Dispute Process FAQs

Who can use Texas Health Aetna’s dispute process for practitioners and organizational providers?

Any health care professional who provides health care services to Texas Health Aetna members can use the dispute process. In terms of our dispute process:

• Practitioners are individuals or groups who are licensed or otherwise authorized by the state in which they provide health care services to perform such services. Examples include physicians, podiatrists and independent nurse practitioners.
• Organizational providers are institutional providers and suppliers of health care services. Examples include hospitals, skilled nursing facilities, independent durable medical equipment vendors and behavioral health organizations, such as mental health or residential treatment centers.

What is a dispute?

A dispute is a disagreement regarding a claim or utilization review decision.

What is the procedure for disputing a claim decision?

You may contact us by phone (for reconsiderations) or mail within 180 days of the decision. State regulations or your provider contract may allow more time.

To facilitate the handling of an issue:

• State the reasons you disagree with our decision
• Have the denial letter or Explanation of Benefits (EOB) statement 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.).
• If the request does not qualify for a reconsideration as defined below, the request must be submitted in writing using the Aetna Provider Complaint and Appeal Form. 

What number should I call to dispute a claim decision?

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

Where should I send a claim dispute if I am submitting by mail?

See the quick reference guide or refer to the denial letter or Explanation of Benefits (EOB) statement for the address.

What is a 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 non-inpatient services denied for not receiving prior authorization.

Can I submit a reconsideration online? If so, how?

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

What is an 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
• An adverse initial utilization review decision
• A denial for non inpatient hospital services that were denied for not receiving prior approval
  

Claims decisions are decisions made during the claims adjudication process. For example, decisions related to the provider contract, our claims payment policies, or processing error.

Utilization review decisions are decisions made during the precertification, concurrent or retrospective review processes for services that require precertification. For these types of 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.

How long do I have to submit a dispute?

See the quick reference guide for the timeframes to submit a reconsideration or appeal.

What is the timeframe for responding to a dispute?

See the quick reference guide for our timeframes for responding to reconsideration or appeal.

Can all practitioners and organizational providers file both Level 1 and Level 2 appeals?

No. According to our policies, we only allow one level of provider appeal.

What can I do if I am contesting an urgent matter?

You may request an expedited appeal. Expedited appeals are available when precertification of urgent or ongoing services has been denied and a delay in decision making might seriously jeopardize the life or health of the member or otherwise jeopardize the member’s ability to regain maximum function.

We will resolve expedited appeals within 36 hours of receipt for a two level appeal process or 72 hours for a one level appeal process or within state mandated guidelines. Please note that the member appeals process applies to expedited appeals. Post-service appeals are not eligible for expedited handling. Refer to the member health plan benefits FAQs for more details.

Is there a fee for using Texas Health Aetna’s dispute process?

No. There is no fee for using the Texas Health Aetna dispute process.

What if my state has regulations that differ from Texas Health Aetna’s process?

State law supersedes our process for disputes and appeals when they apply to the member’s plan. We follow all state laws and regulations. State mandates requiring different time periods will take precedence, except as previously noted.

What is a member’s authorized representative?

A member may designate a practitioner or organizational provider as an “authorized representative” to file an appeal on his or her behalf for claims involving pre-service, urgent care or inpatient urgent concurrent review. The practitioner or organizational provider must be the member’s primary physician or a health care professional with knowledge of the member’s medical condition. The member appeal process applies to pre-service appeals.

Is any documentation required if I am filing an appeal on behalf of the member (acting as the member’s authorized representative) for a post service appeal?

Yes, submit a document signed and dated from the member specifically authorizing you to appeal on the member’s behalf for the services in question.

Related Links:

• Dispute & Appeals Process
• Dispute & Appeals Process: Quick Reference Guide
• Dispute & Appeals Process: State Exceptions