Aetna Denial Appeals Step by Step
Aetna Denial Appeals Step by Step: Overview
Aetna appeals are three-tiered: first review (30 days), second review (60 days if denied), and external medical review if internal appeals fail. The 180-day appeal deadline is strict. Successful appeals require strong clinical documentation directly addressing the denial reason, with clear reference to the CARC code and Aetna's medical necessity criteria.
Key Requirements
- File Within 180 Days: Appeal deadline is strict from denial date. Aetna will not accept appeals after deadline.
- Address Denial Reason: Reference the CARC code and provide targeted clinical evidence directly refuting it.
- Include Documentation: Attach medical records, clinical notes, test results, and physician orders supporting medical necessity.
- Proper Format: Submit in writing via email, fax, or portal with claim number, DOS, CPT/ICD-10 codes, member ID, and NPI.
- Expedited Review: For urgent cases, request expedited review with clinical justification.
Appeal Timeline & Process
Step 1: Prepare Appeal: Gather denial notice, claim info, and clinical documentation. Organize evidence and prepare rebuttal.
Step 2: Submit First-Level Appeal: Send written appeal with complete documentation. Obtain confirmation of receipt.
Step 3: Receive First Decision: Aetna responds within 30 days. Decision is approval or denial with explanation.
Step 4: Request Second-Level Review if Denied: If first appeal denied, request second review with additional clinical evidence. Aetna has 60 days.
Step 5: Escalate to External Review if Needed: If both internal reviews denied, request independent external review if claim qualifies.
Aetna Appeal Levels and Timelines
| Appeal Level | Reviewer | Timeline | Next Step if Denied |
|---|---|---|---|
| Level 1: First Review | Aetna Medical Review Team | 30 calendar days | Request Level 2 (Second Review) |
| Level 2: Second Review | Aetna Senior Medical Review | 60 calendar days | Request External Medical Review |
| Level 3: External Medical Review | Independent Review Organization | Varies (typically 30–45 days) | Final decision; may escalate to legal action if claim exceeds threshold |
Best Practices
Reference the CARC code and Aetna's medical policy. Provide clinical evidence contradicting the denial reason. For medical necessity denials, include specialist recommendations and clinical urgency. For coding denials, provide modifier justification. For frequency/quantity denials, document medical necessity. Include dated correspondence showing receipt acknowledgment.
Common Questions
What is the Aetna appeal deadline?
180 calendar days from the denial date. After 180 days, Aetna will not accept appeals. The clock starts from the date on the denial notice.
How many appeal levels does Aetna have?
Three levels: (1) First review: 30 days. (2) Second review: 60 days (if first is denied). (3) External medical review: independent organization reviews if internal appeals are denied and claim meets criteria.
What should I include in an Aetna appeal?
Include claim number, CPT/HCPCS codes, ICD-10 diagnosis codes, denial code (CARC), date of service, clinical notes, test results, physician orders, and specific rebuttal addressing the denial reason. Organize evidence logically.
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This reference is for informational purposes. Payer policies change frequently. Always verify against Aetna's current provider documentation. Last updated: 2026-03-16.
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