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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.

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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