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Aetna

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What you need to know:

1. General Information

Contact Numbers

Aetna MedicareSM Plan (HMO): 1-800-624-0756
Aetna SelectSM: 1-888-MDAetna
Aetna Elect Choice® (EPO): 1-888-MDAetna
Aetna HMO: 1-800-624-0756
Aetna Managed Choice® POS: 1-888-MDAetna
Aetna Quality Point-of-Service® (QPOS®): 1-800-624-0756
Aetna MedicareSM Plan (HMO) Open Access: 1-800-624-0756
Aetna Health Network OnlySM: 1-888-MDAetna
Aetna Open Access® Elect Choice® : 1-888-MDAetna
Aetna Open Access® HMO: 1-800-624-0756
Open Access Aetna SelectSM: 1-888-MDAetna
Aetna Limited Benefits Insurance Plan® (PPO): 1-888-772-9682
Aetna Open Choice® PPO: 1-888-MDAetna
Aetna Voluntary Group Medical Plan®(Indemnity Plan): 1-888-772-9682
Aetna Traditional Choice®: 1-888-MDAetna

Address Information

Aetna Inc.
151 Farmington Avenue
Hartford, CT 06156

Web Address

www.aetna.com/healthcare-professionals

2. Eligibility, Benefits and Claim Status

Electronic Real-Time Eligibility (RTE)
  • Available 24 hours a day, 7 days a week
  • Available to participating and nonparticipating health care providers
  • Allows you to submit benefits inquiries for up to 18 months prior to the current date
Eligibility, benefits, and claim status can be verified in two ways:
  1. Through Aetna’s secure provider website via NaviNet®, available through www.aetna.com/healthcare-professionals
  2. Through an electronic vendor/clearinghouse

3. Precertification

How to Submit a Precertification Request

Submit precertification requests prior to rendering services through an electronic data interchange (EDI), through www.aetna.com/healthcare-professionals or by phone using the telephone number on the member identification card.

Procedures and services on the precertification lists may require notification and/or a coverage determination.

  • Precertification Code Search Tool
  1. Enter CPT codes to find out if a precert is required
  • Electronic Precertification
    1. Available 24 hours a day, Monday thru Saturday
    2. Recieve a Certification ID number
    3. A submission that rejects is given a unique tracking number

    4. Billing Information

    Three simple ways:
    1. Electronic claims can be submitted through Aetna’s secure provider website via NaviNet®, available through www.aetna.com/healthcare-professionals.
    2. Electronic claims can be submitted through an electronic vendor/clearinghouse.
    3. Paper claims can be submitted to the Aetna claims mailing address listed on the member's ID card.
    Secondary claims:
    • Submit electronically
    • Include adjustment amounts - at both claim level and service line level (if available)
    • Include adjustment reasons - contractual obligation, deductible, coinsurance, etc. Use the codes furnished by the primary payer's remittance
    • Primary payer paid amount - at both claim level and service line level (if available)

    5. Timely Filing Requirements

    Unless state law or other exception applies:
    1. Physicians have 90 days from the date of service to submit a claim for payment.
    2. Hospitals have one year from the date of service to submit a claim for payment.

    6. Corrected Claims

    • When making changes to previously paid claims, submit corrected claims electronically. Update the Claim Frequency Code with:
      7 = Replacement of a prior claim
      8 = Void/cancel of a prior claim
    • When making changes to previously denied claims, submit corrected claims on paper:
      1. Stamp "CORRECTED CLAIM" on the top of the claim
      2. Mail to:

        Aetna
        PO box 14079
        Lexington, KY 40512-4079

    7. Refunds

    Submit a corrected claim and Aetna will recover/recoup the overpayment which will be reported on an ERA with a reversal of the incorrect claim adjudication, followed by the corrected adjudication of the claim.

    8. Appeal Information

    • Reconsideration
      1. Within 180 calendar days of the initial claim decision
      2. Within 3-5 business days of receiving the request. Within 30 business days of receiving the request if review by a specialty unit is needed (for example, clinical coding review
      3. Call 1-800-624-0756 for HMO-based benefits plans and WA Primary Choice plans or call 1-888-632-3862 for indemnity and PPO-based benefits plans
      4. Mailing addresses:

        States
        AL, AK, AR, AZ, CA, FL, GA, HI, ID, LA, MS, NC, NM, NV, OR, SC, UT, TN, WA
        Address
        Aetna P.O. Box 14079 Lexington, KY 40512-4079
        States
        CO, CT, DC, DE, IA, IL, IN, KS, KY, MA, MD, ME, MI, MN, MO, MT, NE, ND, NH, NJ, NY, OH, OK, PA,RI, SD, TX, VA, VT, WI, WV, WY
        Address
        Aetna P.O. Box 981106 El Paso, TX 79998-1106


      5. Submit online through the EOB claim search tool. Log in to the secure provider website via NaviNet® to access this tool.
    • Level 1 Appeal
      1. Within 60 calendar days of the reconsideration decision
      2. Within 30 business days of receiving the request. If additional information is needed, within 30 business days of receiving the additional requested information
      3. Call 1-800-624-0756 for HMO-based benefits plans and WA Primary Choice plans or call 1-888-632-3862 for indemnity and PPO-based benefits plans
      4. Write Aetna Provider Resolution Team P.O. Box 14020 Lexington, KY 40512
    • Level 2 Appeal (available only to practitioners)
      1. Within 60 calendar days of the Level 1 appeal decision
      2. Within 30 business days of receiving the request. If additional information is needed, within 30 business days of receiving the additional requested information
      3. Call 1-800-624-0756 for HMO-based benefits plans and WA Primary Choice plans or call 1-888-632-3862 for indemnity and PPO-based benefits plans
      4. Write Aetna Provider Resolution Team P.O. Box 14020 Lexington, KY 40512

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