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Dispute Process FAQs

Who can use Aetna’s dispute process for providers?
Any health care professional who provides health care services to Aetna members can use the dispute process.

What is a dispute?
A dispute is a disagreement regarding a claim or utilization review decision.

What is the procedure for disputing a claim decision?
You may contact us by phone (for reconsiderations), mail, online or fax within 180 days of receiving the decision. State regulations or your provider contract may allow more time.

To make a claim:

  • State the reasons you disagree with our decision.
  • Have the denial letter or Explanation of Benefits (EOB) statement and the original claim available for reference. Provide appropriate documentation to support your payment dispute (for example, a remittance advice from another carrier; medical records; office notes, etc.).
  • If the request does not qualify for a reconsideration as defined below, the request must be submitted in writing using the Provider complaint and Appeal Form

What number should I call to request a reconsideration of a claim decision?
1-800-451-7715

Where should I send a claim dispute if I am submitting by mail?
See the denial letter or Explanation of Benefits (EOB) statement in question for the appeal address.

Can I submit reconsideration online? If so, how?
Submit online through the EOB claim search tool. Log in to the secure provider website; www.aetnadental.com to access the EOB Tool.

What is a reconsideration?
A reconsideration is a formal review of a previous claim reimbursement or coding decision, or a claim that requires reprocessing.

What is an appeal?
An appeal is a written request by a provider to change:

  • An adverse reconsideration decision
  • An adverse initial claim decision based on medical necessity or experimental/investigational coverage criteria
  • An adverse initial utilization review decision
  • A UCR disagreement

Claims decisions are all decisions made during the claims adjudication process (e.g., decisions related to the provider contract, our claims payment policies, or processing error).

Utilization review decisions are decisions made during the predetermination process or retrospectively for those services requiring medical necessity review.

How long do I have to submit a dispute?
See our timeframes to submit a reconsideration or an appeal.

What is Aetna’s timeframe for responding to a dispute?
See our timeframes for responding to a reconsideration or an appeal.

Is there a fee for using Aetna’s dispute process?
No. However, there may be a charge if you decide to pursue an independent external review process.

What if my state has regulations that differ from Aetna’s process?
State law supersedes our process for disputes and appeals. We follow all state laws and regulations. State mandates requiring different time periods will take precedence, except as previously noted.

Appeals relating to Aetna Medicare plans are an exception. State laws do not apply to Medicare plans.

What is a member’s authorized representative?
A member may designate provider as an “authorized representative” to file an appeal on his or her behalf.  This request would follow the member asppeal process.

Is any documentation required if I am filing an appeal on behalf of the member (acting as the member’s authorized representative) for a post service appeal?

Yes. Complete and have the member sign and date the Authorized Representative Request form. Return the form with the appeal request to authorize you to appeal on the member’s behalf in order to access member appeal rights.
 

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