12/14/2023 0 Comments Aetna appeal timely filing limit 2022Claims paid during the grace period are not subject to overpayment recovery. See the Grievance and appeals section for information on filing an appeal of an adverse benefit. If the member doesn’t pay, their termination date will be effective retrospectively on the last day of the prior month that the premium was paid, and any paid claims with dates of service after termination would be subject to overpayment recovery.įor California members: California applies a 30-day grace period, and if the member doesn’t pay termination of coverage is prospective. You will see “HIX Grace Period” under Plan/Product if the member is in a grace period.įor on-exchange members who don’t receive premium subsidies or off-exchange members:The grace period requirements vary between 30 and 31 days. To determine if a member is in a grace period, log in to Availity to check benefits and eligibility. If the member doesn’t pay their premium and is terminated, claims paid for dates of service in months 2 and 3 of the grace period would be subject to overpayment recovery. If the member doesn’t pay their premium and is terminated, claims paid for dates of service in months 2 and 3 will be denied.įor Texas members: Claims will be processed during the grace period. In all states except Texas, at the start of the second month of non-payment, claims will be pended until premium payment is received in full. Aetna changed the standard nonparticipating-provider timely filing limit from 27 months to 12 months for traditional medical claims. However, the grace period is different between members who receive premium subsidies (Advance Premium Tax Credit) and those who don’t:įor on-exchange members who receive premium subsidies: There is a 90-day premium payment grace period. That means we’ll continue to pay any claims that occur during the first month of non-payment. To confirm benefit information, call your provider support team at 1-88 (TTY: 711). **Note: Some services and equipment may require precertification. *You can review our provider manuals and associated materials online to confirm your state’s direct access referral requirements. To find providers in the exchange network, you can use our online provider search. Therapy (physical therapy, occupational therapy, speech therapy) Mid-level practitioners (for example, physician assistants, nurse practitioners) Gynecology care (obstetrician/gynecologist) We will resolve expedited appeals within 36 hours of receipt for a two level appeal process or 72 hours for a one level appeal process or within state mandated. Note: The following list includes examples of specialties that may be considered direct access and referrals may not be required:* For resubmitted claims, add the word resubmission clearly on the claim form to avoid receiving a denial for a duplicate submission. That’s because members have no out-of-network benefits with any plan, in any state, except for emergencies. You can also mail hard copy claims or resubmissions to: Aetna Better Health of Illinois.
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