What Medical Billers Need to Know About Aetna

How to Submit Claims to this Insurer

Aetna provides a variety of health insurance programs, including those for individuals and workplace-sponsored plans. Medical billers are likely to need information on how to bill and process claims to this insurer. Here is information on their processes.

1
General Information on Aetna for Medical Billers

Receptionist on the phone
Hero Images/Getty Images

Contact Numbers

  • Medical and Behavioral Health: For HMO-based and Medicare Advantage plans, call 1-800-624-0756. For all other plans, call 1-888-MD-Aetna (1-888-632-3862).
  • Aetna Pharmacy Management: 1-800-238-6279
  • Dental providers: 1-800-451-7715
  • Credentialing or re-credentialing status: 1-800-353-1232

Address Information
Aetna Inc.
151 Farmington Avenue
Hartford, CT 06156

Web Address
www.aetna.com/healthcare-professionals

2
Aetna 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

Medical practice, doctor examining the health records of a patient at her desk, discussing them with an assistant
Jochen Tack/Getty Images

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. Receive a Certification ID number
  3. A submission that rejects is given a unique tracking number

More

4
Billing Information for Aetna

General practitioner
VOISIN/PHANIE/Getty Images

There are three simple ways to submit claims to Aetna:

  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

Setting a date on calendar by red pen
kyoshino/Getty Images

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

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

More

7

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.

More

8

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

More

Continue Reading