11/01/2022
Aetna Denials for Diabetic and At-Risk Foot Care
We are having horrific problems with Aetna Insurance Co. that began a few months ago. They have denied at least 90 - 95 % of our diabetic and at risk foot care claims not pay for CPT 99213, 11721, 11056, 11057 and deny the 25 an -59 modifiers. They may pay one code, and not the others, i.e. CPT 99213, 11721, 11056. They will pay below medicare rates on the 11056, and not pay they others for services rendered. They are telling the member that " This charge is incidental to another service. The member does not owe this amount. " We have been writing appeals letters to at least 18 services claims, and have heard nothing from Aetna with an explanation. How do we resolve this situation. ?????????? Any help would be greatly appreciated.
This is a common issue with Aetna denying charges without supporting documentation, even if the coding (modifiers and diagnosis codes) supports separate payment. These denials should be appealed as soon as possible to get additional payment for E&M codes and bundled RFC services. There are two recommended ways to submit appeals:
- Through Avality, a claim denial can be appealed with supporting documentation uploaded as a PDF file- once uploaded and sent for review, a revised EOB will be sent typically within 2-4 weeks from the time of inquiry to determine if additional payment will be made with supporting documentation
- If the office does not have access to Avality, supporting documentation can be faxed along with one of the two forms for commercial and Medicare policies (see links below)- this process can be slower to get a revised EOB, taking 4-6 weeks
If no response is received with an EOB or correspondence within 45 calendar days from Aetna, a call to customer service should be made to follow-up on the status of the appeal.
Practitioner and Provider Compliant and Appeal Request (aetna.com)
mcr-provider-complaint-appeal-request (aetna.com)