How to Submit Claims and Appeals to Aetna

What Medical Billers, Physicians, and Patients Should Know

Aetna provides a variety of health insurance programs, including individual and workplace-sponsored plans. Billings and claim procedures can be complicated and require guidance on how to properly preauthorize, submit, and appeal such claims. Here is an outline of how Aetna works:

1

How to Submit a Precertification Request

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You can submit precertification requests prior to rendering services through their site or by phone using the Member Services number on the member's ID card.

Precertification occurs before hospital admission or certain outpatient procedures and services. These apply to:

  • Procedures and services on Aetna's Participating Provider Precertification list
  • Procedures and services on Aetna's Behavioral Health Precertification list
  • Procedures and services on the member's individual policy, including Medicare Advantage policies

You can search Aetna's precertification list online or by phone by entering the CPT code when prompted.

Electronic precertification is available 24 hours a day, Monday through Sunday. Once precertification is electronically submitted, a tracking number will be assigned to the request.

A tracking number does not indicate approval. You will be notified if the request is approved or denied. Approvals will be given a certification ID number.

2

How to Submit a Claim

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There Are Three Simple Ways to Submit Claims to Aetna

  • Through Aetna’s secure provider portal on NaviNet
  • Through an electronic transaction vendor
  • By submitting paper claims to the Aetna mailing address on the member's ID card

Secondary claims are submitted electronically. This refers to any claim for which Medicaid or Medicare is the secondary payer as well as certain supplemental insurance policies.

When Submitting a Secondary Claim

  • Include the adjustment amounts at both claim level and service-line level (if available)
  • Include adjustment reason (including contractual obligation, deductible, coinsurance, etc.) using the codes provided by the primary payer's remittance
  • Include the primary payer's paid amount at both claim level and service-line level (if available).

Unless state law indicates otherwise, physicians have 90 days from the date of service to submit a claim for payment, while hospitals have up to one year.

3

How to Track Eligibility, Benefits, and Claims

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Eligibility, benefits, and claim status can be verified with Aetna in two ways:

  • Through Aetna’s secure provider portal on NaviNet
  • Through an electronic transaction vendor such as Allscripts, Availity, Change Healthcare, CoverMyMeds, HDX, Healthlogic, and others

Electronic real-time eligibility (RTE) is available 24 hours a day, 7 days a week to both participating and nonparticipating health care providers.

Providers can submit benefits inquiries for up to 18 months prior to the date of the requested procedure or service.

4

How to Correct Claims and Receive Refunds

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When making changes to a previously paid claim, submit the correction electronically by updating the Claim Frequency Code (CFC). Always be sure to include the correct billing code.

After logging on to NaviNet or an electronic transaction vendor website, you can indicate the changes needed with the following Bill and Frequency Type (BFT) codes:

  • 7 = Replacement of a prior claim
  • 8 = Cancellation of a prior claim

You can also submit corrections on paper by stamping "CORRECTED CLAIM" at the top of the claim form and mailing the adjusted request to Aetna, P.O. Box 14079, Lexington, KY 40512-4079.

Upon receipt of the corrected claim, Aetna will recover the overpayment and advise you of the adjustment on an electronic remittance advice (ERA).

Providers can enroll for ERA and electronic funds transfer (EFT) services through the Aetna portal on the CAQH EnrollHub website. Any adjustments can then be deposited electronically into the provider's bank account.

5

How to Appeal a Denial

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If Aetna denies a claim and you do not agree, you can submit an appeal either by calling the Member Services number on the member's ID card or submitting the appeal by mail using the Aetna's Member Complaint and Appeal form.

The process involves up to three phases:

  • The reconsideration phase is in which you, your doctor, or an authorized representative argues for a reversal of Aetna's denial
  • The appeals phase if the reconsideration phase fails to reverse the denial
  • The external review phase in which the appeal is forward to an independent review board

Reconsideration Phase

To better expedite a reconsideration request, be sure include the following documents and pieces of information:

  • Aetna's Member Complaint and Appeal form
  • A copy of the denial or Explanation of Benefits (EOB) letter
  • The original claim
  • Reasons why you think the denial should be reversed
  • Any supporting documents (such as medical records, lab tests, or doctor notes)

You should receive a decision within 3 to 5 days of receiving the reconsideration request. If a specialty review is needed, the decision can take as long as 60 days.

Appeals Phase

If the reconsideration request fails to reverse the denial, you can step up the appeals by contacting Member Services or submitting an appeal, ideally by a physician or authorized representative able to argue the case.

Appeals should be submitted within 60 days of the reconsideration denial and be mailed to Aetna Provider Resolution Team, P.O. Box 14030, Lexington, KY 40512.

A decision should be rendered within 60 days of the receipt of the appeals documentation.

Urgent Appeals

If a denied service or procedure is urgent and likely to place the patient's health at risk, an urgent appeal can be made. Urgent appeals can be submitted by the provider, member, or an authorized representative.

To submit the appeal, contact the Member Services number on the member's ID card and ask for an "expedited appeal." Upon receipt of the request, a decision will be rendered within 72 hours

If the appeal is denied, a second appeal can be lodged. A response for a second-level appeal must be made within 36 hours.

External Review

Under regulations of the Affordable Care Act, you have the right to an external review by experts not associated with Aetna if all efforts to reverse a denial fail.

To begin the process, contact Member Services on the member's ID card and request an External Review Form as well as an Expedited External Review form to be completed by the treating physician.

You can also contact Aetna's National External Review Team at 1-877-848-5855 for instruction on how to properly complete and submit the forms.

Upon receipt of the required documents, a decision will be rendered by the external review team within 30 days.

Submission Instruction

You can submit appeals online through Aetna's Explanation of Benefits (EOB) claim search tool. Log on to NaviNet to begin the appeals process.

Alternatively, you can submit the appeal by mail, as follows:

  • For Alabama, Alaska, Arkansas, Arizona, California, Florida, Georgia, Hawaii, Idaho, Louisiana, Mississippi, North Carolina, New Mexico, Nevada, Oregon, South Carolina, Utah, Tennessee, or Washington State, mail the appeal documentation to Aetna, P.O. Box 14079, Lexington, KY 40512-4079.
  • For all other states, mail the forms to Aetna, P.O. Box 981106, El Paso, TX 79998-1106.
6

General Information

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Contact Numbers

  • Corporate headquarters: 1-800-US-AETNA (1-800-872-3862)
  • Medical and Behavioral Health: For HMO-based and Medicare Advantage plans, call 1-800-624-0756. For all other plans, call 1-888-MD-Aetna (1-888-632-3862).
  • Aetna Pharmacy Management: 1-800-238-6279
  • Dental providers: 1-800-451-7715
  • Credentialing or re-credentialing status: 1-800-353-1232

Important Addresses

  • Corporate headquarters: Aetna, 151 Farmington Avenue, Hartford, CT 06156
  • Pharmacy claims: Aetna Pharmacy Management; P..O. Box 52444, Phoenix, AZ 85072-2444
  • Mail-order drug delivery: Aetna Rx Home Delivery, P.O. Box 417019, Kansas City, MO 64179-9892
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Article Sources

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