Aetna: insurance claim denied

Collect

• denial letter or EOB
• member ID card
• group name and number
• medical records
• provider letter of medical necessity

Steps

1. Call Member Services at the number on the ID card. Ask for the documents needed for your appeal.

   PhoneCorporate contact center (members should call the number on the ID card) +1-800-872-3862

2. File the appeal online or mail the form to the address on your EOB. Include the group name, your name, member ID and any records you want reviewed.

   FormMember complaint, grievance and appeal form (non-Medicare plans)

3. If a delay could seriously risk health or cause severe pain, ask for an urgent appeal by calling the number on the ID card or on the denial letter.

4. For a two-appeal plan, request the second review within 60 days of the first appeal decision.

5. After internal appeals, ask for external review. For self-funded plans that elected the Aetna program, use the form sent with the final denial letter.

   FormAetna External Review Program

6. For fully insured plans, contact your state insurance department. For plans under federal health care reform, EBSA can help.

   RegulatorU.S. Department of Labor, Employee Benefits Security Administration +1-866-444-3272

7. Medicare Advantage members send claim appeals to the Part C appeals address or fax.

   MailAetna Medicare Advantage (HMO, PPO, HMO-POS) Part C appeals Aetna Medicare Part C Appeals, PO Box 14067, Lexington, KY 40512

More contacts for this issue

Facts you can cite

• Deadline

  For non-Medicare plans, you have 180 days to appeal from when you get notice of the denied claim, unless the plan brochure or Summary Plan Description gives more time.

  Source: aetna.com, verified 2026-10-12

• Process

  For one-appeal plans, Aetna decides pre-service appeals within 30 days and other appeals within 60 days. For two-appeal plans, it decides pre-service appeals within 15 days and other appeals within 30 days, and the second review must be requested within 60 days of the appeal decision letter.

  Source: aetna.com, verified 2026-10-12

• Deadline

  An urgent appeal that meets Aetna's guidelines is decided no later than 72 hours after the request for one-appeal plans, and no later than 36 hours for two-appeal plans.

  Source: aetna.com, verified 2026-10-12

• Process

  Member Services can send you the documents you need for your appeal.

  Source: aetna.com, verified 2026-10-12

• Policy

  The Aetna External Review Program applies to self-funded plans whose sponsors elect it, for medical necessity or experimental denials over $500 after the plan appeal process is exhausted. Reviews are generally decided within 30 calendar days, the decision binds Aetna and the plan, and the member pays no fee.

  Source: aetna.com, verified 2026-10-12

• Deadline

  For Aetna Medicare Advantage plans, standard decisions on claim-denial appeals are made within 60 calendar days and expedited decisions are not available for claim denials. Expedited authorization appeals are decided within 72 hours.

  Source: aetna.com, verified 2026-10-12

• Process

  Aetna's state-help guidance says the state insurance office can help if you don't agree with a decision made by your health plan; in California, the Department of Insurance covers insured Traditional plans and the Department of Managed Health Care covers insured HMO and DMO plans.

  Source: aetna.com, verified 2026-10-12

Rules in force

• ACA internal appeals and external review for health coverage
  45 CFR 147.136 (with 29 CFR 2560.503-1 for group health plans)

  After a health plan denies a claim, the patient has 180 days to file an internal appeal. The plan must decide within 30 days (care not yet received), 60 days (care already received) or 72 hours (urgent care). After a final denial, the patient can ask for an independent external review within 4 months; the plan must accept the reviewer's decision.

  Source: law.cornell.edu, verified 2026-10-12

  10 citable points

  • Deadline

    "You must file your internal appeal within 180 days (6 months) of receiving notice that your claim was denied."

    Source: healthcare.gov, verified 2026-10-12

  • Deadline

    The internal appeal must be completed within 30 days for a service not yet received and within 60 days for a service already received.

    Source: healthcare.gov, verified 2026-10-12

  • Deadline

    For urgent care claims, a group health plan must decide an appeal "not later than 72 hours after receipt of the claimant's request for review".

    Source: law.cornell.edu, verified 2026-10-12

  • Process

    In urgent situations, "You may file an internal appeal and an external review request at the same time."

    Source: healthcare.gov, verified 2026-10-12

  • Policy

    Plans must continue coverage pending the outcome of an appeal, and may not reduce or end benefits for an ongoing course of treatment without advance notice and an opportunity for advance review.

    Source: law.cornell.edu, verified 2026-10-12

  • Deadline

    An external review must be requested within "4 months after the date you receive a notice or final determination" from the insurer. A standard decision is due no later than 45 days after the request is received; an expedited decision no later than 72 hours.

    Source: healthcare.gov, verified 2026-10-12

  • Policy

    The insurer is required by law to accept the external reviewer's decision. The HHS-administered process is free; a state or insurer-contracted process may charge, but not more than $25 per review.

    Source: healthcare.gov, verified 2026-10-12

  • Policy

    If the plan fails to strictly follow the internal claims and appeals requirements, the claimant "is deemed to have exhausted the internal claims and appeals process", subject to a de minimis exception.

    Source: law.cornell.edu, verified 2026-10-12

  • Limit

    These internal appeal and external review requirements generally do not apply to grandfathered plans.

    Source: law.cornell.edu, verified 2026-10-12

  • Contact

    For plans that use the HHS-administered external review process, requests can be filed online with MAXIMUS Federal Services, by calling 1-888-866-6205 for a form, or by email to ferp@maximus.com. For a state process, the contact is in the final denial notice or Explanation of Benefits.

    Source: healthcare.gov, verified 2026-10-12

• ERISA claims procedure timelines for employer benefit plans
  29 CFR 2560.503-1

  Employer-sponsored benefit plans covered by ERISA must decide claims and appeals within set deadlines. Group health plans: 72 hours for urgent care, 15 days for pre-service and 30 days for post-service claims; disability plans: 45 days; other plans: 90 days. Group health and disability claimants get at least 180 days to appeal. If the plan does not follow the procedures, the claimant may sue.

  Source: law.cornell.edu, verified 2026-10-12

  7 citable points

  • Deadline

    Group health plan initial decisions: urgent care claims "not later than 72 hours after receipt of the claim by the plan"; pre-service claims within 15 days, with one extension of up to 15 days; post-service claims "not later than 30 days after receipt of the claim", with one extension of up to 15 days.

    Source: law.cornell.edu, verified 2026-10-12

  • Deadline

    Disability claims: notice of decision "not later than 45 days after receipt of the claim by the plan", with an extension of up to 30 days and a second extension of up to 30 days. Other plans (not group health or disability): not later than 90 days, with one extension of up to 90 days.

    Source: law.cornell.edu, verified 2026-10-12

  • Deadline

    Time to appeal a denial: group health plan and disability claimants must have at least 180 days after receiving the adverse benefit determination. Claimants under other plans must have "at least 60 days following receipt of a notification" of the adverse determination.

    Source: law.cornell.edu, verified 2026-10-12

  • Deadline

    Group health plan appeal decisions (one-level appeal): urgent care within 72 hours, pre-service within 30 days, post-service within 60 days after the plan receives the appeal. With two appeal levels, each level has 15 days (pre-service) or 30 days (post-service).

    Source: law.cornell.edu, verified 2026-10-12

  • Deadline

    Appeal decisions for other plans are due not later than 60 days after the request for review (up to 60 more days in special circumstances); for disability plans the period is 45 days.

    Source: law.cornell.edu, verified 2026-10-12

  • Policy

    On appeal, the plan must provide, "upon request and free of charge, reasonable access to, and copies of, all documents" relevant to the claim.

    Source: law.cornell.edu, verified 2026-10-12

  • Policy

    If the plan fails to establish or follow these claims procedures, "a claimant shall be deemed to have exhausted the administrative remedies available under the plan" and may bring a civil action under ERISA section 502(a).

    Source: law.cornell.edu, verified 2026-10-12

If that fails, escalate

Go up one step at a time. Keep the reference numbers and dates from each contact.

1. Customer service

   PhoneCorporate contact center (members should call the number on the ID card) +1-800-872-3862

   Use the number on the back of the member ID card.

2. Written complaint

   FormMember complaint, grievance and appeal form (non-Medicare plans)

   Internal appeal or grievance. Medicare plans use the Medicare appeal addresses.

3. State agency

   Your state’s insurance department. Find it in the list of state agencies (also as JSON: states/<code>.json, for example states/ny.json).

   External review for fully insured plans; complaint to the state where the plan is issued.

4. Federal regulator

   RegulatorU.S. Department of Labor, Employee Benefits Security Administration +1-866-444-3272

   Employer self-funded (ERISA) plans. Aetna's own External Review Program covers self-funded plans whose sponsor elects it.

5. Federal regulator

   RegulatorCMS No Surprises Help Desk +1-800-985-3059

   Surprise bills under the No Surprises Act.

Watch out

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