{"id":"aetna","page":"https://escalate.alexgaoth.com/#/c/aetna","html":"https://escalate.alexgaoth.com/c/aetna/","generated":"2026-10-15","company":{"id":"aetna","name":"Aetna","aliases":["aetna health","aetna inc","aetna cvs health","aetna medicare","aetna better health","silverscript"],"sector":"insurance_health","parent":"CVS Health","website":"https://www.aetna.com","account_url":"https://health.aetna.com/login","regulators":["dol-ebsa","cms-no-surprises"],"channels":[{"id":"member-services-phone","type":"phone","label":"Corporate contact center (members should call the number on the ID card)","value":"+1-800-872-3862","hours":"Mon-Fri 8 AM-6 PM ET","purposes":["poor_service"],"notes":"Aetna asks health plan members to call the number on the member ID card for personalized service.","source":"https://www.aetna.com/about-us/contact-aetna.html","last_verified":"2026-10-12"},{"id":"claim-status","type":"portal","label":"Search claims and EOBs (member login)","value":"https://health.aetna.com/manage/claims","purposes":["claim_delay","claim_denial","billing_error"],"access":"login","source":"https://www.aetna.com/","last_verified":"2026-10-12"},{"id":"grievance-form","type":"web_form","label":"Member complaint, grievance and appeal form (non-Medicare plans)","value":"https://member.aetna.com/MemberPublic/featureRouter/forms?page=commGrievnForm","purposes":["claim_denial","poor_service","billing_error"],"source":"https://www.aetna.com/individuals-families/member-rights-resources/complaints-grievances-appeals.html","last_verified":"2026-10-12"},{"id":"grievance-form-pdf","type":"web_form","label":"Printable complaint and appeal form 68192 (non-Medicare plans; print, then mail or fax)","value":"https://www.aetna.com/content/dam/aetna/pdfs/aetnacom/data/forms_library/68192.pdf","purposes":["claim_denial","poor_service"],"notes":"Send it to the address on your EOB or denial letter. Aetna's appeal page does not publish one national address.","source":"https://www.aetna.com/individuals-families/member-rights-resources/complaints-grievances-appeals.html","last_verified":"2026-10-12"},{"id":"appeals-page","type":"web_form","label":"Appeal a denied claim (instructions)","value":"https://www.aetna.com/individuals-families/member-rights-resources/claim-denials.html","purposes":["claim_denial"],"access":"open","source":"https://www.aetna.com/individuals-families/member-rights-resources/claim-denials.html","last_verified":"2026-10-12"},{"id":"external-review-info","type":"web_form","label":"Aetna External Review Program","value":"https://www.aetna.com/individuals-families/member-rights-resources/claims-coverage/aetna-external-review-program.html","purposes":["claim_denial"],"source":"https://www.aetna.com/individuals-families/member-rights-resources/claims-coverage/aetna-external-review-program.html","last_verified":"2026-10-12"},{"id":"external-review-phone","type":"phone","label":"National External Review Unit","value":"+1-877-848-5855","purposes":["claim_denial"],"source":"https://www.aetna.com/individuals-families/member-rights-resources/claims-coverage/aetna-external-review-program.html","last_verified":"2026-10-12"},{"id":"medicare-appeals-mail","type":"mail","label":"Aetna Medicare Advantage (HMO, PPO, HMO-POS) Part C appeals","value":"Aetna Medicare Part C Appeals, PO Box 14067, Lexington, KY 40512","purposes":["claim_denial"],"notes":"Fax 1-724-741-4953; expedited fax 1-724-741-4958.","source":"https://www.aetna.com/medicare/contact-us/appeal.html","last_verified":"2026-10-12"},{"id":"medicare-part-d-appeals-mail","type":"mail","label":"Aetna Medicare Part D redeterminations (MAPD and I-SNP)","value":"Aetna Medicare Part D Appeals, PO Box 14579, Lexington, KY 40512","purposes":["claim_denial"],"notes":"Fax 1-724-741-4954.","source":"https://www.aetna.com/medicare/contact-us/appeal.html","last_verified":"2026-10-12"},{"id":"pdp-appeals-phone","type":"phone","label":"SilverScript prescription drug plan (PDP) appeals and coverage determinations","value":"+1-866-235-5660","hours":"24 hours a day, 7 days a week","purposes":["claim_denial"],"notes":"Mail: SilverScript Insurance Company, Appeals and Coverage Determination, PO Box 52000 MC109, Phoenix, AZ 85072-2000. Fax 1-855-633-7673. TTY 711.","source":"https://www.aetna.com/medicare/contact-us/appeal.html","last_verified":"2026-10-12"},{"id":"medicaid-contact","type":"web_form","label":"Aetna Better Health (Medicaid) contact page","value":"https://www.aetnabetterhealth.com/contact-us.html","source":"https://www.aetna.com/","last_verified":"2026-10-12"}],"escalation":[{"rung":"frontline","channel":"member-services-phone","note":"Use the number on the back of the member ID card."},{"rung":"written_complaint","channel":"grievance-form","note":"Internal appeal or grievance. Medicare plans use the Medicare appeal addresses."},{"rung":"state_agency","agency_kind":"insurance_department","note":"External review for fully insured plans; complaint to the state where the plan is issued."},{"rung":"regulator","regulator":"dol-ebsa","note":"Employer self-funded (ERISA) plans. Aetna's own External Review Program covers self-funded plans whose sponsor elects it."},{"rung":"regulator","regulator":"cms-no-surprises","note":"Surprise bills under the No Surprises Act."}],"playbooks":[{"issue":"claim_denial","summary":"Appeal within 180 days at the address on the EOB or online, ask for an urgent appeal if health is at risk, then external review.","evidence":["denial letter or EOB","member ID card","group name and number","medical records","provider letter of medical necessity"],"steps":[{"do":"Call Member Services at the number on the ID card. Ask for the documents needed for your appeal.","channel":"member-services-phone"},{"do":"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.","channel":"grievance-form"},{"do":"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."},{"do":"For a two-appeal plan, request the second review within 60 days of the first appeal decision."},{"do":"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.","channel":"external-review-info"},{"do":"For fully insured plans, contact your state insurance department. For plans under federal health care reform, EBSA can help.","regulator":"dol-ebsa"},{"do":"Medicare Advantage members send claim appeals to the Part C appeals address or fax.","channel":"medicare-appeals-mail"}],"facts":[{"kind":"deadline","claim":"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.","issues":["claim_denial"],"source":"https://www.aetna.com/individuals-families/member-rights-resources/claim-denials.html","last_verified":"2026-10-12"},{"kind":"process","claim":"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.","issues":["claim_denial"],"source":"https://www.aetna.com/individuals-families/member-rights-resources/claim-denials.html","last_verified":"2026-10-12"},{"kind":"deadline","claim":"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.","issues":["claim_denial"],"source":"https://www.aetna.com/individuals-families/member-rights-resources/claim-denials.html","last_verified":"2026-10-12"},{"kind":"process","claim":"Member Services can send you the documents you need for your appeal.","issues":["claim_denial"],"source":"https://www.aetna.com/individuals-families/member-rights-resources/claim-denials.html","last_verified":"2026-10-12"},{"kind":"policy","claim":"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.","issues":["claim_denial"],"source":"https://www.aetna.com/individuals-families/member-rights-resources/claims-coverage/aetna-external-review-program.html","last_verified":"2026-10-12"},{"kind":"deadline","claim":"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.","issues":["claim_denial"],"source":"https://www.aetna.com/medicare/contact-us/appeal.html","last_verified":"2026-10-12"}]},{"issue":"billing_error","summary":"Compare the bill with the EOB, ask Member Services to fix processing errors, then file a complaint.","evidence":["provider bill","EOB","member ID card"],"steps":[{"do":"Compare the provider bill with the EOB in the member account.","channel":"claim-status"},{"do":"Call Member Services to ask about a claim processed wrongly. Ask the provider to rebill to the EOB amount.","channel":"member-services-phone"},{"do":"If it is not fixed, file a complaint or appeal online.","channel":"grievance-form"}]},{"issue":"surprise_medical_bill","summary":"Check the bill against the EOB, tell Aetna and the provider, then contact the CMS help desk.","evidence":["the bill","EOB","member ID card"],"steps":[{"do":"Compare the bill with the EOB. Note whether it was emergency care or care at an in-network facility.","channel":"claim-status"},{"do":"Tell Aetna and the provider the bill may be a surprise bill.","channel":"member-services-phone"},{"do":"Contact the CMS No Surprises Help Desk.","regulator":"cms-no-surprises"}]}],"facts":[{"kind":"process","claim":"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.","issues":["claim_denial"],"source":"https://www.aetna.com/individuals-families/member-rights-resources/complaints-grievances-appeals.html","last_verified":"2026-10-12"}],"known_blockers":["Member phone numbers are plan-specific; Aetna directs members to the number on the ID card.","Non-Medicare appeal addresses differ by plan; use the address on the EOB or denial letter.","Claims and EOBs need member login."],"notes":"Aetna is part of CVS Health. Medicare Advantage, Part D (SilverScript) and Medicaid (Aetna Better Health) plans have separate appeal channels and rules. Mailing address of Aetna Inc. is 151 Farmington Avenue, Hartford, CT 06156.","official_domains":["aetna.com","aetnabetterhealth.com"],"security":{"known_scams":[{"kind":"policy","claim":"Aetna's fraud page lists billing for services or supplies never provided and altering claims for higher payment as fraud. Members who see something suspicious on a plan statement should call the number on the ID card or the fraud hotline.","source":"https://www.aetna.com/about-us/fraud-waste-abuse.html","last_verified":"2026-10-12"}],"report_phishing":[{"id":"fraud-hotline","type":"phone","label":"Aetna fraud hotline","value":"+1-800-338-6361","source":"https://www.aetna.com/about-us/fraud-waste-abuse.html","last_verified":"2026-10-12"},{"id":"siu-email","type":"email","label":"Aetna Special Investigations Unit","value":"AetnaSIU@aetna.com","source":"https://www.aetna.com/about-us/fraud-waste-abuse.html","last_verified":"2026-10-12"}]}},"playbooks":{"claim_denial":{"company":{"id":"aetna","name":"Aetna","sector":"insurance_health","website":"https://www.aetna.com","account_url":"https://health.aetna.com/login"},"issue":{"id":"claim_denial","name":"Insurance claim denied"},"playbook_source":"company","summary":"Appeal within 180 days at the address on the EOB or online, ask for an urgent appeal if health is at risk, then external review.","evidence":["denial letter or EOB","member ID card","group name and number","medical records","provider letter of medical necessity"],"steps":[{"do":"Call Member Services at the number on the ID card. Ask for the documents needed for your appeal.","channel":{"id":"member-services-phone","type":"phone","label":"Corporate contact center (members should call the number on the ID card)","value":"+1-800-872-3862","hours":"Mon-Fri 8 AM-6 PM ET","purposes":["poor_service"],"notes":"Aetna asks health plan members to call the number on the member ID card for personalized service.","source":"https://www.aetna.com/about-us/contact-aetna.html","last_verified":"2026-10-12"}},{"do":"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.","channel":{"id":"grievance-form","type":"web_form","label":"Member complaint, grievance and appeal form (non-Medicare plans)","value":"https://member.aetna.com/MemberPublic/featureRouter/forms?page=commGrievnForm","purposes":["claim_denial","poor_service","billing_error"],"source":"https://www.aetna.com/individuals-families/member-rights-resources/complaints-grievances-appeals.html","last_verified":"2026-10-12"}},{"do":"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."},{"do":"For a two-appeal plan, request the second review within 60 days of the first appeal decision."},{"do":"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.","channel":{"id":"external-review-info","type":"web_form","label":"Aetna External Review Program","value":"https://www.aetna.com/individuals-families/member-rights-resources/claims-coverage/aetna-external-review-program.html","purposes":["claim_denial"],"source":"https://www.aetna.com/individuals-families/member-rights-resources/claims-coverage/aetna-external-review-program.html","last_verified":"2026-10-12"}},{"do":"For fully insured plans, contact your state insurance department. For plans under federal health care reform, EBSA can help.","regulator":{"id":"dol-ebsa","name":"U.S. Department of Labor, Employee Benefits Security Administration","level":"federal","when_to_use":"Use for a problem with a private-sector employer health or retirement plan (ERISA plan), such as a denied or delayed claim, after you follow the plan's own claim and appeal steps. Government and church plans are generally not covered.","channels":[{"id":"health-plan-form","type":"web_form","label":"Request help from a Benefits Advisor (health plan)","value":"https://www.askebsa.dol.gov/WebIntake/home.aspx/info?id=3","purposes":["claim_denial","claim_delay"],"notes":"Asks for name, ZIP, state, phone, email, the last four digits of the Social Security number, and an attestation that you are the person the information applies to. The account holder must confirm this personally.","source":"https://beta.dol.gov/about/agencies/ebsa/ask-ebsa","last_verified":"2026-10-12"},{"id":"retirement-plan-form","type":"web_form","label":"Request help from a Benefits Advisor (retirement plan)","value":"https://www.askebsa.dol.gov/WebIntake/home.aspx/info?id=4","source":"https://beta.dol.gov/about/agencies/ebsa/ask-ebsa","last_verified":"2026-10-12"},{"id":"phone","type":"phone","label":"EBSA Benefits Advisors","value":"+1-866-444-3272","source":"https://beta.dol.gov/about/agencies/ebsa/ask-ebsa","last_verified":"2026-10-12"}],"facts":[{"kind":"process","claim":"ERISA sets minimum standards for most voluntarily established retirement and health plans in private industry. In general it does not cover group health plans of government entities or church plans.","source":"https://www.dol.gov/general/topic/health-plans/erisa","last_verified":"2026-10-12"},{"kind":"process","claim":"For a complaint under Title I of ERISA, expect a status report from the assigned benefits advisor every 30 days.","source":"https://www.askebsa.dol.gov/WebIntake/home.aspx/info?id=3","last_verified":"2026-10-12"},{"kind":"process","claim":"EBSA can help you understand your rights, but you should still review the plan documents and meet the plan's claim and appeal deadlines.","issues":["claim_denial"],"source":"https://www.askebsa.dol.gov/WebIntake/home.aspx/info?id=3","last_verified":"2026-10-12"}],"notes":"On 2026-10-12, www.askebsa.dol.gov and the old Ask EBSA page redirected to https://beta.dol.gov/about/agencies/ebsa/ask-ebsa, which links to the WebIntake forms above. EBSA regional offices: https://www.dol.gov/agencies/ebsa/about-ebsa/about-us/regional-offices"}},{"do":"Medicare Advantage members send claim appeals to the Part C appeals address or fax.","channel":{"id":"medicare-appeals-mail","type":"mail","label":"Aetna Medicare Advantage (HMO, PPO, HMO-POS) Part C appeals","value":"Aetna Medicare Part C Appeals, PO Box 14067, Lexington, KY 40512","purposes":["claim_denial"],"notes":"Fax 1-724-741-4953; expedited fax 1-724-741-4958.","source":"https://www.aetna.com/medicare/contact-us/appeal.html","last_verified":"2026-10-12"}}],"channels":[{"id":"claim-status","type":"portal","label":"Search claims and EOBs (member login)","value":"https://health.aetna.com/manage/claims","purposes":["claim_delay","claim_denial","billing_error"],"access":"login","source":"https://www.aetna.com/","last_verified":"2026-10-12"},{"id":"grievance-form","type":"web_form","label":"Member complaint, grievance and appeal form (non-Medicare plans)","value":"https://member.aetna.com/MemberPublic/featureRouter/forms?page=commGrievnForm","purposes":["claim_denial","poor_service","billing_error"],"source":"https://www.aetna.com/individuals-families/member-rights-resources/complaints-grievances-appeals.html","last_verified":"2026-10-12"},{"id":"grievance-form-pdf","type":"web_form","label":"Printable complaint and appeal form 68192 (non-Medicare plans; print, then mail or fax)","value":"https://www.aetna.com/content/dam/aetna/pdfs/aetnacom/data/forms_library/68192.pdf","purposes":["claim_denial","poor_service"],"notes":"Send it to the address on your EOB or denial letter. Aetna's appeal page does not publish one national address.","source":"https://www.aetna.com/individuals-families/member-rights-resources/complaints-grievances-appeals.html","last_verified":"2026-10-12"},{"id":"appeals-page","type":"web_form","label":"Appeal a denied claim (instructions)","value":"https://www.aetna.com/individuals-families/member-rights-resources/claim-denials.html","purposes":["claim_denial"],"access":"open","source":"https://www.aetna.com/individuals-families/member-rights-resources/claim-denials.html","last_verified":"2026-10-12"},{"id":"external-review-info","type":"web_form","label":"Aetna External Review Program","value":"https://www.aetna.com/individuals-families/member-rights-resources/claims-coverage/aetna-external-review-program.html","purposes":["claim_denial"],"source":"https://www.aetna.com/individuals-families/member-rights-resources/claims-coverage/aetna-external-review-program.html","last_verified":"2026-10-12"},{"id":"external-review-phone","type":"phone","label":"National External Review Unit","value":"+1-877-848-5855","purposes":["claim_denial"],"source":"https://www.aetna.com/individuals-families/member-rights-resources/claims-coverage/aetna-external-review-program.html","last_verified":"2026-10-12"},{"id":"medicare-appeals-mail","type":"mail","label":"Aetna Medicare Advantage (HMO, PPO, HMO-POS) Part C appeals","value":"Aetna Medicare Part C Appeals, PO Box 14067, Lexington, KY 40512","purposes":["claim_denial"],"notes":"Fax 1-724-741-4953; expedited fax 1-724-741-4958.","source":"https://www.aetna.com/medicare/contact-us/appeal.html","last_verified":"2026-10-12"},{"id":"medicare-part-d-appeals-mail","type":"mail","label":"Aetna Medicare Part D redeterminations (MAPD and I-SNP)","value":"Aetna Medicare Part D Appeals, PO Box 14579, Lexington, KY 40512","purposes":["claim_denial"],"notes":"Fax 1-724-741-4954.","source":"https://www.aetna.com/medicare/contact-us/appeal.html","last_verified":"2026-10-12"},{"id":"pdp-appeals-phone","type":"phone","label":"SilverScript prescription drug plan (PDP) appeals and coverage determinations","value":"+1-866-235-5660","hours":"24 hours a day, 7 days a week","purposes":["claim_denial"],"notes":"Mail: SilverScript Insurance Company, Appeals and Coverage Determination, PO Box 52000 MC109, Phoenix, AZ 85072-2000. Fax 1-855-633-7673. TTY 711.","source":"https://www.aetna.com/medicare/contact-us/appeal.html","last_verified":"2026-10-12"},{"id":"medicaid-contact","type":"web_form","label":"Aetna Better Health (Medicaid) contact page","value":"https://www.aetnabetterhealth.com/contact-us.html","source":"https://www.aetna.com/","last_verified":"2026-10-12"}],"facts":[{"kind":"deadline","claim":"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.","issues":["claim_denial"],"source":"https://www.aetna.com/individuals-families/member-rights-resources/claim-denials.html","last_verified":"2026-10-12"},{"kind":"process","claim":"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.","issues":["claim_denial"],"source":"https://www.aetna.com/individuals-families/member-rights-resources/claim-denials.html","last_verified":"2026-10-12"},{"kind":"deadline","claim":"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.","issues":["claim_denial"],"source":"https://www.aetna.com/individuals-families/member-rights-resources/claim-denials.html","last_verified":"2026-10-12"},{"kind":"process","claim":"Member Services can send you the documents you need for your appeal.","issues":["claim_denial"],"source":"https://www.aetna.com/individuals-families/member-rights-resources/claim-denials.html","last_verified":"2026-10-12"},{"kind":"policy","claim":"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.","issues":["claim_denial"],"source":"https://www.aetna.com/individuals-families/member-rights-resources/claims-coverage/aetna-external-review-program.html","last_verified":"2026-10-12"},{"kind":"deadline","claim":"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.","issues":["claim_denial"],"source":"https://www.aetna.com/medicare/contact-us/appeal.html","last_verified":"2026-10-12"},{"kind":"process","claim":"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.","issues":["claim_denial"],"source":"https://www.aetna.com/individuals-families/member-rights-resources/complaints-grievances-appeals.html","last_verified":"2026-10-12"}],"rules":{"in_force":[{"id":"aca-appeals-external-review","title":"ACA internal appeals and external review for health coverage","citation":"45 CFR 147.136 (with 29 CFR 2560.503-1 for group health plans)","jurisdiction":"us-federal","status":"in_effect","summary":"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":"https://www.law.cornell.edu/cfr/text/45/147.136","last_verified":"2026-10-12","points":[{"kind":"deadline","claim":"\"You must file your internal appeal within 180 days (6 months) of receiving notice that your claim was denied.\"","issues":["claim_denial"],"source":"https://www.healthcare.gov/appeal-insurance-company-decision/internal-appeals/","last_verified":"2026-10-12"},{"kind":"deadline","claim":"The internal appeal must be completed within 30 days for a service not yet received and within 60 days for a service already received.","issues":["claim_denial","claim_delay"],"source":"https://www.healthcare.gov/appeal-insurance-company-decision/internal-appeals/","last_verified":"2026-10-12"},{"kind":"deadline","claim":"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\".","issues":["claim_denial","claim_delay"],"source":"https://www.law.cornell.edu/cfr/text/29/2560.503-1","last_verified":"2026-10-12"},{"kind":"process","claim":"In urgent situations, \"You may file an internal appeal and an external review request at the same time.\"","issues":["claim_denial"],"source":"https://www.healthcare.gov/appeal-insurance-company-decision/internal-appeals/","last_verified":"2026-10-12"},{"kind":"policy","claim":"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.","issues":["claim_denial"],"source":"https://www.law.cornell.edu/cfr/text/45/147.136","last_verified":"2026-10-12"},{"kind":"deadline","claim":"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.","issues":["claim_denial"],"source":"https://www.healthcare.gov/appeal-insurance-company-decision/external-review/","last_verified":"2026-10-12"},{"kind":"policy","claim":"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.","issues":["claim_denial"],"source":"https://www.healthcare.gov/appeal-insurance-company-decision/external-review/","last_verified":"2026-10-12"},{"kind":"policy","claim":"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.","issues":["claim_denial","claim_delay"],"source":"https://www.law.cornell.edu/cfr/text/45/147.136","last_verified":"2026-10-12"},{"kind":"limit","claim":"These internal appeal and external review requirements generally do not apply to grandfathered plans.","issues":["claim_denial"],"source":"https://www.law.cornell.edu/cfr/text/45/147.136","last_verified":"2026-10-12"},{"kind":"contact","claim":"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.","issues":["claim_denial"],"source":"https://www.healthcare.gov/appeal-insurance-company-decision/external-review/","last_verified":"2026-10-12"}]},{"id":"erisa-claims-procedures","title":"ERISA claims procedure timelines for employer benefit plans","citation":"29 CFR 2560.503-1","jurisdiction":"us-federal","status":"in_effect","summary":"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":"https://www.law.cornell.edu/cfr/text/29/2560.503-1","last_verified":"2026-10-12","points":[{"kind":"deadline","claim":"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.","issues":["claim_delay","claim_denial"],"source":"https://www.law.cornell.edu/cfr/text/29/2560.503-1","last_verified":"2026-10-12"},{"kind":"deadline","claim":"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.","issues":["claim_delay","claim_denial"],"source":"https://www.law.cornell.edu/cfr/text/29/2560.503-1","last_verified":"2026-10-12"},{"kind":"deadline","claim":"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.","issues":["claim_denial"],"source":"https://www.law.cornell.edu/cfr/text/29/2560.503-1","last_verified":"2026-10-12"},{"kind":"deadline","claim":"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).","issues":["claim_denial","claim_delay"],"source":"https://www.law.cornell.edu/cfr/text/29/2560.503-1","last_verified":"2026-10-12"},{"kind":"deadline","claim":"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.","issues":["claim_denial","claim_delay"],"source":"https://www.law.cornell.edu/cfr/text/29/2560.503-1","last_verified":"2026-10-12"},{"kind":"policy","claim":"On appeal, the plan must provide, \"upon request and free of charge, reasonable access to, and copies of, all documents\" relevant to the claim.","issues":["claim_denial"],"source":"https://www.law.cornell.edu/cfr/text/29/2560.503-1","last_verified":"2026-10-12"},{"kind":"policy","claim":"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).","issues":["claim_denial","claim_delay"],"source":"https://www.law.cornell.edu/cfr/text/29/2560.503-1","last_verified":"2026-10-12"}]}],"not_in_force":[]},"tips":[],"escalation":[{"index":0,"rung":"frontline","note":"Use the number on the back of the member ID card.","channel":{"id":"member-services-phone","type":"phone","label":"Corporate contact center (members should call the number on the ID card)","value":"+1-800-872-3862","hours":"Mon-Fri 8 AM-6 PM ET","purposes":["poor_service"],"notes":"Aetna asks health plan members to call the number on the member ID card for personalized service.","source":"https://www.aetna.com/about-us/contact-aetna.html","last_verified":"2026-10-12"}},{"index":1,"rung":"written_complaint","note":"Internal appeal or grievance. Medicare plans use the Medicare appeal addresses.","channel":{"id":"grievance-form","type":"web_form","label":"Member complaint, grievance and appeal form (non-Medicare plans)","value":"https://member.aetna.com/MemberPublic/featureRouter/forms?page=commGrievnForm","purposes":["claim_denial","poor_service","billing_error"],"source":"https://www.aetna.com/individuals-families/member-rights-resources/complaints-grievances-appeals.html","last_verified":"2026-10-12"}},{"index":2,"rung":"state_agency","note":"External review for fully insured plans; complaint to the state where the plan is issued.","agency_kind":"insurance_department","agencies":"Ask for the person's state, then call find_regulators."},{"index":3,"rung":"regulator","note":"Employer self-funded (ERISA) plans. Aetna's own External Review Program covers self-funded plans whose sponsor elects it.","regulator":{"id":"dol-ebsa","name":"U.S. Department of Labor, Employee Benefits Security Administration","level":"federal","when_to_use":"Use for a problem with a private-sector employer health or retirement plan (ERISA plan), such as a denied or delayed claim, after you follow the plan's own claim and appeal steps. Government and church plans are generally not covered.","channels":[{"id":"health-plan-form","type":"web_form","label":"Request help from a Benefits Advisor (health plan)","value":"https://www.askebsa.dol.gov/WebIntake/home.aspx/info?id=3","purposes":["claim_denial","claim_delay"],"notes":"Asks for name, ZIP, state, phone, email, the last four digits of the Social Security number, and an attestation that you are the person the information applies to. The account holder must confirm this personally.","source":"https://beta.dol.gov/about/agencies/ebsa/ask-ebsa","last_verified":"2026-10-12"},{"id":"retirement-plan-form","type":"web_form","label":"Request help from a Benefits Advisor (retirement plan)","value":"https://www.askebsa.dol.gov/WebIntake/home.aspx/info?id=4","source":"https://beta.dol.gov/about/agencies/ebsa/ask-ebsa","last_verified":"2026-10-12"},{"id":"phone","type":"phone","label":"EBSA Benefits Advisors","value":"+1-866-444-3272","source":"https://beta.dol.gov/about/agencies/ebsa/ask-ebsa","last_verified":"2026-10-12"}],"facts":[{"kind":"process","claim":"ERISA sets minimum standards for most voluntarily established retirement and health plans in private industry. In general it does not cover group health plans of government entities or church plans.","source":"https://www.dol.gov/general/topic/health-plans/erisa","last_verified":"2026-10-12"},{"kind":"process","claim":"For a complaint under Title I of ERISA, expect a status report from the assigned benefits advisor every 30 days.","source":"https://www.askebsa.dol.gov/WebIntake/home.aspx/info?id=3","last_verified":"2026-10-12"},{"kind":"process","claim":"EBSA can help you understand your rights, but you should still review the plan documents and meet the plan's claim and appeal deadlines.","issues":["claim_denial"],"source":"https://www.askebsa.dol.gov/WebIntake/home.aspx/info?id=3","last_verified":"2026-10-12"}],"notes":"On 2026-10-12, www.askebsa.dol.gov and the old Ask EBSA page redirected to https://beta.dol.gov/about/agencies/ebsa/ask-ebsa, which links to the WebIntake forms above. EBSA regional offices: https://www.dol.gov/agencies/ebsa/about-ebsa/about-us/regional-offices"}},{"index":4,"rung":"regulator","note":"Surprise bills under the No Surprises Act.","regulator":{"id":"cms-no-surprises","name":"CMS No Surprises Help Desk","level":"federal","when_to_use":"Use for an out-of-network surprise bill for emergency care, for care at an in-network hospital or surgery center, or for air ambulance. Uninsured or self-pay patients use the dispute process when a bill is at least $400 over the good faith estimate.","channels":[{"id":"complaint-form","type":"web_form","label":"Submit a No Surprises complaint","value":"https://www.cms.gov/medical-bill-rights/help/submit-a-complaint/get-started","purposes":["surprise_medical_bill"],"notes":"The form resets after 15 minutes of inactivity and the answers are deleted. Save the confirmation number.","source":"https://www.cms.gov/medical-bill-rights/help/submit-a-complaint","last_verified":"2026-10-12"},{"id":"complaint-update","type":"web_form","label":"Add documents to an existing complaint","value":"https://www.cms.gov/medical-bill-rights/help/submit-a-complaint/update","source":"https://www.cms.gov/medical-bill-rights/help/submit-a-complaint","last_verified":"2026-10-12"},{"id":"help-desk","type":"phone","label":"No Surprises Help Desk","value":"+1-800-985-3059","hours":"Phone support 7 days a week (hours not stated)","notes":"Help in English, Spanish and more than 350 other languages. Call with the confirmation number to check status.","source":"https://www.cms.gov/medical-bill-rights","last_verified":"2026-10-12"},{"id":"bill-dispute","type":"web_form","label":"Patient-provider bill dispute (uninsured or self-pay)","value":"https://nsa-idr.cms.gov/billdisputes/s/","purposes":["surprise_medical_bill"],"notes":"A $25 non-refundable fee applies. A mail or fax initiation form is at https://www.cms.gov/files/document/billing-dispute-initiation-form.pdf","source":"https://www.cms.gov/medical-bill-rights/help/dispute-a-bill","last_verified":"2026-10-12"}],"facts":[{"kind":"process","claim":"The Help Desk reviews the complaint and documents, and may investigate compliance with federal law or refer the complaint to another federal or state authority. If it needs more information it contacts you within 60 days.","issues":["surprise_medical_bill"],"source":"https://www.cms.gov/medical-bill-rights/help/submit-a-complaint","last_verified":"2026-10-12"},{"kind":"process","claim":"Attach the medical bill, a photo of the insurance card, and any explanation of benefits. If you have them, add the good faith estimate, a signed notice and consent form, provider letters, appeal decisions and evidence of coverage.","issues":["surprise_medical_bill"],"source":"https://www.cms.gov/medical-bill-rights/help/submit-a-complaint","last_verified":"2026-10-12"},{"kind":"deadline","claim":"A patient-provider dispute needs an initial bill dated within the last 120 calendar days, from a provider or facility that charged at least $400 more than its good faith estimate, for care on or after January 1, 2022 that you did not use insurance to pay for.","issues":["surprise_medical_bill"],"source":"https://www.cms.gov/medical-bill-rights/help/dispute-a-bill","last_verified":"2026-10-12"},{"kind":"fee","claim":"The patient-provider dispute has a $25 non-refundable administrative fee and does not start until it is paid. If you win, the $25 is deducted from what you owe the provider.","issues":["surprise_medical_bill"],"source":"https://www.cms.gov/medical-bill-rights/help/dispute-a-bill","last_verified":"2026-10-12"},{"kind":"policy","claim":"The No Surprises Act protects you from unexpected out-of-network bills for emergency room visits, for non-emergency care at an in-network hospital, hospital outpatient department or ambulatory surgical center, and for air ambulance services.","issues":["surprise_medical_bill"],"source":"https://www.cms.gov/medical-bill-rights","last_verified":"2026-10-12"}],"notes":"The independent dispute resolution (IDR) process on cms.gov/nosurprises is a separate payment dispute process between providers and plans; it is not the patient complaint path. CMS lists no TTY or mailing address for the Help Desk."}}],"known_blockers":["Member phone numbers are plan-specific; Aetna directs members to the number on the ID card.","Non-Medicare appeal addresses differ by plan; use the address on the EOB or denial letter.","Claims and EOBs need member login."],"security":{"official_domains":["aetna.com","aetnabetterhealth.com"],"never_asks":[],"known_scams":[{"kind":"policy","claim":"Aetna's fraud page lists billing for services or supplies never provided and altering claims for higher payment as fraud. Members who see something suspicious on a plan statement should call the number on the ID card or the fraud hotline.","source":"https://www.aetna.com/about-us/fraud-waste-abuse.html","last_verified":"2026-10-12"}],"report_phishing":[{"id":"fraud-hotline","type":"phone","label":"Aetna fraud hotline","value":"+1-800-338-6361","source":"https://www.aetna.com/about-us/fraud-waste-abuse.html","last_verified":"2026-10-12"},{"id":"siu-email","type":"email","label":"Aetna Special Investigations Unit","value":"AetnaSIU@aetna.com","source":"https://www.aetna.com/about-us/fraud-waste-abuse.html","last_verified":"2026-10-12"}]},"credibility":{"grade":"A","primary_share":0.974,"sources":{"primary":37,"reference":1},"verified_from":{"page":21},"last_verified":"2026-10-12","oldest_verified":"2026-10-12","stale_items":0,"explanation":"Grade A (high: almost everything comes from official pages read directly). 97% of 38 sources are the organization's own pages or government sites.","dossier_last_verified":"2026-10-12"},"context":{"dossier":true,"sector_guide":true,"hint":"Call get_context for how this company handles complaints in practice and which scams use its name."},"notes":"Aetna is part of CVS Health. Medicare Advantage, Part D (SilverScript) and Medicaid (Aetna Better Health) plans have separate appeal channels and rules. Mailing address of Aetna Inc. is 151 Farmington Avenue, Hartford, CT 06156.","warnings":[]},"billing_error":{"company":{"id":"aetna","name":"Aetna","sector":"insurance_health","website":"https://www.aetna.com","account_url":"https://health.aetna.com/login"},"issue":{"id":"billing_error","name":"Billing error"},"playbook_source":"company","summary":"Compare the bill with the EOB, ask Member Services to fix processing errors, then file a complaint.","evidence":["provider bill","EOB","member ID card"],"steps":[{"do":"Compare the provider bill with the EOB in the member account.","channel":{"id":"claim-status","type":"portal","label":"Search claims and EOBs (member login)","value":"https://health.aetna.com/manage/claims","purposes":["claim_delay","claim_denial","billing_error"],"access":"login","source":"https://www.aetna.com/","last_verified":"2026-10-12"}},{"do":"Call Member Services to ask about a claim processed wrongly. Ask the provider to rebill to the EOB amount.","channel":{"id":"member-services-phone","type":"phone","label":"Corporate contact center (members should call the number on the ID card)","value":"+1-800-872-3862","hours":"Mon-Fri 8 AM-6 PM ET","purposes":["poor_service"],"notes":"Aetna asks health plan members to call the number on the member ID card for personalized service.","source":"https://www.aetna.com/about-us/contact-aetna.html","last_verified":"2026-10-12"}},{"do":"If it is not fixed, file a complaint or appeal online.","channel":{"id":"grievance-form","type":"web_form","label":"Member complaint, grievance and appeal form (non-Medicare plans)","value":"https://member.aetna.com/MemberPublic/featureRouter/forms?page=commGrievnForm","purposes":["claim_denial","poor_service","billing_error"],"source":"https://www.aetna.com/individuals-families/member-rights-resources/complaints-grievances-appeals.html","last_verified":"2026-10-12"}}],"channels":[{"id":"claim-status","type":"portal","label":"Search claims and EOBs (member login)","value":"https://health.aetna.com/manage/claims","purposes":["claim_delay","claim_denial","billing_error"],"access":"login","source":"https://www.aetna.com/","last_verified":"2026-10-12"},{"id":"grievance-form","type":"web_form","label":"Member complaint, grievance and appeal form (non-Medicare plans)","value":"https://member.aetna.com/MemberPublic/featureRouter/forms?page=commGrievnForm","purposes":["claim_denial","poor_service","billing_error"],"source":"https://www.aetna.com/individuals-families/member-rights-resources/complaints-grievances-appeals.html","last_verified":"2026-10-12"},{"id":"medicaid-contact","type":"web_form","label":"Aetna Better Health (Medicaid) contact page","value":"https://www.aetnabetterhealth.com/contact-us.html","source":"https://www.aetna.com/","last_verified":"2026-10-12"}],"facts":[],"rules":{"in_force":[{"id":"no-surprises-act","title":"No Surprises Act (surprise billing protections and good faith estimates)","citation":"45 CFR part 149 (including 149.420 and 149.610)","jurisdiction":"us-federal","status":"in_effect","summary":"Protects patients from out-of-network surprise bills for emergency care, for non-emergency care by out-of-network providers at in-network hospitals and surgery centers, and for air ambulance services. People who are uninsured or not using insurance get a good faith estimate and can dispute a bill that is at least $400 over the estimate.","source":"https://www.cms.gov/initiatives/your-patient-rights/medical-bill-rights","last_verified":"2026-10-12","points_omitted":5,"points":[{"kind":"deadline","claim":"Uninsured or self-pay patients must get a written good faith estimate: not later than 1 business day after scheduling when care is scheduled at least 3 business days ahead; not later than 3 business days after scheduling when scheduled at least 10 business days ahead; and not later than 3 business days after a request.","issues":["surprise_medical_bill","billing_error"],"source":"https://www.law.cornell.edu/cfr/text/45/149.610","last_verified":"2026-10-12"},{"kind":"deadline","claim":"Patient-provider dispute resolution is available when the provider charged \"$400 or more\" than its good faith estimate, for care on or after January 1, 2022, with an initial bill dated within the last 120 calendar days. The patient pays a \"$25 non-refundable administrative fee\".","issues":["surprise_medical_bill","billing_error"],"source":"https://www.cms.gov/medical-bill-rights/help/dispute-a-bill","last_verified":"2026-10-12"},{"kind":"policy","claim":"While a patient-provider dispute is in progress, the provider or facility may not move the bill to collections or threaten to, and must stop pursuing payment of a bill already in collections until the dispute is resolved.","issues":["surprise_medical_bill","billing_error"],"source":"https://www.cms.gov/medical-bill-rights/help/dispute-a-bill","last_verified":"2026-10-12"}]},{"id":"rosca-negative-option","title":"Restore Online Shoppers' Confidence Act (ROSCA) negative option requirements","citation":"15 U.S.C. 8401-8405","jurisdiction":"us-federal","status":"in_effect","summary":"A seller that charges consumers online through a negative option feature (for example an automatic renewal or a free trial that converts to paid) must clearly disclose all material terms before taking billing information, get the consumer's express informed consent before charging, and provide simple mechanisms to stop recurring charges. The FTC enforces ROSCA.","source":"https://www.law.cornell.edu/uscode/text/15/8403","last_verified":"2026-10-12","points_omitted":4,"points":[{"kind":"policy","claim":"The seller must obtain \"a consumer's express informed consent before charging the consumer's credit card, debit card, bank account, or other financial account\".","issues":["unauthorized_charge","billing_error"],"source":"https://www.law.cornell.edu/uscode/text/15/8403","last_verified":"2026-10-12"}]}],"not_in_force":[]},"tips":[],"escalation":[{"index":0,"rung":"frontline","note":"Use the number on the back of the member ID card.","channel":{"id":"member-services-phone","type":"phone","label":"Corporate contact center (members should call the number on the ID card)","value":"+1-800-872-3862","hours":"Mon-Fri 8 AM-6 PM ET","purposes":["poor_service"],"notes":"Aetna asks health plan members to call the number on the member ID card for personalized service.","source":"https://www.aetna.com/about-us/contact-aetna.html","last_verified":"2026-10-12"}},{"index":1,"rung":"written_complaint","note":"Internal appeal or grievance. Medicare plans use the Medicare appeal addresses.","channel":{"id":"grievance-form","type":"web_form","label":"Member complaint, grievance and appeal form (non-Medicare plans)","value":"https://member.aetna.com/MemberPublic/featureRouter/forms?page=commGrievnForm","purposes":["claim_denial","poor_service","billing_error"],"source":"https://www.aetna.com/individuals-families/member-rights-resources/complaints-grievances-appeals.html","last_verified":"2026-10-12"}},{"index":2,"rung":"state_agency","note":"External review for fully insured plans; complaint to the state where the plan is issued.","agency_kind":"insurance_department","agencies":"Ask for the person's state, then call find_regulators."},{"index":3,"rung":"regulator","note":"Employer self-funded (ERISA) plans. Aetna's own External Review Program covers self-funded plans whose sponsor elects it.","regulator":{"id":"dol-ebsa","name":"U.S. Department of Labor, Employee Benefits Security Administration","level":"federal","when_to_use":"Use for a problem with a private-sector employer health or retirement plan (ERISA plan), such as a denied or delayed claim, after you follow the plan's own claim and appeal steps. Government and church plans are generally not covered.","channels":[{"id":"health-plan-form","type":"web_form","label":"Request help from a Benefits Advisor (health plan)","value":"https://www.askebsa.dol.gov/WebIntake/home.aspx/info?id=3","purposes":["claim_denial","claim_delay"],"notes":"Asks for name, ZIP, state, phone, email, the last four digits of the Social Security number, and an attestation that you are the person the information applies to. The account holder must confirm this personally.","source":"https://beta.dol.gov/about/agencies/ebsa/ask-ebsa","last_verified":"2026-10-12"},{"id":"retirement-plan-form","type":"web_form","label":"Request help from a Benefits Advisor (retirement plan)","value":"https://www.askebsa.dol.gov/WebIntake/home.aspx/info?id=4","source":"https://beta.dol.gov/about/agencies/ebsa/ask-ebsa","last_verified":"2026-10-12"},{"id":"phone","type":"phone","label":"EBSA Benefits Advisors","value":"+1-866-444-3272","source":"https://beta.dol.gov/about/agencies/ebsa/ask-ebsa","last_verified":"2026-10-12"}],"facts":[{"kind":"process","claim":"ERISA sets minimum standards for most voluntarily established retirement and health plans in private industry. In general it does not cover group health plans of government entities or church plans.","source":"https://www.dol.gov/general/topic/health-plans/erisa","last_verified":"2026-10-12"},{"kind":"process","claim":"For a complaint under Title I of ERISA, expect a status report from the assigned benefits advisor every 30 days.","source":"https://www.askebsa.dol.gov/WebIntake/home.aspx/info?id=3","last_verified":"2026-10-12"},{"kind":"process","claim":"EBSA can help you understand your rights, but you should still review the plan documents and meet the plan's claim and appeal deadlines.","issues":["claim_denial"],"source":"https://www.askebsa.dol.gov/WebIntake/home.aspx/info?id=3","last_verified":"2026-10-12"}],"notes":"On 2026-10-12, www.askebsa.dol.gov and the old Ask EBSA page redirected to https://beta.dol.gov/about/agencies/ebsa/ask-ebsa, which links to the WebIntake forms above. EBSA regional offices: https://www.dol.gov/agencies/ebsa/about-ebsa/about-us/regional-offices"}},{"index":4,"rung":"regulator","note":"Surprise bills under the No Surprises Act.","regulator":{"id":"cms-no-surprises","name":"CMS No Surprises Help Desk","level":"federal","when_to_use":"Use for an out-of-network surprise bill for emergency care, for care at an in-network hospital or surgery center, or for air ambulance. Uninsured or self-pay patients use the dispute process when a bill is at least $400 over the good faith estimate.","channels":[{"id":"complaint-form","type":"web_form","label":"Submit a No Surprises complaint","value":"https://www.cms.gov/medical-bill-rights/help/submit-a-complaint/get-started","purposes":["surprise_medical_bill"],"notes":"The form resets after 15 minutes of inactivity and the answers are deleted. Save the confirmation number.","source":"https://www.cms.gov/medical-bill-rights/help/submit-a-complaint","last_verified":"2026-10-12"},{"id":"complaint-update","type":"web_form","label":"Add documents to an existing complaint","value":"https://www.cms.gov/medical-bill-rights/help/submit-a-complaint/update","source":"https://www.cms.gov/medical-bill-rights/help/submit-a-complaint","last_verified":"2026-10-12"},{"id":"help-desk","type":"phone","label":"No Surprises Help Desk","value":"+1-800-985-3059","hours":"Phone support 7 days a week (hours not stated)","notes":"Help in English, Spanish and more than 350 other languages. Call with the confirmation number to check status.","source":"https://www.cms.gov/medical-bill-rights","last_verified":"2026-10-12"},{"id":"bill-dispute","type":"web_form","label":"Patient-provider bill dispute (uninsured or self-pay)","value":"https://nsa-idr.cms.gov/billdisputes/s/","purposes":["surprise_medical_bill"],"notes":"A $25 non-refundable fee applies. A mail or fax initiation form is at https://www.cms.gov/files/document/billing-dispute-initiation-form.pdf","source":"https://www.cms.gov/medical-bill-rights/help/dispute-a-bill","last_verified":"2026-10-12"}],"facts":[{"kind":"process","claim":"The Help Desk reviews the complaint and documents, and may investigate compliance with federal law or refer the complaint to another federal or state authority. If it needs more information it contacts you within 60 days.","issues":["surprise_medical_bill"],"source":"https://www.cms.gov/medical-bill-rights/help/submit-a-complaint","last_verified":"2026-10-12"},{"kind":"process","claim":"Attach the medical bill, a photo of the insurance card, and any explanation of benefits. If you have them, add the good faith estimate, a signed notice and consent form, provider letters, appeal decisions and evidence of coverage.","issues":["surprise_medical_bill"],"source":"https://www.cms.gov/medical-bill-rights/help/submit-a-complaint","last_verified":"2026-10-12"},{"kind":"deadline","claim":"A patient-provider dispute needs an initial bill dated within the last 120 calendar days, from a provider or facility that charged at least $400 more than its good faith estimate, for care on or after January 1, 2022 that you did not use insurance to pay for.","issues":["surprise_medical_bill"],"source":"https://www.cms.gov/medical-bill-rights/help/dispute-a-bill","last_verified":"2026-10-12"},{"kind":"fee","claim":"The patient-provider dispute has a $25 non-refundable administrative fee and does not start until it is paid. If you win, the $25 is deducted from what you owe the provider.","issues":["surprise_medical_bill"],"source":"https://www.cms.gov/medical-bill-rights/help/dispute-a-bill","last_verified":"2026-10-12"},{"kind":"policy","claim":"The No Surprises Act protects you from unexpected out-of-network bills for emergency room visits, for non-emergency care at an in-network hospital, hospital outpatient department or ambulatory surgical center, and for air ambulance services.","issues":["surprise_medical_bill"],"source":"https://www.cms.gov/medical-bill-rights","last_verified":"2026-10-12"}],"notes":"The independent dispute resolution (IDR) process on cms.gov/nosurprises is a separate payment dispute process between providers and plans; it is not the patient complaint path. CMS lists no TTY or mailing address for the Help Desk."}}],"known_blockers":["Member phone numbers are plan-specific; Aetna directs members to the number on the ID card.","Non-Medicare appeal addresses differ by plan; use the address on the EOB or denial letter.","Claims and EOBs need member login."],"security":{"official_domains":["aetna.com","aetnabetterhealth.com"],"never_asks":[],"known_scams":[{"kind":"policy","claim":"Aetna's fraud page lists billing for services or supplies never provided and altering claims for higher payment as fraud. Members who see something suspicious on a plan statement should call the number on the ID card or the fraud hotline.","source":"https://www.aetna.com/about-us/fraud-waste-abuse.html","last_verified":"2026-10-12"}],"report_phishing":[{"id":"fraud-hotline","type":"phone","label":"Aetna fraud hotline","value":"+1-800-338-6361","source":"https://www.aetna.com/about-us/fraud-waste-abuse.html","last_verified":"2026-10-12"},{"id":"siu-email","type":"email","label":"Aetna Special Investigations Unit","value":"AetnaSIU@aetna.com","source":"https://www.aetna.com/about-us/fraud-waste-abuse.html","last_verified":"2026-10-12"}]},"credibility":{"grade":"A","primary_share":0.974,"sources":{"primary":37,"reference":1},"verified_from":{"page":21},"last_verified":"2026-10-12","oldest_verified":"2026-10-12","stale_items":0,"explanation":"Grade A (high: almost everything comes from official pages read directly). 97% of 38 sources are the organization's own pages or government sites.","dossier_last_verified":"2026-10-12"},"context":{"dossier":true,"sector_guide":true,"hint":"Call get_context for how this company handles complaints in practice and which scams use its name."},"notes":"Aetna is part of CVS Health. Medicare Advantage, Part D (SilverScript) and Medicaid (Aetna Better Health) plans have separate appeal channels and rules. Mailing address of Aetna Inc. is 151 Farmington Avenue, Hartford, CT 06156.","warnings":[]},"surprise_medical_bill":{"company":{"id":"aetna","name":"Aetna","sector":"insurance_health","website":"https://www.aetna.com","account_url":"https://health.aetna.com/login"},"issue":{"id":"surprise_medical_bill","name":"Surprise medical bill"},"playbook_source":"company","summary":"Check the bill against the EOB, tell Aetna and the provider, then contact the CMS help desk.","evidence":["the bill","EOB","member ID card"],"steps":[{"do":"Compare the bill with the EOB. Note whether it was emergency care or care at an in-network facility.","channel":{"id":"claim-status","type":"portal","label":"Search claims and EOBs (member login)","value":"https://health.aetna.com/manage/claims","purposes":["claim_delay","claim_denial","billing_error"],"access":"login","source":"https://www.aetna.com/","last_verified":"2026-10-12"}},{"do":"Tell Aetna and the provider the bill may be a surprise bill.","channel":{"id":"member-services-phone","type":"phone","label":"Corporate contact center (members should call the number on the ID card)","value":"+1-800-872-3862","hours":"Mon-Fri 8 AM-6 PM ET","purposes":["poor_service"],"notes":"Aetna asks health plan members to call the number on the member ID card for personalized service.","source":"https://www.aetna.com/about-us/contact-aetna.html","last_verified":"2026-10-12"}},{"do":"Contact the CMS No Surprises Help Desk.","regulator":{"id":"cms-no-surprises","name":"CMS No Surprises Help Desk","level":"federal","when_to_use":"Use for an out-of-network surprise bill for emergency care, for care at an in-network hospital or surgery center, or for air ambulance. Uninsured or self-pay patients use the dispute process when a bill is at least $400 over the good faith estimate.","channels":[{"id":"complaint-form","type":"web_form","label":"Submit a No Surprises complaint","value":"https://www.cms.gov/medical-bill-rights/help/submit-a-complaint/get-started","purposes":["surprise_medical_bill"],"notes":"The form resets after 15 minutes of inactivity and the answers are deleted. Save the confirmation number.","source":"https://www.cms.gov/medical-bill-rights/help/submit-a-complaint","last_verified":"2026-10-12"},{"id":"complaint-update","type":"web_form","label":"Add documents to an existing complaint","value":"https://www.cms.gov/medical-bill-rights/help/submit-a-complaint/update","source":"https://www.cms.gov/medical-bill-rights/help/submit-a-complaint","last_verified":"2026-10-12"},{"id":"help-desk","type":"phone","label":"No Surprises Help Desk","value":"+1-800-985-3059","hours":"Phone support 7 days a week (hours not stated)","notes":"Help in English, Spanish and more than 350 other languages. Call with the confirmation number to check status.","source":"https://www.cms.gov/medical-bill-rights","last_verified":"2026-10-12"},{"id":"bill-dispute","type":"web_form","label":"Patient-provider bill dispute (uninsured or self-pay)","value":"https://nsa-idr.cms.gov/billdisputes/s/","purposes":["surprise_medical_bill"],"notes":"A $25 non-refundable fee applies. A mail or fax initiation form is at https://www.cms.gov/files/document/billing-dispute-initiation-form.pdf","source":"https://www.cms.gov/medical-bill-rights/help/dispute-a-bill","last_verified":"2026-10-12"}],"facts":[{"kind":"process","claim":"The Help Desk reviews the complaint and documents, and may investigate compliance with federal law or refer the complaint to another federal or state authority. If it needs more information it contacts you within 60 days.","issues":["surprise_medical_bill"],"source":"https://www.cms.gov/medical-bill-rights/help/submit-a-complaint","last_verified":"2026-10-12"},{"kind":"process","claim":"Attach the medical bill, a photo of the insurance card, and any explanation of benefits. If you have them, add the good faith estimate, a signed notice and consent form, provider letters, appeal decisions and evidence of coverage.","issues":["surprise_medical_bill"],"source":"https://www.cms.gov/medical-bill-rights/help/submit-a-complaint","last_verified":"2026-10-12"},{"kind":"deadline","claim":"A patient-provider dispute needs an initial bill dated within the last 120 calendar days, from a provider or facility that charged at least $400 more than its good faith estimate, for care on or after January 1, 2022 that you did not use insurance to pay for.","issues":["surprise_medical_bill"],"source":"https://www.cms.gov/medical-bill-rights/help/dispute-a-bill","last_verified":"2026-10-12"},{"kind":"fee","claim":"The patient-provider dispute has a $25 non-refundable administrative fee and does not start until it is paid. If you win, the $25 is deducted from what you owe the provider.","issues":["surprise_medical_bill"],"source":"https://www.cms.gov/medical-bill-rights/help/dispute-a-bill","last_verified":"2026-10-12"},{"kind":"policy","claim":"The No Surprises Act protects you from unexpected out-of-network bills for emergency room visits, for non-emergency care at an in-network hospital, hospital outpatient department or ambulatory surgical center, and for air ambulance services.","issues":["surprise_medical_bill"],"source":"https://www.cms.gov/medical-bill-rights","last_verified":"2026-10-12"}],"notes":"The independent dispute resolution (IDR) process on cms.gov/nosurprises is a separate payment dispute process between providers and plans; it is not the patient complaint path. CMS lists no TTY or mailing address for the Help Desk."}}],"channels":[{"id":"medicaid-contact","type":"web_form","label":"Aetna Better Health (Medicaid) contact page","value":"https://www.aetnabetterhealth.com/contact-us.html","source":"https://www.aetna.com/","last_verified":"2026-10-12"}],"facts":[],"rules":{"in_force":[{"id":"no-surprises-act","title":"No Surprises Act (surprise billing protections and good faith estimates)","citation":"45 CFR part 149 (including 149.420 and 149.610)","jurisdiction":"us-federal","status":"in_effect","summary":"Protects patients from out-of-network surprise bills for emergency care, for non-emergency care by out-of-network providers at in-network hospitals and surgery centers, and for air ambulance services. People who are uninsured or not using insurance get a good faith estimate and can dispute a bill that is at least $400 over the estimate.","source":"https://www.cms.gov/initiatives/your-patient-rights/medical-bill-rights","last_verified":"2026-10-12","points":[{"kind":"limit","claim":"For emergency services, \"you can't be charged any more for emergency medical services than the in-network 'cost-sharing' rate\". This covers the hospital, the providers who treat you there, and air ambulance providers.","issues":["surprise_medical_bill"],"source":"https://www.cms.gov/initiatives/your-patient-rights/medical-bill-rights/know-your-rights/insurance","last_verified":"2026-10-12"},{"kind":"policy","claim":"The protections cover non-emergency care related to a visit to an in-network hospital, hospital outpatient department or ambulatory surgical center, and air ambulance services. Ground ambulance services generally are not covered by the No Surprises Act billing protections.","issues":["surprise_medical_bill"],"source":"https://www.cms.gov/medical-bill-rights/know-your-rights","last_verified":"2026-10-12"},{"kind":"policy","claim":"A patient gives up the protections for non-emergency care only by signing a notice-and-consent form. Providers of ancillary services cannot use that form: emergency medicine, anesthesiology, pathology, radiology and neonatology; assistant surgeons, hospitalists and intensivists; diagnostic services including radiology and laboratory; and any out-of-network provider when no in-network provider is available at the facility.","issues":["surprise_medical_bill"],"source":"https://www.law.cornell.edu/cfr/text/45/149.420","last_verified":"2026-10-12"},{"kind":"deadline","claim":"A notice-and-consent form for services scheduled at least 72 hours in advance must be given not later than 72 hours before the services. For services scheduled within 72 hours, it must be given on the day of scheduling, and no later than 3 hours before the services if given on the same day.","issues":["surprise_medical_bill"],"source":"https://www.law.cornell.edu/cfr/text/45/149.420","last_verified":"2026-10-12"},{"kind":"deadline","claim":"Uninsured or self-pay patients must get a written good faith estimate: not later than 1 business day after scheduling when care is scheduled at least 3 business days ahead; not later than 3 business days after scheduling when scheduled at least 10 business days ahead; and not later than 3 business days after a request.","issues":["surprise_medical_bill","billing_error"],"source":"https://www.law.cornell.edu/cfr/text/45/149.610","last_verified":"2026-10-12"},{"kind":"deadline","claim":"Patient-provider dispute resolution is available when the provider charged \"$400 or more\" than its good faith estimate, for care on or after January 1, 2022, with an initial bill dated within the last 120 calendar days. The patient pays a \"$25 non-refundable administrative fee\".","issues":["surprise_medical_bill","billing_error"],"source":"https://www.cms.gov/medical-bill-rights/help/dispute-a-bill","last_verified":"2026-10-12"},{"kind":"policy","claim":"While a patient-provider dispute is in progress, the provider or facility may not move the bill to collections or threaten to, and must stop pursuing payment of a bill already in collections until the dispute is resolved.","issues":["surprise_medical_bill","billing_error"],"source":"https://www.cms.gov/medical-bill-rights/help/dispute-a-bill","last_verified":"2026-10-12"},{"kind":"contact","claim":"No Surprises Help Desk: 1-800-985-3059, weekdays 8:00 am to 8:00 pm ET and weekends 10:00 am to 6:00 pm ET. Complaints can also be filed online through CMS.","issues":["surprise_medical_bill"],"source":"https://www.cms.gov/medical-bill-rights/help","last_verified":"2026-10-12"}]}],"not_in_force":[]},"tips":[],"escalation":[{"index":0,"rung":"frontline","note":"Use the number on the back of the member ID card.","channel":{"id":"member-services-phone","type":"phone","label":"Corporate contact center (members should call the number on the ID card)","value":"+1-800-872-3862","hours":"Mon-Fri 8 AM-6 PM ET","purposes":["poor_service"],"notes":"Aetna asks health plan members to call the number on the member ID card for personalized service.","source":"https://www.aetna.com/about-us/contact-aetna.html","last_verified":"2026-10-12"}},{"index":1,"rung":"written_complaint","note":"Internal appeal or grievance. Medicare plans use the Medicare appeal addresses.","channel":{"id":"grievance-form","type":"web_form","label":"Member complaint, grievance and appeal form (non-Medicare plans)","value":"https://member.aetna.com/MemberPublic/featureRouter/forms?page=commGrievnForm","purposes":["claim_denial","poor_service","billing_error"],"source":"https://www.aetna.com/individuals-families/member-rights-resources/complaints-grievances-appeals.html","last_verified":"2026-10-12"}},{"index":2,"rung":"state_agency","note":"External review for fully insured plans; complaint to the state where the plan is issued.","agency_kind":"insurance_department","agencies":"Ask for the person's state, then call find_regulators."},{"index":3,"rung":"regulator","note":"Employer self-funded (ERISA) plans. Aetna's own External Review Program covers self-funded plans whose sponsor elects it.","regulator":{"id":"dol-ebsa","name":"U.S. Department of Labor, Employee Benefits Security Administration","level":"federal","when_to_use":"Use for a problem with a private-sector employer health or retirement plan (ERISA plan), such as a denied or delayed claim, after you follow the plan's own claim and appeal steps. Government and church plans are generally not covered.","channels":[{"id":"health-plan-form","type":"web_form","label":"Request help from a Benefits Advisor (health plan)","value":"https://www.askebsa.dol.gov/WebIntake/home.aspx/info?id=3","purposes":["claim_denial","claim_delay"],"notes":"Asks for name, ZIP, state, phone, email, the last four digits of the Social Security number, and an attestation that you are the person the information applies to. The account holder must confirm this personally.","source":"https://beta.dol.gov/about/agencies/ebsa/ask-ebsa","last_verified":"2026-10-12"},{"id":"retirement-plan-form","type":"web_form","label":"Request help from a Benefits Advisor (retirement plan)","value":"https://www.askebsa.dol.gov/WebIntake/home.aspx/info?id=4","source":"https://beta.dol.gov/about/agencies/ebsa/ask-ebsa","last_verified":"2026-10-12"},{"id":"phone","type":"phone","label":"EBSA Benefits Advisors","value":"+1-866-444-3272","source":"https://beta.dol.gov/about/agencies/ebsa/ask-ebsa","last_verified":"2026-10-12"}],"facts":[{"kind":"process","claim":"ERISA sets minimum standards for most voluntarily established retirement and health plans in private industry. In general it does not cover group health plans of government entities or church plans.","source":"https://www.dol.gov/general/topic/health-plans/erisa","last_verified":"2026-10-12"},{"kind":"process","claim":"For a complaint under Title I of ERISA, expect a status report from the assigned benefits advisor every 30 days.","source":"https://www.askebsa.dol.gov/WebIntake/home.aspx/info?id=3","last_verified":"2026-10-12"},{"kind":"process","claim":"EBSA can help you understand your rights, but you should still review the plan documents and meet the plan's claim and appeal deadlines.","issues":["claim_denial"],"source":"https://www.askebsa.dol.gov/WebIntake/home.aspx/info?id=3","last_verified":"2026-10-12"}],"notes":"On 2026-10-12, www.askebsa.dol.gov and the old Ask EBSA page redirected to https://beta.dol.gov/about/agencies/ebsa/ask-ebsa, which links to the WebIntake forms above. EBSA regional offices: https://www.dol.gov/agencies/ebsa/about-ebsa/about-us/regional-offices"}},{"index":4,"rung":"regulator","note":"Surprise bills under the No Surprises Act.","regulator":{"id":"cms-no-surprises","name":"CMS No Surprises Help Desk","level":"federal","when_to_use":"Use for an out-of-network surprise bill for emergency care, for care at an in-network hospital or surgery center, or for air ambulance. Uninsured or self-pay patients use the dispute process when a bill is at least $400 over the good faith estimate.","channels":[{"id":"complaint-form","type":"web_form","label":"Submit a No Surprises complaint","value":"https://www.cms.gov/medical-bill-rights/help/submit-a-complaint/get-started","purposes":["surprise_medical_bill"],"notes":"The form resets after 15 minutes of inactivity and the answers are deleted. Save the confirmation number.","source":"https://www.cms.gov/medical-bill-rights/help/submit-a-complaint","last_verified":"2026-10-12"},{"id":"complaint-update","type":"web_form","label":"Add documents to an existing complaint","value":"https://www.cms.gov/medical-bill-rights/help/submit-a-complaint/update","source":"https://www.cms.gov/medical-bill-rights/help/submit-a-complaint","last_verified":"2026-10-12"},{"id":"help-desk","type":"phone","label":"No Surprises Help Desk","value":"+1-800-985-3059","hours":"Phone support 7 days a week (hours not stated)","notes":"Help in English, Spanish and more than 350 other languages. Call with the confirmation number to check status.","source":"https://www.cms.gov/medical-bill-rights","last_verified":"2026-10-12"},{"id":"bill-dispute","type":"web_form","label":"Patient-provider bill dispute (uninsured or self-pay)","value":"https://nsa-idr.cms.gov/billdisputes/s/","purposes":["surprise_medical_bill"],"notes":"A $25 non-refundable fee applies. A mail or fax initiation form is at https://www.cms.gov/files/document/billing-dispute-initiation-form.pdf","source":"https://www.cms.gov/medical-bill-rights/help/dispute-a-bill","last_verified":"2026-10-12"}],"facts":[{"kind":"process","claim":"The Help Desk reviews the complaint and documents, and may investigate compliance with federal law or refer the complaint to another federal or state authority. If it needs more information it contacts you within 60 days.","issues":["surprise_medical_bill"],"source":"https://www.cms.gov/medical-bill-rights/help/submit-a-complaint","last_verified":"2026-10-12"},{"kind":"process","claim":"Attach the medical bill, a photo of the insurance card, and any explanation of benefits. If you have them, add the good faith estimate, a signed notice and consent form, provider letters, appeal decisions and evidence of coverage.","issues":["surprise_medical_bill"],"source":"https://www.cms.gov/medical-bill-rights/help/submit-a-complaint","last_verified":"2026-10-12"},{"kind":"deadline","claim":"A patient-provider dispute needs an initial bill dated within the last 120 calendar days, from a provider or facility that charged at least $400 more than its good faith estimate, for care on or after January 1, 2022 that you did not use insurance to pay for.","issues":["surprise_medical_bill"],"source":"https://www.cms.gov/medical-bill-rights/help/dispute-a-bill","last_verified":"2026-10-12"},{"kind":"fee","claim":"The patient-provider dispute has a $25 non-refundable administrative fee and does not start until it is paid. If you win, the $25 is deducted from what you owe the provider.","issues":["surprise_medical_bill"],"source":"https://www.cms.gov/medical-bill-rights/help/dispute-a-bill","last_verified":"2026-10-12"},{"kind":"policy","claim":"The No Surprises Act protects you from unexpected out-of-network bills for emergency room visits, for non-emergency care at an in-network hospital, hospital outpatient department or ambulatory surgical center, and for air ambulance services.","issues":["surprise_medical_bill"],"source":"https://www.cms.gov/medical-bill-rights","last_verified":"2026-10-12"}],"notes":"The independent dispute resolution (IDR) process on cms.gov/nosurprises is a separate payment dispute process between providers and plans; it is not the patient complaint path. CMS lists no TTY or mailing address for the Help Desk."}}],"known_blockers":["Member phone numbers are plan-specific; Aetna directs members to the number on the ID card.","Non-Medicare appeal addresses differ by plan; use the address on the EOB or denial letter.","Claims and EOBs need member login."],"security":{"official_domains":["aetna.com","aetnabetterhealth.com"],"never_asks":[],"known_scams":[{"kind":"policy","claim":"Aetna's fraud page lists billing for services or supplies never provided and altering claims for higher payment as fraud. Members who see something suspicious on a plan statement should call the number on the ID card or the fraud hotline.","source":"https://www.aetna.com/about-us/fraud-waste-abuse.html","last_verified":"2026-10-12"}],"report_phishing":[{"id":"fraud-hotline","type":"phone","label":"Aetna fraud hotline","value":"+1-800-338-6361","source":"https://www.aetna.com/about-us/fraud-waste-abuse.html","last_verified":"2026-10-12"},{"id":"siu-email","type":"email","label":"Aetna Special Investigations Unit","value":"AetnaSIU@aetna.com","source":"https://www.aetna.com/about-us/fraud-waste-abuse.html","last_verified":"2026-10-12"}]},"credibility":{"grade":"A","primary_share":0.974,"sources":{"primary":37,"reference":1},"verified_from":{"page":21},"last_verified":"2026-10-12","oldest_verified":"2026-10-12","stale_items":0,"explanation":"Grade A (high: almost everything comes from official pages read directly). 97% of 38 sources are the organization's own pages or government sites.","dossier_last_verified":"2026-10-12"},"context":{"dossier":true,"sector_guide":true,"hint":"Call get_context for how this company handles complaints in practice and which scams use its name."},"notes":"Aetna is part of CVS Health. Medicare Advantage, Part D (SilverScript) and Medicaid (Aetna Better Health) plans have separate appeal channels and rules. Mailing address of Aetna Inc. is 151 Farmington Avenue, Hartford, CT 06156.","warnings":[]}},"escalation":[{"index":0,"rung":"frontline","note":"Use the number on the back of the member ID card.","channel":{"id":"member-services-phone","type":"phone","label":"Corporate contact center (members should call the number on the ID card)","value":"+1-800-872-3862","hours":"Mon-Fri 8 AM-6 PM ET","purposes":["poor_service"],"notes":"Aetna asks health plan members to call the number on the member ID card for personalized service.","source":"https://www.aetna.com/about-us/contact-aetna.html","last_verified":"2026-10-12"}},{"index":1,"rung":"written_complaint","note":"Internal appeal or grievance. Medicare plans use the Medicare appeal addresses.","channel":{"id":"grievance-form","type":"web_form","label":"Member complaint, grievance and appeal form (non-Medicare plans)","value":"https://member.aetna.com/MemberPublic/featureRouter/forms?page=commGrievnForm","purposes":["claim_denial","poor_service","billing_error"],"source":"https://www.aetna.com/individuals-families/member-rights-resources/complaints-grievances-appeals.html","last_verified":"2026-10-12"}},{"index":2,"rung":"state_agency","note":"External review for fully insured plans; complaint to the state where the plan is issued.","agency_kind":"insurance_department","agencies":"Ask for the person's state, then call find_regulators."},{"index":3,"rung":"regulator","note":"Employer self-funded (ERISA) plans. Aetna's own External Review Program covers self-funded plans whose sponsor elects it.","regulator":{"id":"dol-ebsa","name":"U.S. Department of Labor, Employee Benefits Security Administration","level":"federal","when_to_use":"Use for a problem with a private-sector employer health or retirement plan (ERISA plan), such as a denied or delayed claim, after you follow the plan's own claim and appeal steps. Government and church plans are generally not covered.","channels":[{"id":"health-plan-form","type":"web_form","label":"Request help from a Benefits Advisor (health plan)","value":"https://www.askebsa.dol.gov/WebIntake/home.aspx/info?id=3","purposes":["claim_denial","claim_delay"],"notes":"Asks for name, ZIP, state, phone, email, the last four digits of the Social Security number, and an attestation that you are the person the information applies to. The account holder must confirm this personally.","source":"https://beta.dol.gov/about/agencies/ebsa/ask-ebsa","last_verified":"2026-10-12"},{"id":"retirement-plan-form","type":"web_form","label":"Request help from a Benefits Advisor (retirement plan)","value":"https://www.askebsa.dol.gov/WebIntake/home.aspx/info?id=4","source":"https://beta.dol.gov/about/agencies/ebsa/ask-ebsa","last_verified":"2026-10-12"},{"id":"phone","type":"phone","label":"EBSA Benefits Advisors","value":"+1-866-444-3272","source":"https://beta.dol.gov/about/agencies/ebsa/ask-ebsa","last_verified":"2026-10-12"}],"facts":[{"kind":"process","claim":"ERISA sets minimum standards for most voluntarily established retirement and health plans in private industry. In general it does not cover group health plans of government entities or church plans.","source":"https://www.dol.gov/general/topic/health-plans/erisa","last_verified":"2026-10-12"},{"kind":"process","claim":"For a complaint under Title I of ERISA, expect a status report from the assigned benefits advisor every 30 days.","source":"https://www.askebsa.dol.gov/WebIntake/home.aspx/info?id=3","last_verified":"2026-10-12"},{"kind":"process","claim":"EBSA can help you understand your rights, but you should still review the plan documents and meet the plan's claim and appeal deadlines.","issues":["claim_denial"],"source":"https://www.askebsa.dol.gov/WebIntake/home.aspx/info?id=3","last_verified":"2026-10-12"}],"notes":"On 2026-10-12, www.askebsa.dol.gov and the old Ask EBSA page redirected to https://beta.dol.gov/about/agencies/ebsa/ask-ebsa, which links to the WebIntake forms above. EBSA regional offices: https://www.dol.gov/agencies/ebsa/about-ebsa/about-us/regional-offices"}},{"index":4,"rung":"regulator","note":"Surprise bills under the No Surprises Act.","regulator":{"id":"cms-no-surprises","name":"CMS No Surprises Help Desk","level":"federal","when_to_use":"Use for an out-of-network surprise bill for emergency care, for care at an in-network hospital or surgery center, or for air ambulance. Uninsured or self-pay patients use the dispute process when a bill is at least $400 over the good faith estimate.","channels":[{"id":"complaint-form","type":"web_form","label":"Submit a No Surprises complaint","value":"https://www.cms.gov/medical-bill-rights/help/submit-a-complaint/get-started","purposes":["surprise_medical_bill"],"notes":"The form resets after 15 minutes of inactivity and the answers are deleted. Save the confirmation number.","source":"https://www.cms.gov/medical-bill-rights/help/submit-a-complaint","last_verified":"2026-10-12"},{"id":"complaint-update","type":"web_form","label":"Add documents to an existing complaint","value":"https://www.cms.gov/medical-bill-rights/help/submit-a-complaint/update","source":"https://www.cms.gov/medical-bill-rights/help/submit-a-complaint","last_verified":"2026-10-12"},{"id":"help-desk","type":"phone","label":"No Surprises Help Desk","value":"+1-800-985-3059","hours":"Phone support 7 days a week (hours not stated)","notes":"Help in English, Spanish and more than 350 other languages. Call with the confirmation number to check status.","source":"https://www.cms.gov/medical-bill-rights","last_verified":"2026-10-12"},{"id":"bill-dispute","type":"web_form","label":"Patient-provider bill dispute (uninsured or self-pay)","value":"https://nsa-idr.cms.gov/billdisputes/s/","purposes":["surprise_medical_bill"],"notes":"A $25 non-refundable fee applies. A mail or fax initiation form is at https://www.cms.gov/files/document/billing-dispute-initiation-form.pdf","source":"https://www.cms.gov/medical-bill-rights/help/dispute-a-bill","last_verified":"2026-10-12"}],"facts":[{"kind":"process","claim":"The Help Desk reviews the complaint and documents, and may investigate compliance with federal law or refer the complaint to another federal or state authority. If it needs more information it contacts you within 60 days.","issues":["surprise_medical_bill"],"source":"https://www.cms.gov/medical-bill-rights/help/submit-a-complaint","last_verified":"2026-10-12"},{"kind":"process","claim":"Attach the medical bill, a photo of the insurance card, and any explanation of benefits. If you have them, add the good faith estimate, a signed notice and consent form, provider letters, appeal decisions and evidence of coverage.","issues":["surprise_medical_bill"],"source":"https://www.cms.gov/medical-bill-rights/help/submit-a-complaint","last_verified":"2026-10-12"},{"kind":"deadline","claim":"A patient-provider dispute needs an initial bill dated within the last 120 calendar days, from a provider or facility that charged at least $400 more than its good faith estimate, for care on or after January 1, 2022 that you did not use insurance to pay for.","issues":["surprise_medical_bill"],"source":"https://www.cms.gov/medical-bill-rights/help/dispute-a-bill","last_verified":"2026-10-12"},{"kind":"fee","claim":"The patient-provider dispute has a $25 non-refundable administrative fee and does not start until it is paid. If you win, the $25 is deducted from what you owe the provider.","issues":["surprise_medical_bill"],"source":"https://www.cms.gov/medical-bill-rights/help/dispute-a-bill","last_verified":"2026-10-12"},{"kind":"policy","claim":"The No Surprises Act protects you from unexpected out-of-network bills for emergency room visits, for non-emergency care at an in-network hospital, hospital outpatient department or ambulatory surgical center, and for air ambulance services.","issues":["surprise_medical_bill"],"source":"https://www.cms.gov/medical-bill-rights","last_verified":"2026-10-12"}],"notes":"The independent dispute resolution (IDR) process on cms.gov/nosurprises is a separate payment dispute process between providers and plans; it is not the patient complaint path. CMS lists no TTY or mailing address for the Help Desk."}}],"security":{"official_domains":["aetna.com","aetnabetterhealth.com"],"never_asks":[],"known_scams":[{"kind":"policy","claim":"Aetna's fraud page lists billing for services or supplies never provided and altering claims for higher payment as fraud. Members who see something suspicious on a plan statement should call the number on the ID card or the fraud hotline.","source":"https://www.aetna.com/about-us/fraud-waste-abuse.html","last_verified":"2026-10-12"}],"report_phishing":[{"id":"fraud-hotline","type":"phone","label":"Aetna fraud hotline","value":"+1-800-338-6361","source":"https://www.aetna.com/about-us/fraud-waste-abuse.html","last_verified":"2026-10-12"},{"id":"siu-email","type":"email","label":"Aetna Special Investigations Unit","value":"AetnaSIU@aetna.com","source":"https://www.aetna.com/about-us/fraud-waste-abuse.html","last_verified":"2026-10-12"}]},"credibility":{"grade":"A","primary_share":0.974,"sources":{"primary":37,"reference":1},"verified_from":{"page":21},"last_verified":"2026-10-12","oldest_verified":"2026-10-12","stale_items":0,"explanation":"Grade A (high: almost everything comes from official pages read directly). 97% of 38 sources are the organization's own pages or government sites.","dossier_last_verified":"2026-10-12"},"dossier":{"title":"Aetna — how complaints actually go","last_verified":"2026-10-12","file":"dossiers/aetna.md","markdown":"## In short\n\nCall the number on your member ID card, then appeal a denied claim within 180 days. Aetna's decision clock depends on whether your plan has one or two appeal levels, and urgent appeals are decided within 72 or 36 hours. After the internal appeal, ask for external review: through the state for insured plans, or through Aetna's External Review Program for some self-funded employer plans. Your state insurance office (in California, the DMHC for insured HMOs and the Department of Insurance for insured traditional plans) can help if you disagree with a decision. Report billing for care you never got to Aetna's fraud hotline, 1-800-338-6361.\n\n## How complaints actually go\n\n- Members should call the number on the member ID card; Aetna's corporate contact center is 1-800-872-3862 (Monday-Friday, 8 a.m.-6 p.m. ET), and its mailing address is Aetna Inc., 151 Farmington Avenue, Hartford, CT 06156. [Contact Aetna](https://www.aetna.com/about-us/contact-aetna.html)\n- Non-Medicare members can file a complaint online or on a printable form; Medicare members use a separate grievance process. [Aetna complaints, grievances and appeals](https://www.aetna.com/individuals-families/member-rights-resources/complaints-grievances-appeals.html)\n- Non-Medicare appeals: 180 days from the denial notice (longer if the plan documents allow). One-appeal plans decide pre-service appeals within 30 days and others within 60 days; two-appeal plans decide within 15 and 30 days, and the second review must be requested within 60 days of the first decision. [Aetna claim denials](https://www.aetna.com/individuals-families/member-rights-resources/claim-denials.html)\n- Urgent appeals are decided within 72 hours (one-appeal plans) or 36 hours (two-appeal plans). [Aetna claim denials](https://www.aetna.com/individuals-families/member-rights-resources/claim-denials.html)\n- Medicare Advantage: expedited authorization appeals within 72 hours, standard authorization appeals within 30 calendar days, standard claim-denial appeals within 60 calendar days with no expedited option, and standard Part D redeterminations within 7 days. [Aetna Medicare appeals](https://www.aetna.com/medicare/contact-us/appeal.html)\n\n## What tends to work\n\n- Include the group name, your name, your member ID and the records you want reviewed with the appeal. [Aetna claim denials](https://www.aetna.com/individuals-families/member-rights-resources/claim-denials.html)\n- If your employer's self-funded plan has opted into the Aetna External Review Program, a denial for lack of medical necessity or as experimental that would cost you more than $500 can go to an independent reviewer after appeals; reviews are generally decided within 30 calendar days and bind Aetna and the plan. Call the National External Review Unit at 1-877-848-5855. [Aetna External Review Program](https://www.aetna.com/individuals-families/member-rights-resources/claims-coverage/aetna-external-review-program.html)\n- Ask the state for help: Aetna says your state insurance office can help if you disagree with a plan decision, and for plans under federal health reform the Employee Benefits Security Administration (1-866-444-3272) can help with an appeal. [Aetna complaints, grievances and appeals](https://www.aetna.com/individuals-families/member-rights-resources/complaints-grievances-appeals.html)\n- Appeal Medicare Advantage post-acute denials: CVS Health (Aetna's parent) overturned 98.2 percent of appealed denials for skilled nursing facility admission in June 2024. [HHS OIG OEI-09-24-00331, June 2026](https://oig.hhs.gov/documents/audit/11694/OEI-09-24-00331.pdf)\n\n## Traps and fine print\n\n- In California, the right regulator depends on the plan: the Department of Managed Health Care for insured HMO and DMO plans, the Department of Insurance for insured traditional plans. [Aetna complaints, grievances and appeals](https://www.aetna.com/individuals-families/member-rights-resources/complaints-grievances-appeals.html)\n- The Aetna External Review Program applies only when the self-funded plan sponsor elects it and the plan appeal process is exhausted. [Aetna External Review Program](https://www.aetna.com/individuals-families/member-rights-resources/claims-coverage/aetna-external-review-program.html)\n- Expedited decisions are not available for Medicare Advantage claim-denial appeals, only for authorizations. [Aetna Medicare appeals](https://www.aetna.com/medicare/contact-us/appeal.html)\n\n## By the numbers\n\n- Medicare Advantage, June 2024: CVS Health denied 13.5 percent of skilled nursing facility admission requests (2,170 denials) and overturned 375 of 382 appealed denials. [HHS OIG OEI-09-24-00331, June 2026](https://oig.hhs.gov/documents/audit/11694/OEI-09-24-00331.pdf)\n- In Medicaid managed care, CVS overturned 22 percent of appealed prior authorization denials in 2025 data. [KFF, August 2026](https://www.kff.org/patient-consumer-protections/prior-authorization-metrics-provide-new-insights-into-insurer-practices-but-gaps-remain/)\n\n## Scams that target customers\n\n- Check every plan statement; billing for services or supplies never provided is fraud. Call the number on your ID card, the fraud hotline at 1-800-338-6361, or email AetnaSIU@aetna.com. [Aetna fraud and abuse](https://www.aetna.com/about-us/fraud-waste-abuse.html)\n- \"Free\" genetic tests and cheek swabs offered by phone, at events or door to door are used to steal Medicare information; refuse kits your doctor did not order. [HHS OIG genetic testing alert](https://oig.hhs.gov/fraud/consumer-alerts/fraud-alert-genetic-testing-scam/)\n- Medicare will never call to sell you anything or visit your home; give your Medicare number only to your doctor, your insurer or others who should have it. [Medicare.gov: reporting fraud and abuse](https://www.medicare.gov/basics/reporting-medicare-fraud-and-abuse)\n"},"guide":{"key":"insurance_health","title":"Health insurance — how complaints work","last_verified":"2026-10-12","file":"guides/insurance_health.md","page":"https://escalate.alexgaoth.com/#/guides/insurance_health"}}