level I appeal in writing within 30 business days of Aetna’s receipt of the appeal.
  • If the Level I appeal is decided in the dentist’s favor, Aetna will notify the dentist of the new decision and will issue an updated EOB on behalf of the member.
  • If the Level I decision upholds Aetna’s original position, the dentist will receive a letter from Aetna that includes: the company’s decision; a description of the documentation that supports the decision; and a notice of the dentist’s right to request a “Level II” appeal; or a notice that specifies the outcome with no further opportunity to appeal.

Level II Appeals (subject to individual state laws/regulations)

  • If the dentist is not satisfied with the resolution of the Level I appeal, they may file a Level II appeal. This appeal must be filed within 60 days from the date of a Level I appeal decision. State mandates allowing a longer time period for a provider appeal will take precedence.
  • Aetna will issue a written response within 30 business days of receipt of the appeal.
  • If the Level II denial is decided in the dentist’s favor, Aetna will notify the dentist of the new decision and will issue an updated EOB on behalf of the member.
  • If Aetna’s original position is upheld, the dentist will receive a final resolution letter that includes: the decision and a description of the documentation that supports the decision.

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To Dispute a UCR Denial
Aetna offers several options by which to dispute a UCR decision (either in part or full):
  • By telephone (subject to individual state laws/regulations)
  • By mail
  • By fax

Initial Steps

To dispute a UCR denial by telephone, call the following number:

  • 1-800-451-7715
  • Have a copy of the dentist Explanation of Benefits (EOB), formerly known as Explanation of Provider Payment (EPP), statement and the original claim for reference.

To dispute a claim denial by mail or fax, you must submit the following information:

  • A copy of the EOB
  • A copy of the original claim
  • Any supporting documentation the dentist believes will assist Aetna in its review, including, but not limited to a cover letter, a brief description of the complexity of the applicable procedure, the dentist’s geographical location.
  • Fax to 1-860-262-7603
  • Send this information to:
    Aetna Dental
    Complaints, Appeals and Grievances
    P.O. Box 14080
    Lexington, KY 40512-4080
  • Once all necessary information is received, Aetna will re-evaluate the initial determination. A verbal or written response will be provided within 30 business days of receipt. State mandates allowing a longer time period for a provider appeal will take precedence.
  • If the dispute is decided in the dentist’s favor, Aetna will recalculate and reprocess the claim for any services affected by the decision.
  • Nothing herein shall require Aetna to provide proprietary or confidential information of a third party or in any way to warrant the performance by any third party with respect to any database referenced.

Level I Appeals

  • If the dispute is not decided in the dentist’s favor, it will automatically be elevated by Aetna to “Level I” appeal status. A Level I appeal is an oral or written request that asks Aetna to change the adverse decision.
  • Dentists will be notified of Aetna’s determination of the Level I appeal in writing within 30 business days of Aetna’s receipt of the appeal.
  • If the Level I appeal is decided in the dentist’s favor, Aetna will recalculate and reprocess the claim for any services affected by the decision.
  • If the Level I decision upholds Aetna’s original position, dentists will receive a letter that includes: the decision; a description of the documentation that supports the decision; and a notice of the right to request review of the adverse determination as a “Level II” appeal; or notice that specifies the outcome with no further opportunity to appeal.

Level II Appeals (subject to individual state laws/regulations)

  • If a dentist is not satisfied with the resolution of the Level I appeal, they may file a Level II appeal. This appeal must be filed within 60 days of the date of the Level I appeal decision. State mandates allowing a longer time period for a provider appeal will take precedence.
  • Aetna will provide a written response of the Level II appeal within 30 business days of receipt of the appeal.
  • If the Level II claim dispute is decided in the dentist’s favor, Aetna will recalculate and reprocess the claim for any services affected by the decision.
  • If the Level II decision upholds Aetna’s original position, the dentist will receive a final resolution letter that includes: the decision and a description of the documentation that supports the decision.

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