Aetna behavioral health appeals: routes, deadlines and criteria

Who manages behavioral health for Aetna plans?

Aetna does it in house. Its June 2026 provider manual describes Aetna Behavioral Health as an internal business unit and covers behavioral health in the same manual as medical care. Medicare Advantage disputes follow CMS rules. Aetna Better Health Medicaid plans follow state rules, which we could not verify for this guide.

Two changes matter for 2026. CVS Health's filings say Aetna exited the ACA individual exchanges for 2026, so a 2026 exchange denial will come from another carrier. And from January 1, 2026, Aetna removed concurrent review for outpatient behavioral health services that need precertification, including ABA, TMS and PHP; care beyond the initial authorization now needs a new precertification request. Inpatient concurrent review continues.

What are Aetna's appeal levels and deadlines?

Aetna has two dispute paths. A reconsideration covers reimbursement, coding and reprocessing issues and must be filed within 180 calendar days of the initial claim decision. An appeal follows within 60 days of a reconsideration decision, or within 180 days when the issue went straight to appeal. The provider process has one appeal level.

Reconsiderations usually get an answer within 30 business days and appeals within 60 business days. Post-service appeals are not eligible for expedited handling. For fully insured plans, Aetna publishes state exceptions to its 180-day standard, for example 24 months in Georgia and 4 years in Texas; self-funded plans follow the plan and federal rules. Aetna does not charge for disputes.

Which Aetna denials skip reconsideration?

Aetna sends adverse medical-necessity decisions, utilization-review decisions, retroactive authorizations, experimental or investigational decisions and some no-precertification denials straight to appeal. If you file one of these as a reconsideration, Aetna says it will route it to the right place, but filing correctly avoids delay and keeps your timeline clear.

• Appeal directly: IOP or PHP days denied as not medically necessary (CARC 50), adverse concurrent-review decisions, retro-authorization denials.
• Reconsider first: bundling (CARC 97), modifier (CARC 4) and other coding or payment disputes.
• Member process: a provider's pre-service or concurrent medical-necessity appeal is handled as a member appeal; say it is on behalf of the member or attach written authorization.
• Medicare Advantage: contracted providers use Aetna's dispute process; non-contracted providers appeal within 65 days with a waiver of liability.

How do you request a peer-to-peer with Aetna?

Aetna gives providers a chance to discuss a case with a peer reviewer as part of utilization review, before an appeal. It publishes no fixed request window; its manual says timing follows state, federal, CMS and NCQA requirements. Start with the prior-authorization number on the member's ID card or the behavioral health line in the manual.

Aetna's member page notes that its peer-to-peer details do not apply to Texas members. If the conversation does not resolve the case, the appeal follows, and appeals on the patient's behalf need the patient's consent. Prepare with the peer-to-peer prep sheet.

Which clinical criteria does Aetna say it uses?

For commercial mental health, Aetna uses LOCUS for adults and CALOCUS-CASII for ages 6 to 17, replacing its older LOCAT tool. For substance use it names the ASAM Criteria, Third Edition, with LOCADTR in New York. It also lists MCG guidelines, its Clinical Policy Bulletins and an ABA medical necessity guide revised on January 1, 2026.

Aetna's pages do not mention ECSII, and as of October 14, 2026 we found no Aetna adoption of the ASAM fourth edition. If a notice names a different edition, ask Aetna to confirm which one governed the decision.

How do you get the criteria and the claim file from Aetna?

Participating physicians can ask Aetna for a hard copy of the criteria used for a determination, and criteria are also available through the provider portal and Aetna's website. Members can ask Member Services for documents for an appeal. For the full claim file, put a written request in the appeal itself.

Federal rules back the request. For mental health and substance use benefits, plans must disclose medical-necessity criteria on request to participants and contracting providers, and employer plans must give claimants free copies of documents relevant to the claim. The criteria request letter asks for both.

Where do you submit an Aetna appeal?

Availity is Aetna's fastest channel: open the finalized claim in Claim Status, choose Dispute Claim and track it on the Appeals dashboard. The dispute form is not required when filing through Availity. For written appeals, Aetna's disputes overview lists mailing addresses and fax numbers by product and state.

Only finalized claims can be disputed. Written appeals need the Practitioner and Provider Complaint and Appeal Request form, a written explanation and the medical records. For services not yet provided, Aetna's form directs you to the member complaint and appeal form instead.

Which denial codes come up on Aetna behavioral health claims?

Aetna uses the standard claim adjustment reason codes. For behavioral health claims, the codes that decide the Aetna route are medical necessity (50) and denial at authorization (39), which go to appeal, and coding or bundling codes such as 4 and 97, which go to reconsideration. Authorization codes 197 and 198 depend on the facts.