Aetna

1. General Information

2. Eligibility, Benefits and Claim Status

• 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

1. Through Aetna’s secure provider website via NaviNet®, available through www.aetna.com/healthcare-professionals
2. Through an electronic vendor/clearinghouse

3. Precertification

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

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.

• 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

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

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