Skip to main content

Disputes and appeals

Questions?

Just check your provider manual (PDF) for answers about disputes and appeals. Or contact us.

Filing a dispute

An informal dispute is a verbal or written expression of dissatisfaction concerning a decision that directly impacts the provider. Disputes are typically administrative and do not include decisions concerning medically necessary decisions.

 
Both in-network and out-of-network providers may file verbal and written informal disputes with us. We can resolve them outside the formal disputes and appeals process. Your disputes could be based on things like:

 

  • Policies and procedures

  • One of our decisions

  • A disagreement about whether a service, supply or procedure is a covered benefit

  • Any other issue of concern


Some provider disputes are subject to the member process. In these cases, we transfer them. These include disputes that you may file on behalf of a member. 

Filing an appeal

You should only file an appeal if you were unsuccessful at first resolving the matter through the informal dispute process.

 

Both in-network and out-of-network providers have the right to appeal our claims determinations within 60 calendar days of receipt of the claim denial. 

 

You can file an appeal in regard to things like:

 

  • Provider credentialing

  • Network provider claims, including payment that was denied for services you’d already provided to a member

  • Provider Agreement termination by Aetna Better Health®

File a dispute or appeal now

Online

You can file a dispute or appeal in your Provider Portal. Need help with registration? Just contact Availity at 1-800-282-4548. You can get help from 8 AM to 8 PM ET, Monday through Friday.

By email

By fax

You can fax your dispute or appeal: 1-860-754-1757.

By mail

You can send your written dispute or appeal to:

 

Aetna Better Health® Kids

Attn: Complaints, Grievances & Appeals

 

            PO Box 81040

            5801 Postal Road

            Cleveland, OH 44181

 

Be sure to include information about your case, including all supporting documents such as remittance advice(s), medical records and claims.

Reviews of disputes and appeals

Provider Clinical Appeals Committee

 

Our Provider Clinical Appeals Committee reviews and makes decisions on provider appeals. The decision is final. We send decision notification letters to the requesting provider within five business days of the committee decision. We’ll also not take any punitive action against a provider for using the provider appeal process. 

 

Clinical disputes and appeals reviews are completed by health professionals who: 

 

  • Hold an active, unrestricted license to practice medicine or in a health profession 

  • Are board certified (if applicable) 

  • Are in the same profession or in a similar specialty as normally manages the condition, procedure or treatment concerned in the case 

  • Are neither the same reviewer that made the original decision nor someone who reports to that person 

Also of interest: