Aetna
Operated by CVS Health.
Aetna denials follow a predictable pattern — and most of them are appealable. We track the specific reasons Aetna most commonly cites, what's worked to overturn them, and which federal and state protections apply. If you're appealing a Aetna denial, this is your starting line.
Appeal process
Internal appeal to Aetna must be filed within 180 days of the denial notice. Aetna has 30 days to decide standard appeals, 72 hours for urgent. After internal exhaustion, external review by an Independent Review Organization is available for non-grandfathered plans under ACA §2719.
Common Aetna denial patterns
- UM-2575 medical necessity denials
- Prior auth absent
- Step therapy on specialty drugs
- Out-of-network ER reduction
Portals
- Member portal: https://www.aetna.com
- Provider portal: https://www.aetnaprovider.com
Aetna-specific notes
Owned by CVS Health since 2018. CVS Caremark is the PBM. Aetna ASA administers self-funded ERISA plans. Meritain Health is Aetna's TPA brand.
Common Aetna plans
- Choice POS II
- Open Access HMO
- Open Access Aetna Select
- Premier
- Aexcel
- Better Health
- Medicare Eagle
- SmartCare
- Innovation Health
Frequently asked questions
How do I appeal a Aetna denial?
File an internal appeal in writing within 180 days of the denial. Aetna has 30 days to decide standard appeals (72 hours for urgent). After internal exhaustion, request external review by an Independent Review Organization (IRO) — federal law requires this for non-grandfathered plans (ACA §2719).
What are the most common Aetna denial patterns?
UM-2575 medical necessity denials; Prior auth absent; Step therapy on specialty drugs; Out-of-network ER reduction.
What's specific to Aetna?
Owned by CVS Health since 2018. CVS Caremark is the PBM. Aetna ASA administers self-funded ERISA plans. Meritain Health is Aetna's TPA brand.
Which federal regulations apply to Aetna appeals?
Depends on plan type: ERISA §503 + ACA §2719 for commercial/employer plans, 42 CFR Part 422 Subpart M for Medicare Advantage, 42 CFR Part 438 Subpart F for Medicaid managed care.
Other National commercial
Appeal a Aetna denial
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