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Dispute & Appeal Process: Quick Reference Guide

This quick reference guide shows you when and where to submit disputes

Issue types

Claims issues

These issues relate to all decisions made during the claims adjudication process. For example, issues related to the provider contract, our claims payment policies, or processing errors.

Utilization review issues

These issues relate to decisions made during the precertification, concurrent or retrospective review processes for services that require precertification. For these 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.

Application of state laws and regulations

If 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 if there is any question regarding the applicability of any particular law.

Claims issues for reimbursement or coding decisions

Dispute Level

Practitioner/Organizational Provider Submission Timeframe

Response Timeframe

Contact Information

Reconsideration

Within 180 calendar days of the initial claim decision.

Within 7-10 business days of receiving the request. Within 60 business days of receiving the request if review by a specialty unit is needed (i.e., clinical coding review).

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

Write See reconsideration mailing addresses below.

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

Appeal

Within 60 calendar days of the reconsideration decision.

Within 60 calendar days of receiving the request. If additional information is needed, within 60 calendar days of receiving the additional requested information.

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

Write Provider Resolution Team
PO Box 981106
El PASO, TX 79998-1106.

See state exceptions to these timeframes

Mailing addresses for reconsiderations

State

Address

TX

Provider Resolution Team
PO Box 981106
El PASO, TX 79998-1106

Utilization review issues or claim issues based on medical necessity or cosmetic or experimental/investigational or non-inpatient services denied for not receiving prior approval coverage criteria.

Dispute Level

Practitioner/Organizational Provider Submission Timeframe

Texas Health Aetna Response Timeframe

Contact Information

Appeal

Within 180 calendar days of an initial claim decision or utilization review decision.

Within 60 calendar days of receiving the request. If additional information is needed, within 60 calendar days of receiving the additional requested information.

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

Write Provider Resolution Team
PO Box 981106
El PASO, TX 79998-1106.

Language services can be provided by calling the number on your member ID card. For additional language assistance: Español | 中文 | Tiếng Việt | 한국어 | Tagalog | Pусский | العربية | Kreyòl | Français | Polski | Português | Italiano | Deutsch | 日本語 | فارسی | Other Languages…

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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