Dispute & Appeals Process | Allina Health Aetna

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.)

Have questions?

See our answers regarding the insurance dispute process

Definitions

The following definitions apply in an insurance dispute: 

Practitioners:

• Individual or group licensed or authorized by the state to provide health care services. Examples include doctors, podiatrists, dentists and independent nurse practitioners.

 

Organizational providers:

• Institutional providers and suppliers of health care services. Some examples include: 
  • Hospitals
  • Skilled nursing facilities
  • Independent durable medical equipment vendors
  • Behavioral health organizations such as: mental health hospitals and residential treatment facilities

Dispute:

• A disagreement about a claim or utilization review decision.

Reconsideration:

• A formal review of a previous claim reimbursement or coding decision, or a claim that needs reprocessing when the denial is not based on medical necessity or missing prior authorization for non-inpatient services.
  

Appeal:

• A written request by a practitioner or organizational provider to change:
  • An adverse reconsideration decision
  • An initial claim decision based on medical necessity or experimental/investigational coverage criteria
  • A denial for non-inpatient hospital services due to missing prior approval
  • An initial adverse utilization review decision
  • An adverse decision on a Medicare non-participating provider claim
  • An adverse decision on a claim where required authorization wasn't obtained (retroactive authorization)
  • Certain adverse decisions on non-Medicare claims based on state legislation. 

Claims decisions:

• Decisions made during the claims adjudication process, such as those related to the provider contract, claims payment policies or processing error.
  

Utilization review decisions:

• Decisions made during precertification, concurrent or retrospective review for services that require precertification. For these cases, the practitioner and organizational provider appeals process applies only after services have been rendered. The member appeal process applies to appeals related to pre-service or concurrent medical necessity decisions.
  

The Dispute Process

1. How to submit a dispute

A practitioner or organizational provider may submit a dispute in one of four ways:

1. Online: Use the Explanation of Benefits (EOB) claim search tool – Log in to our provider website on Availity®.
2. Mail: Write to the P.O. box listed on the EOB statement, denial letter or overpayment letter related to the issue.Fax:
3. • Non Medicare members: 1-866-455-8650
   • Medicare members: 1-860-900-7995
4. Phone: Call the number on the back of the member’s ID card for indemnity and PPO-based benefits plans.

You have 180 days from the date of the initial decision to submit a dispute. 

To make handling your dispute easier:

• Provide a completed copy of the appropriate form, if it applies
• State the reasons you disagree with our decision.
• Include supporting documents fort your payment dispute (for example, a Medicare remittance advice, medical records or office notes.
• Keep the denial letter and the original claim available for reference.

2. Reconsideration

After you submit your disputes, most claims payment issues go through our reconsideration process. Claims payment disputes related to reimbursement or coding are subject to reconsideration. Initial adverse decisions based on medical necessity, experimental or investigational coverage criteria, or non-inpatient services denied for missing prior authorization, are handled as appeals and reviewed by clinicians. Utilization review disputes are also handled as appeals.

Once we recieve your dispute, here's how the reconsideration process works:

• A provider contact center representative reviews how the claim was handled. 
• We usually resolve payment issues related to contract terms within seven to ten business days. 
• If the decision changes in your favor, we'll recalculate and reprocess the claim for any affected services. 

If the issue involves reimbursement or coding, we may forward it to a specialty unit for investigation. We'll responds within 60 business days if no additional information is needed, or within 60 business days after we receive any additional requested information. If the decision is in your favor, we will recalculate and reprocess the claim for any affected services.

If the reconsideration doesn't go in your favor, you can file an appeal. We'll provide instructions on how and when to appeal the reconsideration decision.

3. Appeal

You can request an appeal:

Medicare Advantage Aetna Provider Complaint and Appeal Form

If you are not satisfied with:

• The reconsideration decision (for claims disputes)
• An initial claim denial based on medical necessity or experimental/investigational coverage criteria
• A denial for non-inpatient hospital services that were denied due to missing prior approval
• An initial precertification/patient management review decision

We'll notify you of our appeal decision in writing within 60 calendar days of receiving the appeal, unless we need more information. If we need more information, we'll send the appeal decision within 60 calendar days after we receive the additional requested information.

If the appeal decision is in your favor, we'll recalculate and reprocess the claim for any affected services. If the appeal decision upholds our original position, we'll send a written response.

Laws and regulations

Our policy differs from the laws or regulations of a specific state, the state requirements apply to the member's plan and override our policy. 

Our law department makes the final determination if there is any question about how a law applies. 

Questions

If you have questions about our appeal process, you can contact our provider service center:

• Call the number on the back of the member’s ID card for indemnity and PPO-based benefits plans

Related Links:

• Dispute & Appeal Process: Quick Reference Guide
• Dispute & Appeal Process FAQs
• Dispute & Appeal Process: State Exceptions

We combimne local expertise with the strength of a leading national insurance brand. Our plans offer the services members value and provide clear costs.