As healthcare providers, they can use the Aetna dispute and appeal process when they do not agree with a claim or utilization review decision. To submit an appeal, the providers should fill the form to support your appeal. Filling the form is a must in submitting an appeal.
If you are an Aetna provider and want to submit an appeal, you may need to download the appeal form first. Unfortunately, you do not know yet where to download the appeal form. No worries! This post will show you an example of an appeal form that you can download and fill it then. Here you go!
An Example of Aetna Appeal Form for Providers
As a healthcare provider of Aetna, you can find an example of Aetna appeal form HERE. If you want to submit an appeal, you definitely should download the form and fill it as correctly as possible. Make sure to fill the form in detail.
On the form, there are a bunch of sections that you should fill including medical records, discharge summaries, office notes, lab records and also member history to the address that is listed on your Explanation of Benefits (EOB) or also other correspondence received from Aetna. However, the form actually supports your appeal.
Here are a number of sections that you should fill on an appeal form:
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- Today’s Date
- Member’s ID Number
- Play Type: Medical – Dental
- Member’s Group Number (Optional)
- Member’s First Name
- Member’s Last Name
- Member’s Birthdate
- Provider Name
- TIN/NPI
- Provider Group (If applicable)
- Contact Name and Title
- Contact Address
- Contact Phone
- Contact Fax
- Contact Email Address
Aside from that, to assist Aetna review and respond to your request, you may also need to provide some information on the form to appeal multiple dates of service for the same member, here are they:
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- Claim ID Number (s)
- Reference Number/ Authorization Number
- Service Date (s)
- Initial Denial Notification Date (s)
- Reconsideration Denial Notification Date (s)
- CPT/ HCPC/ Service Being Disputed
- Explanation of Your Request
Okay, those are some information that you should provide on an appeal form. It’s important to note, you surely can use the member complaint and appeal form if you are acting on the member’s behalf and have a signed authorization from the member if you’re appealing a pre authorization denial and the services should be rendered yet.
The Process of Appeal for Healthcare Provider
The process of Appeal for providers will pass three steps to complete. The appeal process include:
Process 1: Peer to Peer Review
For the first process, Aetna actually offers the healthcare providers a chance to provide the additional information and discuss the cases with a peer-to-peer reviewer. This process is part of the utilization review coverage determination process. The review timing is prior to an appeal and incorporates states, federal, NCQA and CMS requirements.
Process 2: Reconsideration
The reconsideration process includes coding decisions, claims which require reprocessing or formal reviews of claims reimbursements. To submit reconsideration, here’s a list of mailing addresses:
Address 1
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- 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
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- 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
Process 3: Appeal
The last process is about submitting an appeal. This process is a request to change an initial claim decision, change a reconsideration decision, experimental/ investigational coverage criteria or an initial utilization review decision based on medical necessity.
To make it easier for you to understand more about the appeal process, we’ll show you the utilization review issues or claim issues in detail based on cosmetic, medical necessity or experimental/ investigational coverage criteria. Here you go!
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 accepting the additional requested information, within 30 business days of accepting the request if additional information is needed. | Call at 1-800-624-0756 for the WA Primary Choice plan and HMO based benefits plan.
Call at 1-888-632-3862 for PPO and indemnity based benefits plans.
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 accepting the additional requested information, within 30 business days of accepting the request if additional information is needed. | Call at 1-800-624-0756 for the WA Primary Choice plan and HMO based benefits plan.
Call at 1-888-632-3862 for indemnity and PPO based benefits plans.
Mail to Aetna Provider Resolution Team P.O. Box 14020 Lexington, KY 40512 |
Submitting An Appeal, Here’s How!
To submit an appeal for healthcare providers of Aetna, they may need to file a Complaint and Appeal Form (The link to download the form has been mentioned above). The healthcare providers can also submit any medical records or other documents to support the request available on the adverse determination notification.
Afterward, they will receive the notification that may be a claim EPP, denial letter from Clinical Claim Review, a verbal notification from Provider Call Center or rework. You should know that all processes of appeal will need supporting documentation.
The healthcare providers of Aetna cannot accommodate attachments for electronic submissions if they don’t provide the additional documents. Furthermore, they can receive the appeals via mail or fax.
Once submitting an appeal, the healthcare provider will be able to check on the status of an appeal by contacting the Provider Service Center. Aside from checking on the status of an appeal, they can also confirm that they accepted an appeal, talk to a network representative and also ask questions about an appeal decision.
Okay, that’s all about the appeal process that the healthcare providers of Aetna should complete.
AUTHOR BIO
On my daily job, I am a software engineer, programmer & computer technician. My passion is assembling PC hardware, studying Operating System and all things related to computers technology. I also love to make short films for YouTube as a producer. More at about me…
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