Aetna denied your claim — here's how to appeal
CVS Health-owned insurer covering employer, marketplace, Medicare and Medicaid plans across most states.
Plans this covers
Deadlines and how the process runs
- Aetna splits appeals between 'clinical' (medical necessity) and 'administrative' (coding, timely filing). Say which one you're filing — clinical appeals are read by a physician reviewer.
- PR-204 denials (service not covered under the plan) are worth checking against your Summary of Benefits and Coverage before appealing; if the SBC lists the benefit, quote it verbatim.
- Aetna Better Health Medicaid appeals follow state Medicaid timelines, which are often shorter than commercial windows.
Rights that apply to every plan
- You generally have at least 180 days from the date on your denial notice (EOB) to file an internal appeal with your insurer.
- The insurer must decide standard internal appeals within 30 days for pre-service claims and 60 days for care you already received.
- Urgent cases get an expedited review — typically within 72 hours.
- If the internal appeal fails, you can request an independent external review, usually within 4 months of the final internal denial. The external reviewer's decision is binding on the plan.
- Self-funded employer plans follow ERISA rules; fully insured plans also fall under your state insurance department, which can be a second place to complain.
Denial codes you'll most likely see from Aetna
A real example
- The situation
- A sleep study (CPT 95810) denied as an excluded benefit at $1,900.
- What went wrong
- The claim posted under an out-of-network sleep lab even though the ordering pulmonologist was in-network, triggering PR-204.
- What worked
- A network-adequacy appeal showing no in-network lab within 60 miles got the study reprocessed at in-network rates.
Appealing a Aetna denial, step by step
- 1Get the itemized bill from the provider and the EOB from the insurer, and line them up against each other.
- 2Find the denial code on the EOB and read what it actually means — it tells you whether the fix belongs to the insurer or the billing office.
- 3Note the appeal deadline printed on the denial notice and calendar it the same day.
- 4Request the clinical records or authorization number that answer the stated reason for denial.
- 5Send a written internal appeal that names the claim number, quotes the denial code, and states the specific correction you want.
- 6If it is upheld, request an independent external review before that window closes.
Aetna appeal FAQs
How do I appeal an Aetna claim denial?
File a written internal appeal with the member appeals address on your EOB, within the window that notice states (commonly 180 days). Include the claim number, the denial code, the clinical records that answer the stated reason, and a one-paragraph summary of why the decision is wrong.
What is a PR-204 denial on an Aetna EOB?
PR-204 means the service is not covered under your specific plan. Before appealing, compare the denial against your Summary of Benefits and Coverage — plans frequently apply the wrong benefit category, and quoting the SBC language is the fastest way to get it corrected.
Does Aetna have a deadline to answer my appeal?
Yes. Standard internal appeals must be decided within 30 days for care not yet received and 60 days for care already provided. Urgent appeals are decided within 72 hours.
Let BillCheck write the Aetna appeal for you
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BillCheck provides informational analysis only and is not legal, medical, or financial advice. Verify all details before submitting any correspondence to insurers or providers. Deadlines and processes vary by plan — the notice you received governs.