Aetna

Timely Filing Limits

Aetna typically allows 120 days from the date of service for commercial plans. Medicare Advantage plans may allow up to 90 days. Check the specific plan's provider agreement for the exact deadline.

Appeal Time Limits

Aetna typically allows 180 days to submit a provider appeal from the date of the original denial. Check the denial letter or EOB for the exact deadline. Aetna offers a reconsideration process before formal appeal.

Corrected Claim Process

Submit corrected claims using Frequency Code 7 on the CMS-1500 or 837 transaction through the Aetna provider portal or clearinghouse. Include the original claim number and a brief explanation of the correction.

Prior Authorization

Aetna requires prior authorization for many services including: advanced imaging (MRI/CT/PET), specialty drugs, DME, behavioral health (certain services), surgical procedures, genetic testing, and certain therapies. Use the Availity or Aetna provider portal to check requirements and submit authorization requests.

Referral Requirements

HMO plans require PCP referrals; PPO plans generally do not. Check the member's plan type. Aetna HMO plans require referrals before specialist visits. Aetna Open Access plans typically do not require referrals.

Eligibility Verification

Verify eligibility through Availity, the Aetna provider portal, or the 270/271 transaction. Check for plan type, deductible, copay, coinsurance, and any carve-out services (e.g., behavioral health to Magellan or another vendor).

Claim Status Resources

Check claim status through Availity, the Aetna provider portal, or the 277 transaction. The portal provides detailed claim status including payment and denial information.

Coordination of Benefits

Aetna follows the birthday rule for dependents and the active employee rule for adults. Report other coverage on the claim. Aetna may use a COB questionnaire to determine primary/secondary status.

Modifier Policies

Aetna follows NCCI modifier policies. Aetna has specific policies for modifier 25, 59, and therapy modifiers (GN, GO, GP). Check the Aetna provider manual (Clinical Policy Bulletins) for specific modifier requirements.

Telehealth Policies

Aetna expanded telehealth coverage and maintains a list of covered telehealth services. Use modifier 95 for synchronous telehealth. Check the Aetna provider portal for current telehealth policies and covered services.

Medical Necessity Resources

Aetna uses Clinical Policy Bulletins (CPBs) for medical necessity determinations. CPBs are available on the Aetna provider website. Aetna may also use InterQual or MCG criteria. Check the specific CPB for the service to be provided.

NDC Billing Requirements

Aetna requires NDCs for physician-administered drugs. Report NDCs in the 5-4-2 format on the CMS-1500 claim form. See the Aetna provider manual for formatting requirements.

Common Denial Reasons

• CO-16 (missing/incomplete information)
• CO-50 (not medically necessary)
• CO-97 (bundling)
• CO-45 (charges exceed fee schedule)
• CO-197 (authorization/notification absent)
• CO-151 (frequency/number of services not supported)
• PR-1 (deductible)
• PR-2 (coinsurance).

Common Rejection Reasons

• Missing referral (HMO plans)
• missing prior authorization
• invalid member ID
• eligibility not active on date of service
• missing NPI
• invalid taxonomy
• missing NDC for drugs.

Documentation Requirements

Documentation must support the level of service billed, medical necessity, and treatment provided. Aetna may request records through the provider portal or via letter. Check the Aetna provider manual for specific documentation requirements.

Electronic Claim Submission

Submit claims electronically via the 837 transaction to Aetna. The Aetna payer ID is typically 60054 for commercial plans (check your clearinghouse for the correct ID). Use Availity or the Aetna provider portal for direct submission and status check.

Provider Portal

Aetna uses Availity as its primary provider portal. The Aetna provider website also offers a provider portal with eligibility, claim status, authorization requests, remittance, and appeals. The portal includes Clinical Policy Bulletins, fee schedules, and provider education.

Provider Manual

Aetna publishes Clinical Policy Bulletins (CPBs), reimbursement policies, and administrative policies on the Aetna provider website. Plan-specific manuals may be available for Medicare Advantage and Aetna Better Health (Medicaid).

Contact Information

Contact Aetna Provider Services: 1-800-624-0756 (commercial) or check the member's ID card for the correct number. Aetna Better Health (Medicaid) contacts vary by state. Contact information is available on the Aetna provider website.

Educational Notes

Aetna has distinct policies for commercial, Medicare Advantage, and Medicaid (Aetna Better Health) lines of business. Behavioral health may be carved out. Coventry Health plans have some legacy processes. Check the member's ID card for the correct payer ID and contact information.

Related Academy Courses

• Denial Codes Decoded
• Prior Authorization & Medical Necessity Mastery
• Insurance Verification & Eligibility Mastery
• Appeals That Get Paid.

Related Knowledge Center Articles

• CO-16 Denial Resolution Guide
• Prior Authorization Resource Center
• Aetna Clinical Policy Bulletins
• Modifier 25 Documentation
• Medical Necessity Denials.

Related AI Investigation Topics

CO-16 missing information investigations, CO-50 medical necessity (CPB criteria), CO-97 bundling/NCCI disputes, CO-197 authorization/notification investigations, Aetna commercial vs. Medicare Advantage vs. Better Health policy investigations.