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Dispute & Appeal Process: Quick Reference Guide

This quick reference guide shows you when and where to submit disputes

Issue types

Claims issues

These issues relate to all decisions made during the claims adjudication process. For example, issues related to the provider contract, our claims payment policies, or processing errors.

Utilization review issues

These issues relate to decisions made during the precertification, concurrent or retrospective review processes for services that require precertification. For these 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.

Application of state laws and regulations

If our policy varies from the applicable laws or regulations of an individual state, the requirements of the state regulation supersede our policy when they apply to the member’s plan. Our law department makes the final determination if there is any question regarding the applicability of any particular law.

Claim Issues for Reimbursement or Coding Designs Table

Dispute Level

Practitioner/Organizational Provider Submission Timeframe

Response Timeframe

Contact Information

Reconsideration

Within 180 calendar days of the initial claim decision.

Within 7-10 business days of receiving the request. Within 60 business days of receiving the request if review by a specialty unit is needed (i.e., clinical coding review).

Call us at the number on the back of the member's ID card.

Write See reconsideration mailing addresses below.

Submit online through the EOB claim search tool. Log in to the secure provider website via NaviNet® to access this tool.

Appeal

 Within 60 calendar days of the reconsideration decision.

Within 60 calendar days of receiving the request. If additional information is needed, within 60 calendar days of receiving the additional requested information.

Call us at the number on the back of the member's ID card.

Write Provider Resolution Team
PO Box 14079
Lexington, KY 40512-4079.

See state exceptions to these timeframes

Mailing Addresses for Reconsiderations Table

State

Address

AZ

 Provider Resolution Team
PO Box 14079
Lexington, KY 40512-4079

Utilization review issues or claim issues based on medical necessity or cosmetic or experimental/investigational or non-inpatient services denied for not receiving prior approval coverage criteria.

Utilization Review Issues or Claim Issues Table

Dispute Level

Practitioner/Organizational Provider Submission Timeframe

Texas Health Aetna Response Timeframe

Contact Information

Appeal

Within 180 calendar days of an initial claim decision or utilization review decision.

Within 60 calendar days of receiving the request. If additional information is needed, within 60 calendar days of receiving the additional requested information.

Call us at the number on the back of the member's ID card.

Write Provider Resolution Team
PO Box 14079
Lexington, KY 40512-4079.

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Health benefits and health insurance plans are offered, underwritten, and/or administered by Banner Health and Aetna Health Insurance Company and/or Banner Health and Aetna Health Plan Inc. (Banner|Aetna). Banner|Aetna is an affiliate of Banner Health and of Aetna Life Insurance Company and its affiliates (Aetna). Each insurer has sole financial responsibility for its own products. Aetna and Banner Health provide certain management services to Banner|Aetna. Aetna, CVS Pharmacy® and MinuteClinic, LLC (which either operates or provides certain management support services to MinuteClinic-branded walk-in clinics) are part of the CVS Health® family of companies.

On-Demand Virtual Care with 98point6 by Transcarent

Banner|Aetna offers access to 98point6 by Transcarent, a virtual care solution that enables members to connect to care anytime, anywhere via secure in-app messaging.

Treatment is provided by a U.S.-based care team, including board-certified doctors, who can diagnose and treat over 1,000 conditions, outline care options, prescribe* medication, and order labs or imaging when appropriate—all through the convenience of a mobile app.

Key Features:

  • Audio, video, and Spanish translation support available as needed
  • Access to care plans and lab results directly within the app
  • Referrals to in-network resources and specialists
  • Care is available in all 50 states and Washington D.C.
  • 24/7/365 access with an average wait time of under 2 minutes—no appointment required.

Available to enrolled Banner|Aetna members and covered dependents age 1+* in an eligible plan.

Cost: Low-to-no-cost per visit*, depending on plan details.

*FOR ENROLLED MEMBERS AND COVERED DEPENDENTS AGE 1+: 98point6 by Transcarent is available to members age 1-17 when an adult parent or guardian is also enrolled in the plan. Access to 98point6 by Transcarent is not included in all plans.

*FOR LOW-TO-NO-COST WITH 98POINT6 BY TRANSCARENT: Members enrolled in a health savings account (HSA) or qualified high-deductible health plan (HDHP) must pay the applicable cost-share for virtual care visit until their deductible is met, after which services will be provided at no cost-share. All other health plan members pay $0 per virtual care visit regardless of whether their deductible has been met. Please refer to your plan documents for your applicable cost-share amounts.

*FOR 98POINT6 BY TRANSCARENT PRESCRIBING: 98point6 by Transcarent providers do not prescribe controlled substances (such as opioids), lifestyle medications (such as Viagra and Propecia) or weight loss medications (Wegovy or Ozempic). 98point6 by Transcarent and Transcarent Clinic clinicians are independent contractors and are neither agents nor employees of Banner|Aetna or plans administered by Banner|Aetna, and does not guarantee that a prescription will be written. Transcarent Clinic providers will not prescribe DEA-controlled substances, non-therapeutic drugs and certain other drugs that may be harmful because of their potential for abuse. Clinicians reserve the right to deny care for potential misuse of services

This material is for information only. An application must be completed to obtain coverage. Rates and benefits vary by location. Providers are independent contractors and are not agents of Banner|Aetna. Provider participation may change without notice.

Health insurance plans contain exclusions and limitations.