How to Appeal an Aetna Claim Denial

Online: sign in at aetna.com or the Aetna Health app, open the denied claim, and use the appeal/dispute option. Keep the confirmation number.

By mail: use the grievance-and-appeals address on your denial letter or EOB, with proof of delivery. No address on the letter? The member services number on your ID card will supply it — note the date and representative.

Include: your appeal letter (denial reason quoted exactly, arguments, remedy), your member ID and claim number, a physician letter of medical necessity for clinical denials, and the supporting records. Pharmacy denials administered through CVS Caremark follow the prescription-benefit appeal route named on that denial notice.

You generally have 180 days from the denial notice to file (your plan documents control). Many Aetna plans offer two internal appeal levels — the level-one decision letter tells you whether a level-two appeal or external review is next. Decision clocks follow the regulatory windows: generally 30 days pre-service, 60 days post-service, 72 hours expedited when delay would jeopardize your health.

Employer self-funded plans are governed by ERISA: full-and-fair review, and the claim file — criteria, documents, reviewer credentials — free on request. Ask for it in your appeal.

For medical-judgment denials, request independent external review within the window your final denial letter states (generally 4 months). The external decision binds Aetna. State insurance regulators take complaints in parallel; Medicare members follow the Medicare appeals track described on their notice.