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The Simplified Appeal Process for Aetna


Main Points

  • Fill out the Aetna appeal form completely and with the most accurate information possible

  • Make sure you send it to the correct location

  • Keep all your documentation and track your follow-ups

According to a recent survey, only 1% of patients ever appeal their claims and of that group, 70% see an overturned denial.

That appeals process is not always straight forward and it can vary by payer. This blog is to serve as the guide for those who have to or want to submit an appeal to Aetna. We will include a step by step process, where to send it, and why you should track the appeal.

Fill out the Aetna appeal form completely and with the most accurate information possible.

First, you will want to fill out the Aetna appeal form. If you don't have a copy of the form you can find it here. When you look at the form there are a variety of fields. Here is how you should fill out each field.

  1. The first few boxes are definitely self-explanatory. You will want to enter the current date, the ID number from the insurance card, select Medical and enter the group number from the patient's card.

  2. Then you will want to enter their name exactly how it shows on the insurance ID card

  3. Then you will fill out your information and the contact information. This includes your name (as it appears on the claim), your TIN and NPI. Again, both numbers you will want to match the claim that was submitted.

  4. Finally, you will want to enter all of your contact information so the insurance company can get back to you if they have any questions or concerns. Be sure to enter a valid mailing address and valid phone number.

  5. The Claim ID box is next. This ID can be found on the EOB or explanation of benefits that you received the denial on. This will be very important for Aetna to process the appeal

  6. Then you will want to include a reference number or authorization number. If you have completed a verification of benefits, you can include that number here for their reference.

  7. Then you will enter the date of service or the date that you saw the patient.

  8. Then you will write the initial denial notification date, which would come from the EOB or ERA. You will want to match this number exactly as it shows on the EOB.

  9. Then you will include the CPT code that you used for the claim. This will be the five digit number that describes what kind of session this ways (e.g. 90791)

  10. Then you get a chance to describe why you are denying the claim. It is best to start from the beginning. Say what information you received when you did the eligibility check and who you spoke with. Include reference numbers or authorization or any information that will help your appeal.

Make sure you send it to the correct location. Finally, after you have the appeal form completely filled out you will want to send it to the following address:

Aetna

Provider Resolution Team

PO Box 14020

Lexington, KY 40512

Or you can send it to their fax number at 859-455-8650.

This is paramount that you send the appeal to the correct location for proper processing.

Keep all your documentation and track your follow-ups. The most important part of the appeal process is to keep your documentation in an orderly place and to track your follow-ups.

The best way to keep your documentation is in your EHR in the patient face sheet section of the EHR. This way you can keep a time date stamped version of your appeals and it will follow the patient through the time they are in your practice.

The difficult part of this process is to track your follow-ups with the insurance company. Keep a spreadsheet that documents when you have followed-up or make repeated calendar reminders in your email to maintain your attention on the appeal.

Once you receive a determination be sure to follow the steps that Aetna gives you to ensure compliance and appropriate documentation.

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