Any health care professional who provides health care services to Banner|Aetna members can use the dispute process. In terms of our dispute process:
A dispute is a disagreement regarding a claim or utilization review decision.
You may contact us by phone (for reconsiderations) or mail within 180 days of the decision. State regulations or your provider contract may allow more time.
To facilitate the handling of an issue:
Call us at the number on the back of the member’s ID card.
See the quick reference guide or refer to the denial letter or Explanation of Benefits (EOB) statement for the address.
A reconsideration is a formal review of a previous claim reimbursement or coding decision, or a claim that requires reprocessing where the denial is not based on medical necessity or where non-inpatient services denied for not receiving prior authorization.
Submit online through the EOB claim search tool. Log in to the secure provider website via NaviNet® to access this tool.
An appeal is a written request by a practitioner/organizational provider to change:
Claims decisions are decisions made during the claims adjudication process. For example, decisions related to the provider contract, our claims payment policies, or processing error.
Utilization review decisions are decisions made during the precertification, concurrent or retrospective review processes for services that require precertification. For these types of issues, the practitioner and organizational provider appeal process only applies to appeals received subsequent to the services being rendered. The member appeal process applies to appeals related to pre-service or concurrent medical necessity decisions.
See the quick reference guide for the timeframes to submit a reconsideration or appeal.
See the quick reference guide for our timeframes for responding to reconsideration or appeal.
No. According to our policies, we only allow one level of provider appeal.
You may request an expedited appeal. Expedited appeals are available when precertification of urgent or ongoing services has been denied and a delay in decision making might seriously jeopardize the life or health of the member or otherwise jeopardize the member’s ability to regain maximum function.
We will resolve expedited appeals within 36 hours of receipt for a two level appeal process or 72 hours for a one level appeal process or within state mandated guidelines. Please note that the member appeals process applies to expedited appeals. Post-service appeals are not eligible for expedited handling. Refer to the member health plan benefits FAQs for more details.
No. There is no fee for using the Banner|Aetna dispute process.
State law supersedes our process for disputes and appeals when they apply to the member’s plan. We follow all state laws and regulations. State mandates requiring different time periods will take precedence, except as previously noted.
A member may designate a practitioner or organizational provider as an “authorized representative” to file an appeal on his or her behalf for claims involving pre-service, urgent care or inpatient urgent concurrent review. The practitioner or organizational provider must be the member’s primary physician or a health care professional with knowledge of the member’s medical condition. The member appeal process applies to pre-service appeals.
Yes, submit a document signed and dated from the member specifically authorizing you to appeal on the member’s behalf for the services in question.
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Banner|Aetna aims to offer access to more efficient and effective member care at a more affordable cost. We join the right medical professionals with the right technology, so members benefit from quality, personalized health care designed to help them reach their health ambitions.