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Dispute & Appeals Process

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.)

Got 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 and/or underwritten by Texas Health + Aetna Health Plan Inc. and Texas Health + Aetna Health Insurance Company (Texas Health Aetna). Each insurer has sole financial responsibility for its own products. Texas Health Aetna are affiliates of Texas Health Resources and of Aetna Life Insurance Company and its affiliates (Aetna). Aetna provides certain management services to Texas Health Aetna.

Self-funded plans are administered by Texas Health + Aetna Health Insurance Company.

This material is for information only and is not an offer or invitation to contract. An application must be completed to obtain coverage. Health benefits and health insurance plans contain exclusions and limitations. Providers are independent contractors and not our agents. Provider participation may change without notice. We do not provide care or guarantee access to health services. Not all health services are covered. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability are subject to change and may vary by location. If you are in a plan that requires the selection of a primary care physician and your primary care physician is part of an integrated delivery system or physician group, your primary care physician will generally refer you to specialists and hospitals that are part of the delivery system or physician group. Information is believed to be accurate as of the production date; however, it is subject to change.

Physicians on the medical staff practice independently and are not agents or employees of the hospital or Texas Health Resources.

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