What Is Aetna’s Timely Filing Limit for Corrected Claims?

Navigating health insurance claims involves timely filing requirements, dictating the window for providers to submit claims for reimbursement. Adhering to these deadlines is important for providers, who rely on prompt payment, and for insurance companies managing vast claim volumes. This framework ensures efficient claim processing, preventing delays and financial discrepancies. This discussion addresses Aetna’s requirements for corrected claims.

Aetna’s Initial Claim Filing Deadlines

Aetna, like other major health insurers, establishes specific timeframes for initial claims. Generally, providers must submit claims within 180 days from the date of service. This is a standard guideline for most traditional medical claims. Providers under specific contracts or in certain states might encounter different filing limits.

Deadlines can also vary by plan or service. For instance, some participating providers may have a 90-day limit for electronic submissions, while non-participating providers often adhere to the 180-day rule. Providers should consult their contracts and Aetna’s provider manuals to confirm applicable limits. Adherence to these initial deadlines is a prerequisite for successful claim processing and avoids denials for late submission.

Understanding Corrected Claims and Their Deadlines

A corrected claim is a resubmission to rectify errors or omissions in a claim previously submitted and processed by Aetna. These corrections might involve updating an incorrect procedure code, adjusting a date of service, or amending patient demographic information.

Aetna’s timely filing limit for corrected claims generally allows resubmission within 365 days from the original date of service. This applies even if the initial claim was submitted within the 180-day window. Some Aetna plans, such as Aetna Better Health of Illinois, specify a 180-day limit for both initial and corrected claims from the date of service. Verifying specific plan guidelines is recommended to avoid denials.

When submitting a corrected claim, properly identify it within Aetna’s system. For professional claims on a CMS-1500 form, providers typically use a claim frequency code of “7” in Box 22 to indicate a replacement, along with the original claim number. For institutional claims on a UB-04 form, a bill type ending in “XX7” signifies a corrected claim. Failure to include the appropriate frequency code can result in the claim being denied as a duplicate.

Gathering Information for a Corrected Claim

Before submitting a corrected claim, careful preparation and information gathering are necessary. The primary information required is the original claim number, sometimes referred to as the Internal Control Number (ICN). This number links the corrected submission to the initial claim in Aetna’s system, allowing for proper adjustment.

Providers must also have the original date of service, the patient’s full name and identification number, and the provider’s details readily available. Identifying the exact error that necessitates the correction is important. This often involves reviewing the original Explanation of Benefits (EOB) or Electronic Remittance Advice (ERA) from Aetna, which typically outlines the reason for denial or incorrect payment.

Knowing precisely what information needs to be changed or added, such as a corrected CPT code or an updated diagnosis, is vital for accurate resubmission. Any supporting documentation that validates the correction, like medical records or updated coding information, should also be prepared for submission.

Submitting a Corrected Claim

Once all necessary information is gathered and the corrected claim form prepared, submit it to Aetna. Providers have several submission methods: online provider portals, electronic data interchange (EDI), or traditional mail. The Aetna provider portal, often accessed through platforms like Availity, allows for electronic submission of corrected claims. When using an online portal, providers typically navigate to the claims submission section, select an option for corrected or voided claims, and input the original claim number before entering the revised details.

For electronic submissions via EDI, providers must ensure their practice management system or clearinghouse vendor can properly format the corrected claim, including the original claim number and the appropriate claim frequency code (e.g., “7” for replacement claims). If submitting via mail, the corrected claim form should be clearly marked as a “resubmission” and include a copy of the original claim and the remittance advice, along with a brief note explaining the correction. Regardless of the method, retain records of the submission, such as confirmation numbers for electronic filings or mailing receipts for paper submissions, to track the claim’s progress.

Corrected Claims Versus Appeals

Understanding the distinction between a corrected claim and an appeal is important for claims management. A corrected claim is used when the healthcare provider identifies an error in their original submission and seeks to rectify it. This means the provider acknowledges the initial claim contained incorrect or missing information, such as an inaccurate diagnosis code, a wrong date of service, or a billing error.

In contrast, an appeal is a formal process initiated when the provider disagrees with Aetna’s decision on a claim, believing the original claim was submitted correctly and the denial or payment decision was unjustified. This might occur if a claim is denied for medical necessity, lack of prior authorization, or if the provider disputes the reimbursement amount. Appeals involve presenting arguments and additional documentation to persuade the payer to reverse its decision. These two processes have distinct forms, submission requirements, and timely filing limits, with appeals generally having their own specific deadlines, typically within 60 to 180 days from the initial claim decision or denial notification.