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Aetna Assure Premier Plus (HMO D-SNP) and our contracted providers are responsible for resolving any disputes between parties in a timely manner. Disputes will be settled according to the terms of our contractual agreement. There will be no disruption to — or interference with — the provision of services to enrollees as a result of disputes.
You can speak with a Provider Experience representative to discuss your dissatisfaction with a decision based on this policy and contractual provisions, including claim disputes.
In the case of a claim dispute, you may be asked to complete and submit the provider dispute form (PDF) and any appropriate supporting documentation to the Provider Experience department.
We will inform you of our decision via email, fax or telephone or in writing.
If you are still not satisfied with the dispute determination, you will be notified that a grievance or appeal may be initiated. You can learn more about our grievance and appeal policies in our provider manual, which includes the process you can follow to submit a grievance or appeal.
You may also submit disputes through the online Provider Portal. Instructions for filing online disputes can be found on the forms page.
Noncontracting providers have the right to request a noncontracting provider claim appeal (PDF) after a payment on a claim for a covered item or service is denied. Noncontracting provider claim appeals must be submitted in writing with a completed waiver of liability (WOL) form (PDF) within 60 calendar days of the remittance advice.
Non-contracting providers have the right to request a payment dispute if they disagree with a payment on a submitted claim for a covered item or service.
A non-contracting provider payment appeal form (PDF) must be submitted in writing, with the supporting documentation stating they should receive a different payment under Original Medicare, within 60 calendar days of the remittance advice.
If the provider still disagrees with the decision, they can submit a request in writing for an Independent Review Entity (IRE) review within 180 calendar days of the remittance advice. The noncontracting provider payment dispute decision letter will give information on how to request an IRE review. The IRE will process the request within 60 calendar days of receipt and will notify all parties of their decision concerning the appeal. If the decision is overturned, we will effectuate the decision within 30 calendar days of receiving the IRE’s notification of the decision.
Filing a grievance
Both network and out-of-network providers may file a grievance directly with us regarding our policies, procedures or any aspect of our administrative functions.
You may file a grievance verbally or in writing:
By fax
You can fax your grievance anytime to 1-844-721-0622.
By mail
You can mail your grievance to:
Aetna Assure Premier Plus (HMO-DSNP)
Claims and Resubmissions
PO Box 982967
El Paso, TX 79998-2967
Next steps
An acknowledgement letter will be sent within three business days. It will summarize the grievance and include instructions on how to:
Revise the grievance within the time frame specified in the acknowledgement letter
Withdraw a grievance at any time until the Grievance Committee review
If the grievance requires research or input by another department, the Grievance and Appeals department will forward the information to that department and coordinate with them to thoroughly research each grievance using:
Applicable statutory, regulatory and contractual provisions
Our written policies and procedures
Any pertinent facts collected from all parties
The grievance, with all research included, will be presented to the Grievance Committee for a decision. If the grievance is related to a clinical issue, the Grievance Committee will include a provider who has the same or a similar specialty. The Grievance Committee will consider the additional information and will resolve the grievance within 45 business days.
We will communicate our decision by telephone, email or fax within two business days of the decision — or in writing, if requested, within 10 calendar days from the date of the decision.