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Dispute & Appeals Process

Plans that are currently available effective on or after January 1, 2018 are underwritten by Banner Health and Aetna Health Insurance Company.

Our process for disputes and appeals

Health care professionals and organizational health care providers can dispute adverse decisions. The information below explains when and how to submit a dispute. It applies to all our medical benefits plans (please note that state requirements take precedence when they differ from our policy).

Have Questions?

See our answers regarding the insurance dispute process

Definitions

The following definitions apply in an insurance dispute: 

Practitioner:

An individual who is licensed or otherwise authorized by the state to provide health care services. Examples include doctors, podiatrists and independent nurse practitioners.

Organizational providers:

Institutional providers and suppliers of health care services, including behavioral health care organizations. Examples of organizational providers include, but are not limited to: hospitals, nursing homes, skilled nursing facilities (SNF), home care agencies, free standing surgical centers, birthing centers, urgent care centers, pain management centers, ambulance services, pharmacies, hospices, infusion centers, blood banks, diagnostic testing centers, diabetic treatment centers, residential treatment facilities, MRI centers, independent durable medical equipment vendors, orthotics facilities, oncology treatment centers, optical facilities and sleep diagnostic centers.

Behavioral health organizations include, but are not limited to: mental health and chemical dependency hospitals, residential treatment facilities, partial hospital programs, intensive outpatient programs and clinics. Behavioral health organizations can be freestanding or hospital-based.

Dispute:

A disagreement regarding a claim or utilization review decision.

Reconsideration:

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 outpatient services were denied for not receiving precertification.

Appeal:

An appeal is a written request by a practitioner/organizational provider to change:

  • An adverse reconsideration decision
  • An adverse initial claim decision based on medical necessity or experimental/investigational coverage criteria
  • A denial for non-inpatient hospital services that were denied for not receiving prior approval
  • An adverse initial utilization review decision

Claims issues:

Issues related to decisions made during the claims adjudication process, including those that result in an overpayment (i.e., related to the provider contract, our claims payment policies, processing error, etc.).

Utilization review issues:

Issues related to decisions made during the precertification, concurrent or retrospective review processes for services that require precertification. For these types of issues, the practitioner/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.

The Dispute Process

Dispute

A practitioner or organizational provider may submit a dispute in one of four ways:

  1. Submit online through the Explanation of Benefits (EOB) claim search tool – log in to the secure provider website via NaviNet®.
  2. Write to the P.O. box listed on the EOB statement, denial letter or overpayment letter related to the issue being disputed.
  3. Fax the request to 1-866-455-8650
  4. Call our Provider Service Center using the phone number on the back of the member’s ID Card.

You have 180 days from the date of the initial decision to submit a dispute. However, you may have more time if state regulations or your organizational provider contract allows more time.

To facilitate the handling of an issue, you should:

  • State the reasons you disagree with our decision.
  • Have the denial letter, EOB statement or overpayment letter and the original claim available for reference.
  • Provide appropriate documentation to support your payment dispute (i.e., a remittance advice from a Medicare carrier, medical records, office notes, etc.).

Claims payment disputes related to reimbursement or coding are subject to our reconsideration process. Initial adverse claims decisions based on medical necessity, experimental or investigational coverage criteria, as well as non-inpatient services that were denied for not receiving prior authorization, are handled as appeals and reviewed by clinicians. Utilization review disputes are handled as appeals and reviewed by clinicians as well.

Reconsideration

If you would like to dispute a claim payment decision, contact us to have the decision reconsidered. This is the first step in disputing a claim payment decision.

A provider contact center representative will research the handling of the claim in question. We will generally resolve claims payment issues related to contract application within seven to ten business days. If the decision is in your favor, we will recalculate and reprocess the claim for any services affected by the decision.

It may be necessary to forward claims payment issues involving reimbursement or coding reviews to a specialty unit for investigation and resolution. We will issue a response within 60 business days if no additional information is required, or within 60 business days of when the specialty unit receives any additional requested information. If the decision is in your favor, we will recalculate and reprocess the claim for any services affected by the decision.

Following reconsideration, if the decision is not in your favor, you may initiate an appeal. We will provide instructions on how and when to file an appeal when we issue the reconsideration decision.

Appeal

You may request an appeal in writing using the Aetna Provider Complaint and Appeal Form, if you are not satisfied with:

  • The reconsideration decision (for claims disputes)
  • An initial claim decision based on medical necessity or experimental/investigational coverage criteria
  • A denial for non-inpatient hospital services that were denied for not receiving prior approval
  • An initial precertification/patient management review decision

We will notify you of our appeal decision in writing within 60 calendar days of our receipt of the appeal, unless we need additional information. If we need additional information, we will send the appeal decision within 60 calendar days of receipt of the additional requested information.

If the appeal decision is in your favor, we will recalculate and reprocess the claim for any services affected by the decision. If the appeal decision upholds our original position, we will send a written response.

State laws and regulations

To the extent that 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 when there is any question as to the applicability of a law.

Questions

If you have questions about our appeal process, please contact our provider service center using the number on the back of the member’s ID card.

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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.