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Dispute & Appeal Process: State Exceptions

In the absence of an exception below, Texas Health Aetna's 180-day dispute filing standard will apply. The exceptions below apply to requests regarding members covered under fully insured plans only.



Exception Applies To

Time Allowed to File & Pursue a Dispute



All participating providers and nonparticipating providers who are paid on a participating basis (examples include an emergency situation, a network inadequacy issue, a nonparticipating provider who is pre-approved by Texas Health Aetna or a hospital-based physician who is a nonparticipating provider but provides services at a participating facility)

4 years for claims and non-claims issues -- (complaints are handled as appeals in TX)

A preferred provider that received an underpayment in relation to an audit must notify Texas Health Aetna within 270 days per Texas law to qualify to receive a penalty for the underpaid amount.

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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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