Provider dispute resolution policy for California HMO business
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Governs Aetna's practitioner/provider dispute resolution process for California HMO business for services rendered on or after January 1, 2004; applies to practitioners, facilities and provider organizations submitting disputes about claims, billing, contracts, or delegated payer determinations.
No material clinical or coverage changes in this revision.
Submission requirements and timelines
Submission content requirements
Required information for submitting provider disputes varies by dispute type.
ALL of the following
- Provider's name.
- Provider's tax identification number.
- Provider's contact information.
If the dispute is about a claim or reimbursement
- An explanation of the issue, including the original claim number.
- The date of service.
- An explanation of why the provider believes the payment amount, request for additional information, request for reimbursement of a claim overpayment, or other action taken is incorrect.
If the dispute is not about a claim (e.g., contract dispute)
- An explanation of the issue.
- The provider's position on that issue.
If the dispute involves a member or group of members
- The name(s) and identification number(s) of each member.
- An explanation of the issue, including the date of service.
- The provider's position on the dispute.
If the dispute involves a delegated payer determination
- An explanation of the issue, including a copy of the original claim.
- The date of service.
- An explanation of why the provider believes the payment amount, request for additional information, request for reimbursement of a claim overpayment, or other action taken is incorrect.
- A copy of the delegated payer's written determination/correspondence.
Provider disputes that do not include all required information may be returned to the submitter. Provider disputes submitted on behalf of a member or group of members treated by the provider will be handled according to the Aetna member grievance process (not the provider dispute resolution process).
Batch submission instructions
Providers may batch multiple similar disputes; follow the recommended format to help processing.
ALL of the following
- Sort disputes by similar issue.
- Provide a cover sheet for each batch of similar issues; individually number and list the required information for the type of dispute for each disputed item within the batch.
- Number each cover sheet.
- Provide a cover letter for the entire submission that describes each provider dispute and references the applicable numbered cover sheets.
Use the provided batch template fields when submitting multiple 'LIKE' claims to ensure consistent data for each item.
Process timeframes and post-resolution payment
Key timeframes for receipt, acknowledgement, resolution, and payment following determination.
ALL of the following
- Disputes related to a demonstrable and unfair payment pattern by the Plan: Deadline is 365 days after the most recent action, or if no action, 365 days after time for contesting or denying claims has expired.
- Dispute regarding a Plan notice of overpayment of a claim: Deadline is within 30 working days of receipt of the Plan notice of overpayment.
- Amended Provider Dispute (returned dispute with written Plan notice): Deadline is within 30 working days of the provider's receipt of the returned dispute with written Plan notice.
ALL of the following
- Electronic provider disputes (directly into the system): Acknowledgement provided within 2 working days of receipt.
- Paper provider disputes (mail, fax, e-mail, physical delivery): Acknowledgement provided within 15 working days of receipt.
ALL of the following
- Plan's goal is to resolve and issue a written determination within 45 working days after the date of receipt of the provider dispute or the amended provider dispute.
ALL of the following
- Plan goal is to issue payment with the resolution letter, and in all cases payment will be made no later than within 5 working days of the issuance of the written determination.
- Accrual of interest and penalties for payment of resolved disputes commences on the day following the expiration of 'Time for Reimbursement' of the complete claim.
These timeframes reflect Plan goals and statutory deadlines for provider dispute handling and post-resolution payment.
Identifiers, acknowledgements, and timelines
| No codes listed |
How to submit disputes and billing rules during dispute
Submission methods
Providers can submit written disputes to: Aetna Correspondence Unit P.O. Box 24019 Fresno, CA 93779-4019. Written disputes can be submitted on the Provider Dispute Resolution Request Form (Attachment A) or in the form of a letter. Providers may call the Provider Service Center at 1-800-624-0756 with questions about the dispute process. Verbal complaints from providers will be handled through Aetna’s national practitioner/provider dispute process.
- Aetna Correspondence Unit, P.O. Box 24019, Fresno, CA 93779-4019
- Provider Dispute Resolution Request Form (Attachment A) or a letter
- Provider Service Center: 1-800-624-0756
Billing restriction during dispute
Submission of the Provider Dispute Resolution Request Form (Attachment A) or otherwise submitting a provider dispute constitutes agreement not to bill the patient during the dispute resolution process.
Key terms
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