06/02/2022

Issues with Aetna Payments and Claim Processing

I am currently having issues with payment & claims processing from Aetna. Although I participate with Aetna, starting mid January 2022, all of my patients that are enrolled in Aetna Medicare plans are being processed at the out of network rate even though I am an in-network provider. Due to this issue, my patients are being left with higher copayment amounts as well as OON deductible amounts. When I contact the credentialing department, they confirm I am in-network and advise me to contact the claims department. Upon contacting the claims dept. They also confirm my network status as participating and submit the claims for reprocessing. When following up on the reprocessed claims, I am informed that Aetna has processed the claim correctly and no changes will be made. The representatives I speak to at the claims department are unable to tell me why this is the case even though I am a participating provider. This issue is currently effecting 30+ of my claims and has been very time consuming, as Aetna does not allow me to submit a dispute request online as the claims are reflecting I am OON, and when I contact the claims dept., I am only able to deal with 3 different patients per call. Please advise how I should proceed. Thank you.

Aetna does not list provider/contract representatives publicly- there are two ways to approach this:

• Review your contract for reaching out to the specific individual that helped with contracting, or
• Reach out to customer service, and get directed to a non-specific contact within the contracting & credentialing department that could further explain the claim processing problems