Dispute & Appeal Process Overview │Aetna Dental (2024)

Our process for dental provider disputes and appeals

We have a formal process that allows participating and non-participating dentists to file an appeal when they:

Do not agree with a payment decision
Do not agree with a clinical decision; or
Do not agree with the Usual and Customary Reimbursem*nt (UCR) allowance

Dentists have one level of appeal available which is subject to individual state laws and regulations.

A dentist may file an appeal on behalf of an Aetna member, if the member designates the provider as his or her authorized representative. Members can do this by filling out the Authorized Representative Request form. In these instances, Aetna’s Member Appeals Process will be followed.

The following is designed to give dentists step-by-step instructions to appeal a claims denial, a clinical decision or a usual and customary determination.

To dispute a payment denial

There are several options by which to dispute a payment decision, either in part or full:

By mail
By fax
By logging into the secure provider website, www.aetnadental.com, to access the EOB Tool

How to submit an appeal by mail or fax

To dispute a claim denial by mail or fax, you must submit the following information:

A completed copy of the Provider Complaint and Appeal Form
A copy of the Explanation of Benefits (EOB)
A copy of the original claim
Any supporting documentation you believe will assist Aetna in its review, including a brief description of the situation, and any pertinent information

For all states except California, send this information to:

Aetna Dental
Complaints, Appeals and Grievances
P.O. Box 14597
Lexington, KY 40512-4597

Or fax to: 1-877-867-8729

Use this box for California grievances and appeals:

Aetna Dental
P.O. Box 10462
Van Nuys, CA 91410

Once all necessary information is received, Aetna will re-evaluate the determination. If the dispute is decided in the dentist’s favor, Aetna will reprocess the claim for any services affected by the decision and the dentists will be notified of Aetna’s determination of the appeal in writing within 60 calendar days of Aetna’s receipt of the appeal.

If the appeal decision upholds Aetna’s original position, dentists will receive a letter that includes: the decision; a description of the documentation that supports the decision; and any additional appeal rights.

To dispute a clinical decision

A clinical appeal is a request to change an adverse initial determination for care or services that were denied by Aetna. A dentist may dispute a clinical denial on a member’s behalf with written authorization by the member. This would follow the member appeal process.

Initial steps

Aetna offers providers several options by which to dispute a clinical decision:

By mail
By fax
Online (Log in to the secure provider website, www.aetnadental.com, to access the EOB Tool.)

To dispute a denial by mail or fax, the dentist should submit the following information:

A completed copy of the Provider Complaint and Appeal Form
A copy of the EOB
A copy of the original request for services
A copy of the original denial letter
Any supporting documentation the dentist believes will assist Aetna in its review, including a brief description of the situation. Providers should include their Aetna provider identification number with their documentation.
The dentist also must state in writing that they are disputing this decision on behalf of the member. This would follow the member appeal process.

For all states except California, send this information to:

Aetna Dental
Complaints, Appeals and Grievances
P.O. Box 14597
Lexington, KY 40512-4597

Or fax to 1-877-867-8729

Use this box for California grievances and appeals:

Aetna Dental
P.O. Box 10462
Van Nuys, CA 91410

All clinical disputes will be reviewed by an Aetna dental consultant who was not involved in the initial determination. A written response will be provided by Aetna within 60 calendar days of receipt of the appeal. If denial is decided in the dentist’s favor, Aetna will notify the dentist of the new decision and issue an updated EOB on behalf of the member.

The Dentists will be notified of Aetna’s determination of the appeal in writing within 60 calendar days of Aetna’s receipt of the appeal.
If the appeal is decided in the dentist’s favor, Aetna will notify the dentist of the new decision and will issue an updated EOB on behalf of the member.
If the decision upholds Aetna’s original position, the dentist will receive a letter from Aetna that includes:
- Our decision
- Documentation that supports the decision
- A notice of the dentist’s right to additional review, if available

To dispute a UCR denial

Aetna offers several options by which to dispute a UCR decision (either in part or full):

By telephone (subject to individual state laws/regulations)
By mail
By fax
Online (Log in to the secure provider website, www.aetnadental.com, to access the EOB Tool.)

Initial steps

To dispute a UCR denial by telephone, call 1-800-451-7715. Please have a copy of the dentist Explanation of Benefits (EOB) statement and the original claim for reference.

To dispute a claim denial by mail or fax, you must submit the following information:

A copy of the EOB
A copy of the original claim
Any supporting documentation the dentist believes will assist Aetna in its review, including, but not limited to a cover letter, a brief description of the complexity of the applicable procedure, the dentist’s geographical location

For all states except California, send this information to:

Aetna Dental
Complaints, Appeals and Grievances
P.O. Box 14597
Lexington, KY 40512-4597

Or fax to 1-877-867-8729

Use this box for California disputes:

Aetna Dental
P.O. Box 10462
Van Nuys, CA 91410

Once all necessary information is received, Aetna will re-evaluate the initial determination. A written response will be provided within 30 business days of receipt. State mandates allowing a longer time period for a provider appeal will take precedence.

If the dispute is decided in the dentist’s favor, Aetna will reprocess the claim for any services affected by the decision.

Nothing herein shall require Aetna to provide proprietary or confidential information of a third party or in any way to warrant the performance by any third party with respect to any database referenced.

How to submit an appeal

Dentists will be notified of Aetna’s determination of the appeal in writing within 60 calendar days of Aetna’s receipt of the appeal.
If the appeal is decided in the dentist’s favor, Aetna will reprocess the claim for any services affected by the decision.
If the decision upholds Aetna’s original position, dentists will receive a letter that includes:
- Our decision
- Documentation that supports the decision
- A notice of the right to additional review if applicable

Cost Savings of electronic transactions

NJ External Alternative Dispute Resolution (ADR) of Payment Decisions.

In accordance with N.J.A.C. 11:22-1.12, for disputes involving the payment of claims resulting in an adverse decision through the Company’s internal appeal procedure, participating providers may access the Company's external Alternative Dispute Resolution ("ADR") mechanism. The cost of ADR will be shared equally by the Company and the Provider. The decision of the arbitrator shall be non-binding unless both parties agree otherwise. A summary of the ADR mechanism is below:

o Provider shall notify the Company in writing at Aetna-Provider Resolution Team, PO Box 14597, Lexington KY 40512 or via fax at 859-455-8650 or at the address specified in the appeal response letter, within 60 days from receipt of the appeal response letter. The notice shall state Provider’s request to have the dispute reviewed through ADR and include a copy of the adverse appeal response letter.

o Upon receipt of the notice, the Company will forward the case to a firm or independent arbitrator with whom the Company has arranged to provide ADR services.

o The assigned independent arbitrator will conduct a review based on the submitted documents only, unless the participating provider and Company mutually agree to a hearing.

Once all documentation necessary to complete the review has been received, the arbitrator will issue the decision to the Company and the participating provider within thirty (30) days.