How Do You Appeal an Aetna Claim Denial?

How Do You Appeal an Aetna Claim Denial?

Follow these steps in order, and write each date on the account as you go.

1. Read the denial letter or EOB and note the date of the decision. Every deadline counts from a decision date.
2. Decide the route. Coding, reimbursement and reprocessing disputes are reconsiderations. Medical-necessity, experimental or investigational, no-prior-approval and retroactive-authorization denials are appeals.
3. File on the Availity provider website. Select the claim, start the dispute, upload the support and finish by selecting Submit.
4. Save the Case Number from the confirmation screen and track the dispute in the Availity appeals tracker.
5. If a reconsideration is upheld and you still disagree, file the one appeal, and tell Aetna what you already sent.

The Aetna payer guide lists the state exceptions to the 180-day standard, which this post does not repeat. Check it before you count days on a fully insured plan.

Is Your Denial a Reconsideration or an Appeal?

Aetna defines a reconsideration as a formal review of a claim reimbursement or coding decision, or of a claim that needs to be processed again. An appeal is a written request to change a reconsideration decision, or an initial claim or utilization review decision based on medical need or experimental or investigational coverage criteria.

You do not have to get the sorting exactly right when you file online. On Availity, Aetna says it determines whether the dispute goes to a reconsideration or an appeal using these criteria. If you send a reconsideration that is really an appeal, Aetna routes it and tells you if it needs the appeal form.

How to tell afterward: an appeal response letter says so, usually in the subject line, and a reconsideration letter points you to where to file an appeal.

What Are the Deadlines?

The overview page gives general time frames and notes that some states have different ones.

The FAQ page also says that state regulations or your provider contract may allow more time, and that state mandates requiring different time periods take precedence. Medicare plans and most self-insured plans are generally not subject to state law.

How Do You File the Dispute on Availity?

Use the Claim Status transaction. The provider manual says a claim must be in Finalized status before you can dispute it. Complete a Claim Status inquiry, select the claim and select the Dispute Claim button.

Availity then gives one of three responses:

• Initiated: the claim is eligible. Go to the Appeals dashboard, upload the supporting documents and select Submit.
• Submitted: this is a duplicate request. Search the Appeals dashboard for the existing dispute and its status.
• Not eligible: for technical reasons the claim cannot be disputed in the portal. Use the Disputes and appeals page on Aetna.com.

The trap is in the first one. The manual states that disputes remaining in an Initiated status are not submitted to the payer. A reconsideration left at that status never reaches Aetna, and the clock keeps running.

Online filing also solves the form problem. Aetna cannot handle an appeal that arrives without the appeal form and sends a letter asking you to resubmit within the time frame, but when you file on Availity the form is created for you. For reconsiderations you can also call or mail. The mailing address is the PO box on the denial letter or EOB.

What Should You Attach?

The overview page lists what Aetna wants to close a dispute. Send all of it in one submission.

• A completed dispute and appeal form for the plan type, unless you file on Availity.
• A copy of the denial letter or the EOB.
• The original claim.
• Your reasons for disagreeing with the decision, stated plainly.
• Documents that support your reason, such as medical records or office notes, or a remittance advice from a Medicare carrier when the dispute is about Medicare as primary.

Aetna says to provide medical records when you ask for a review for medical necessity, and for a reconsideration of an adverse claim decision that is clinical in nature. The appeal letter guide covers how to put the argument in order.

For an appeal after a reconsideration, Aetna says you do not have to resubmit everything. State in the appeal that you submitted information with the reconsideration, and add anything new you want considered. An upheld reconsideration does not go to appeal automatically.

What Happens If Aetna Upholds the Denial?

Aetna allows only one level of appeal for practitioners and providers, so the appeal decision is the end of Aetna's internal process. The next step is what your agreement and state law provide. Aetna states that there is no fee to use its dispute process, though there may be a charge if you pursue an independent external review.

Handle the member carefully while you wait. The provider manual says you may not bill or balance bill members when a claim is denied for administrative reasons such as a lack of referral or authorization when one was required.

Two cases belong elsewhere. A peer-to-peer call is part of the coverage decision process and happens before the appeal. Contact customer service for it, and do not use the appeal request form to ask for one. If you want a peer to review as part of an appeal, send the appeal form with a note asking for it. And for a pre-service or concurrent medical necessity decision, the member appeal process applies, not the provider appeal. Expedited handling is for urgent precertification denials and is not available for post-service appeals.

What Is the Checklist Before You File?

• Decision date written on the account, with the reconsideration date and the appeal date calculated.
• Route chosen and recorded: reconsideration or appeal.
• Denial letter or EOB, original claim and supporting records in one file.
• Dispute taken through to Submit, with the Case Number saved.
• Plan type confirmed (Medicare or non-Medicare, fully insured or self-insured) before you trust a state exception.

For the same task at another payer, see the UnitedHealthcare appeal steps. Aetna's CO-50 medical necessity denials follow the appeal route above, and the timely filing limits by payer rule covers the filing side.

How Nucleus Align Handles It

We work denials within 48 hours and record the decision date, route and deadline when the denial lands. Book a call to review your Aetna denials, or read more on the blog.