![]() There are several options by which to dispute a payment decision, either in part or full:īy logging into the secure provider website, to access the EOB Tool The following is designed to give dentists step-by-step instructions to appeal a claims denial, a clinical decision or a usual and customary determination. In these instances, Aetna’s Member Appeals Process will be followed. Members can do this by filling out the Authorized Representative Request form. Return the form with the appeal request to authorize you to appeal on the member’s behalf in order to access member appeal rights.A dentist may file an appeal on behalf of an Aetna member, if the member designates the provider as his or her authorized representative. Complete and have the member sign and date the Authorized Representative Request form. 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? This request would follow the member asppeal process. What is a member’s authorized representative?Ī member may designate provider as an “authorized representative” to file an appeal on his or her behalf. State laws do not apply to Medicare plans. State mandates requiring different time periods will take precedence, except as previously noted.Īppeals relating to Aetna Medicare plans are an exception. We follow all state laws and regulations. State law supersedes our process for disputes and appeals. What if my state has regulations that differ from Aetna’s process? However, there may be a charge if you decide to pursue an independent external review process. Is there a fee for using Aetna’s dispute process? See our timeframes for responding to a reconsideration or an appeal. What is Aetna’s timeframe for responding to a dispute? See our timeframes to submit a reconsideration or an appeal. Utilization review decisions are decisions made during the predetermination process or retrospectively for those services requiring medical necessity review. ![]() An adverse initial utilization review decisionĬlaims decisions are all decisions made during the claims adjudication process (e.g., decisions related to the provider contract, our claims payment policies, or processing error). ![]()
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