This quick reference guide shows you when and where to submit disputes
Issue types
Claims issues
These issues relate to all decisions made during the claims adjudication process. For example, issues related to the provider contract, our claims payment policies, or processing errors.
Utilization review issues
These issues relate to decisions made during the precertification, concurrent or retrospective review processes for services that require precertification. For these issues, the practitioner and organizational provider appeal process only applies to appeals received subsequent to the services being rendered. The member appeal process applies to appeals related to pre-service or concurrent medical necessity decisions.
Application of state laws and regulations
If our policy varies from the applicable laws or regulations of an individual state, the requirements of the state regulation supersede our policy when they apply to the member’s plan. Our law department makes the final determination if there is any question regarding the applicability of any particular law.
Claims issues for reimbursem*nt or coding decisions
Dispute Level | Practitioner/Organizational Provider Submission Timeframe | Response Timeframe | Contact Information |
|---|---|---|---|
Reconsideration | Within180 calendar daysof the initial claim decision. | Within 7-10business days of receiving the request. Within 60 business days of receiving the request if review by a specialty unit is needed (i.e., clinical coding review). | Callus at the number on the back of the member's ID card. Write See reconsideration mailing addresses below. Submit online through the EOB claim search tool. Log in to the secure provider website viaNaviNetÆto access this tool. |
Appeal | Within 60 calendar days of the reconsideration decision. | Within 60 calendardays of receiving the request. If additional information is needed, within 60 calendardays of receiving the additional requestedinformation. | Callus at the number on the back of the member's ID card. WriteProvider Resolution Team |
See state exceptions to these timeframes
Mailing addresses for reconsiderations
State | Address |
|---|---|
TX | Provider Resolution Team PO Box 981106 El PASO, TX 79998-1106 |
Utilization review issues or claim issues based on medical necessity or cosmetic or experimental/investigational or non-inpatient services denied for not receiving prior approval coverage criteria.
Dispute Level | Practitioner/Organizational Provider Submission Timeframe | Texas Health Aetna Response Timeframe | Contact Information |
|---|---|---|---|
Appeal | Within 180 calendar days of an initial claim decision or utilization review decision. | Within60 calendardays of receiving the request. If additional information is needed, within 60 calendardays of receiving the additional requested information. | Call us at the number on the back of the member's ID card. WriteProvider Resolution Team |
Related Links:
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Self-funded plans are administered by Texas Health + Aetna Health Insurance Company.
This material is for information only and is not an offer or invitation to contract. An application must be completed to obtain coverage. Health benefits and health insurance plans contain exclusions and limitations. Providers are independent contractors and not our agents. Provider participation may change without notice. We do not provide care or guarantee access to health services. Not all health services are covered. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability are subject to change and may vary by location. If you are in a plan that requires the selection of a primary care physician and your primary care physician is part of an integrated delivery system or physician group, your primary care physician will generally refer you to specialists and hospitals that are part of the delivery system or physician group. Information is believed to be accurate as of the production date; however, it is subject to change.
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Physicians on the medical staff practice independently and are not agents or employees of the hospital or Texas Health Resources.
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