Whether you send your appeal by mail, fax or online through our provider website on Availity, we will send you an appeal decision letter.Whether you send your non-Medicare reconsideration by phone call, mail, fax or online through our provider website on Availity, the reconsideration decision will be verbal, or an EOB.Whether you send your Medicare reconsideration by phone call, mail, fax or online through our provider website on Availity, the reconsideration decision will be verbal, an EOB or a decision letter by mail.When you submit a dispute online through our provider website on Availity, the process for determining whether it goes to a reconsideration or an appeal is determined by Aetna using the criteria above.

The member appeal process applies to appeals related to pre-service or concurrent medical necessity decisions.

For these types of issues, the practitioner and organizational provider appeal process applies only to appeals received subsequent to the services being rendered. Utilization review decisions are decisions made during the precertification, concurrent or retrospective review processes for services that require precertification. Adverse decisions on certain non-Medicare claims based on state legislationĬlaims decisions are all decisions made during the claims adjudication process: For example, decisions related to the provider contract, our claims payment policies or a processing error.An adverse decision on a claim where a required authorization wasn’t obtained (retroactive authorization).An adverse Medicare non-participating provider claim decision.An adverse initial utilization review decision.A denial for non-inpatient hospital services that were denied for not receiving prior approval.An adverse initial claim decision based on medical necessity or experimental/investigational coverage criteria.*Exceptions may exist based on your state’s regulations.Īn appeal is a written request by a practitioner/organizational provider to change: If the request does not qualify for a reconsideration as defined below, the request must be submitted as an appeal online through our provider website on Availity, or by mail/fax, using the appropriate form on forms for health care professionals.* Provide appropriate documentation to support your payment dispute (for example, a remittance advice from a Medicare carrier medical records office notes, etc).

Have the denial letter or Explanation of Benefits (EOB) statement and the original claim available for reference.

State the reasons you disagree with our decision.

Reconsiderations can be submitted online, by phone or by mail/fax.Īppeals must be submitted online through our provider website on Availity, or by mail/fax, using the appropriate form on forms for health care professionals.* State regulations or your provider contract may allow more time. You may contact us within 180 days of receiving the decision.

Aetna claims timely filing limit