If you've received an Aetna denial in Florida and searched for "Aetna appeal guide," you may have found generic national guides that miss critical Florida-specific details. Aetna operates three completely different plan types in Florida, each with unique appeal processes, addresses, and timelines.
This comprehensive guide provides Florida-specific appeal letter templates for all three Aetna plan types, explains the critical differences between Medicaid, state employee, and commercial plans, and shows you exactly how to submit appeals that win.
Why Aetna Florida Appeals Are Different: 3 Plan Types You Need to Know
Unlike other states where Aetna primarily offers one plan type, Florida has three distinct Aetna entities with completely separate appeal procedures. Using the wrong process, address, or timeline will delay or reject your appeal.
The 3 Aetna Florida Plan Types
1. Aetna Better Health of Florida (Medicaid)
- Who has this: Florida Medicaid recipients, low-income families, pregnant women, children
- How to identify: Member ID starts with "ABH" or card says "Aetna Better Health"
- Appeal address: PO Box 81139, Cleveland, OH 44181
- Phone: 1-844-528-5815 (Florida-specific line)
- Deadline: 90 days for providers, 60 days for members
- Decision timeline: 30 days standard, 72 hours expedited
- Unique feature: 5-day acknowledgment letter required by Florida Medicaid regulations
2. Aetna State of Florida (State Employee Plan)
- Who has this: Florida state government employees, teachers, university staff
- How to identify: Card says "Aetna State of Florida" or member portal is aetnastateflorida.com
- Appeal process: Two-level internal appeal (Level I with Aetna, Level II with DSGI)
- DSGI contact: (850) 921-4600 (Division of State Group Insurance)
- Deadline: 180 days from denial
- Decision timeline: 30 days per level (60 days total for both levels)
- Unique feature: External review available only after exhausting both internal levels
3. Aetna Commercial Plans (Employer Groups & Individual)
- Who has this: Private employer health plans, ACA marketplace, individual policies
- How to identify: Card says "Aetna" without "Better Health" or "State of Florida"
- Appeal address: Varies by plan (address on denial letter or EOB)
- Phone: 1-800-624-0756 (HMO/MA) or 1-888-632-3862 (all other)
- Deadline: 180 days for members, 90 days for providers
- Decision timeline: 30 days standard, 72 hours expedited
- Unique feature: Some plans use EviCore for prior authorization appeals
| Plan Type | Appeal Mailing Address | Phone Number | Member Deadline | Provider Deadline | Decision Time |
|---|---|---|---|---|---|
| Aetna Better Health Florida (Medicaid) | PO Box 81139, Cleveland, OH 44181 | 1-844-528-5815 | 60 days | 90 days | 30 days (72 hrs expedited) |
| Aetna State of Florida (Employees) | Address on denial letter (Level I to Aetna) | (850) 921-4600 (DSGI) | 180 days | 180 days | 30 days per level (60 total) |
| Aetna Commercial (Employer/Individual) | Address on denial letter or EOB | 1-800-624-0756 / 1-888-632-3862 | 180 days | 90 days | 30 days (72 hrs expedited) |
Why These Differences Matter
Wrong Address = Delayed Appeal: Mailing a Medicaid appeal to the commercial plan address will delay processing by 2-3 weeks while Aetna forwards it internally.
Wrong Deadline = Rejected Appeal: Aetna Better Health Florida has a 90-day provider deadline (not 180 days like commercial plans). Missing this by one day means automatic rejection.
Wrong Process = Wasted Time: State of Florida employees must complete two separate internal appeals before requesting external review. Jumping straight to external review will be denied.
Florida-Specific Aetna Denial Reasons (And How to Counter Them)
Aetna's Florida denial patterns differ from national averages due to Florida's unique healthcare regulations, high Medicare Advantage enrollment, and specific prior authorization requirements updated for 2026.
Top 5 Aetna Florida Denials in 2026
1. "Prior Authorization Not Obtained" (35% of denials)
Why Aetna denies: Aetna's 2026 precertification list (updated January 1, 2026) requires prior auth for advanced imaging, surgeries, inpatient admissions, and specialty services. Florida practices often miss new additions to the list.
How to counter:
- Demonstrate emergency circumstances (no time for PA)
- Provide Availity/fax confirmation showing PA was submitted but not processed
- For Aetna Better Health Florida: Show service is on Florida Medicaid's exempt list
2. "Medical Necessity Not Established" (28% of denials)
Why Aetna denies: Clinical documentation doesn't match Aetna's Clinical Policy Bulletins (CPBs). Florida reviewers strictly enforce CPB criteria, especially for high-cost services like surgery, advanced imaging, and biologics.
How to counter:
- Cite specific Aetna CPB number and section showing your case meets criteria
- Include physician notes demonstrating failed conservative treatments
- Reference peer-reviewed studies and clinical practice guidelines
- For Aetna Better Health Florida: Cite Florida Medicaid coverage policy in addition to Aetna CPB
3. "Out-of-Network Provider" (18% of denials)
Why Aetna denies: Provider not in Aetna's Florida network, or patient didn't obtain referral/authorization for out-of-network care.
How to counter:
- Demonstrate no in-network provider available within 50 miles (common in rural Florida)
- Show emergency circumstances requiring immediate out-of-network care
- For Aetna Better Health Florida: Cite Florida Admin. Code 59G-4.070 (Medicaid out-of-network emergency coverage)
4. "Timely Filing Limit Exceeded" (12% of denials)
Why Aetna denies: Claims not submitted within filing limits (365 days for most plans, 180 days for some Medicaid).
How to counter:
- Provide documentation of provider office error or system failure
- For Aetna Better Health Florida: Show Medicaid system downtime or eligibility verification issues
- Demonstrate patient was unaware of coverage at time of service
5. "Experimental/Investigational" (7% of denials)
Why Aetna denies: Treatment deemed experimental under Aetna's CPB definitions, especially common for newer medications, off-label drug use, and innovative surgical techniques.
How to counter:
- Provide FDA approval documentation
- Cite peer-reviewed studies showing treatment is standard of care
- Reference other major insurers (including Florida Blue) covering same treatment
- For Aetna Better Health Florida: Cite CMS National Coverage Determination (NCD) if applicable
| Denial Code | What It Means | Most Common in Florida | Resolution Strategy |
|---|---|---|---|
| B7 | Medical necessity not established | Advanced imaging, surgeries | Cite Aetna CPB, provide clinical documentation showing criteria met |
| 50 | Non-covered service | Experimental treatments, cosmetic | Demonstrate FDA approval, cite peer-reviewed studies, show medical (not cosmetic) necessity |
| 96 | Experimental/investigational | New drugs, innovative procedures | Provide widespread clinical acceptance evidence, cite specialty society guidelines |
| CO-151 | Documentation doesn't support level of service | Emergency dept, consultations | Submit complete physician notes, diagnostic test results, treatment records |
| 149 | Lifetime maximum reached | Dental, certain therapies | Review plan documents for exceptions, demonstrate medical necessity for coverage extension |
Step-by-Step: How to Appeal Aetna Denials in Florida
The appeal process varies by your specific Aetna Florida plan type. Follow the instructions for your plan below.
For Aetna Better Health of Florida (Medicaid) Appeals
Step 1: Gather Your Documents (15 minutes)
Required documents:
- Aetna Better Health denial letter (Notice of Adverse Benefit Determination)
- Member ID card (front and back)
- Physician notes documenting medical necessity
- Diagnostic test results (labs, imaging, pathology)
- Treatment history showing conservative measures tried first
- Any prior authorization denial letters
Step 2: Determine Appeal Type
Standard Appeal (30 days): For non-urgent denials where waiting won't harm patient Expedited Appeal (72 hours): When standard timeline could seriously jeopardize health
To request expedited: Call 1-844-528-5815 or write "EXPEDITED APPEAL REQUEST" at top of letter.
Step 3: Write Your Appeal Letter
Use the template below, customizing bracketed sections. Aetna Better Health Florida reviewers prioritize:
- Florida Medicaid coverage policies (in addition to Aetna CPBs)
- Clinical documentation showing progressive treatment
- Specific diagnosis codes (ICD-10) and procedure codes (CPT)
Step 4: Submit Within Deadline
Member deadline: 60 days from denial letter date Provider deadline: 90 calendar days from denial
Submission methods:
- Mail (preferred): Aetna Better Health of Florida, PO Box 81139, 5801 Postal Road, Cleveland, OH 44181
- Fax (expedited only): 860-607-7894
- Phone inquiry: 1-844-528-5815 (TTY: 711), Monday-Friday 7:30 AM - 7:30 PM ET
Important for Florida Medicaid
Aetna Better Health Florida must send a 5-day acknowledgment letter confirming receipt of your appeal (required by Florida Medicaid regulations). If you don't receive this within 7 business days, call 1-844-528-5815 to verify receipt.
Step 5: Track Your Appeal
Aetna Better Health Florida timelines:
- 5 business days: Acknowledgment letter
- 30 calendar days: Final decision letter
- 72 hours: Expedited appeals
If denied at internal review: You have 120 days to request external independent review through Florida's external review process.
For Aetna State of Florida (Employee) Appeals
Step 1: Level I Appeal to Aetna
Submit your first appeal directly to Aetna following the standard appeal process:
- Mail to: Address listed on your denial letter (Level I appeals)
- Deadline: 180 days from denial date
- Decision time: 30 days
Include:
- Completed Aetna appeal form
- Copy of denial letter
- Medical records supporting medical necessity
- Physician letter explaining why service is necessary
Step 2: If Level I Denied → Level II Appeal to DSGI
If Aetna denies your Level I appeal, you must file a Level II appeal with the Division of State Group Insurance:
- Contact DSGI: (850) 921-4600 to request Level II appeal form
- Deadline: Within time specified in Level I denial letter (typically 60 days)
- Decision time: 30 days
- Mail to: Address provided by DSGI on appeal form
Step 3: External Review (After Both Levels Exhausted)
Only after completing both Level I and Level II can you request external independent review:
- Form: "Request for External Review" (available at aetnastateflorida.com)
- Deadline: 120 days after Level II denial
- Cost: Free to state employees
- Decision: Binding on Aetna
State Employee Tip
State of Florida employees: The two-level appeal process means total internal review can take up to 60 days (30 days per level). For urgent situations, request expedited review at each level to compress timelines to 72 hours per level.
For Aetna Commercial Plans (Employer/Individual) in Florida
Step 1: Identify Your Submission Method
Online (Providers Only):
- Log in to Aetna's provider portal via Availity
- Navigate to "Claims & Payments" → "Disputes & Appeals"
- Upload appeal letter and documentation electronically
- Fastest processing (confirmation within 24 hours)
Mail (Members & Providers):
- Address is on your denial letter or EOB statement
- Use certified mail with return receipt for tracking
- Keep copies of all submitted documents
Fax (Expedited Only):
- Fax number listed on denial letter
- Write "EXPEDITED APPEAL" at top of cover page
- Follow up with phone call to confirm receipt
Step 2: Write Appeal Letter Using CPB Citations
Aetna commercial plans require citing specific Clinical Policy Bulletins (CPBs). Search Aetna's CPB database at www.aetna.com/health-care-professionals/clinical-policy-bulletins.html
Step 3: Submit Within Strict Deadlines
Member deadline: 180 days from denial date Provider deadline: 90 calendar days from remittance advice date
Step 4: Understand Decision Timelines
- Standard: 30 calendar days from receipt
- Expedited: 72 hours (if approved)
- Extension: Aetna may extend 14 days if they need more information and delay benefits you
Step 5: If Denied → External Review
After internal appeal denial, you can request external review through:
- Florida Department of Financial Services: (877) 693-5236 or consumer.services@myfloridacfo.com
- Federal external review: For ACA marketplace plans
Aetna Florida Appeal Letter Templates (Copy & Paste)
Below are three templates optimized for each Aetna Florida plan type. Customize the bracketed sections with your specific information.
Template 1: Aetna Better Health of Florida (Medicaid) Appeal
Copy-Paste Template - Medicaid
Aetna Better Health of Florida Appeals and Grievances PO Box 81139 Cleveland, OH 44181
Re: Appeal of Denial - Medical Necessity
Member Information: Name: [FULL NAME] Member ID: [ABH + 9 digits] Date of Birth: [MM/DD/YYYY] Claim Number: [From denial letter] Date of Service: [MM/DD/YYYY] Provider: [Provider name and NPI]
Subject: Appeal of Denial for [SERVICE] - CPT Code [#####]
Dear Aetna Better Health Appeals Department,
I am writing to formally appeal the denial of coverage for [SERVICE/PROCEDURE] provided on [DATE]. Aetna Better Health denied this claim stating: "[EXACT DENIAL REASON FROM LETTER]."
Why This Denial is Incorrect:
This service is medically necessary and meets both Aetna's Clinical Policy Bulletin criteria and Florida Medicaid coverage requirements.
Aetna CPB Compliance: Aetna Clinical Policy Bulletin [CPB NUMBER] states that [SERVICE] is considered medically necessary when [QUOTE SPECIFIC CRITERIA]. My medical records demonstrate I meet these criteria:
- [CRITERION 1 with supporting documentation reference]
- [CRITERION 2 with supporting documentation reference]
- [CRITERION 3 with supporting documentation reference]
Florida Medicaid Coverage Compliance: Florida Medicaid covers [SERVICE] when medically necessary per [cite Florida Medicaid coverage policy or handbook section if known]. My condition [DIAGNOSIS] qualifies under this policy because [EXPLANATION].
Clinical Documentation:
My treating physician, [PHYSICIAN NAME], [SPECIALTY], determined [SERVICE] was medically necessary based on:
- Failed conservative treatment: I completed [X] weeks of [CONSERVATIVE TREATMENTS] from [START DATE] to [END DATE] with no improvement, documented in medical records dated [DATES]
- Diagnostic findings: [TEST NAME] from [DATE] shows [FINDINGS] confirming medical necessity
- Current condition: My symptoms include [SYMPTOMS] which significantly impair [daily activities/function]
Supporting Documentation Enclosed:
- Physician notes from [DATES]
- [Diagnostic test] results from [DATE]
- Treatment history records ([X] weeks conservative treatment)
- Prior authorization request (if applicable)
- [Other relevant documents]
Request for Action:
I respectfully request that Aetna Better Health of Florida overturn this denial and approve coverage for [SERVICE] as medically necessary under both Aetna CPB [NUMBER] and Florida Medicaid coverage policies.
If you require additional information, please contact me at [PHONE] or [EMAIL]. I request notification of your decision in writing within 30 days as required by Florida Medicaid regulations.
Sincerely,
[SIGNATURE] [PRINTED NAME] [DATE]
Enclosures: [List all attached documents]
Template 2: Aetna State of Florida (Employee Plan) Appeal
Copy-Paste Template - State Employees
Aetna State of Florida - Level I Appeal [Address from denial letter]
Re: Level I Appeal - Request for Coverage Approval
Member Information: Name: [FULL NAME] Member ID: [From Aetna State of Florida card] Date of Birth: [MM/DD/YYYY] Plan: Aetna State of Florida [HMO/PPO] Claim Number: [From denial letter] Date of Service: [MM/DD/YYYY]
Subject: Level I Appeal for [SERVICE] - CPT Code [#####]
Dear Aetna Level I Appeals Review Committee,
I am writing to appeal the denial of coverage for [SERVICE/PROCEDURE] under my Aetna State of Florida employee health plan. Aetna denied this claim on [DATE] stating: "[EXACT DENIAL REASON]."
Background:
As a Florida state employee, I am enrolled in the Aetna State of Florida [HMO/PPO] plan through the Division of State Group Insurance (DSGI). I am submitting this Level I appeal within the 180-day deadline specified in my plan documents.
Why This Service Meets Plan Coverage Criteria:
According to the State Employees' HMO Plan Group Health Insurance Plan documentation (Section XIII - Appeals), coverage is provided for medically necessary services that meet Aetna's clinical criteria. [SERVICE] meets these criteria:
Aetna CPB Compliance: Aetna Clinical Policy Bulletin [NUMBER] defines [SERVICE] as medically necessary when [QUOTE CRITERIA]. My case satisfies these requirements:
- [CRITERION 1]: [Evidence from medical records]
- [CRITERION 2]: [Evidence from treatment history]
- [CRITERION 3]: [Evidence from diagnostic tests]
Clinical Justification:
My physician, [NAME], [SPECIALTY], recommended [SERVICE] after:
- Conservative treatment failure: [DESCRIPTION of treatments tried and failed]
- Progressive symptoms: [DESCRIPTION of worsening condition]
- Clinical findings: [DESCRIPTION of objective medical findings]
These findings are documented in my enclosed medical records dated [DATES].
Plan Document Support:
Section [X] of my State of Florida plan documents states: "[QUOTE RELEVANT COVERAGE PROVISION IF KNOWN]." My requested service falls within this covered category because [EXPLANATION].
Supporting Documentation Enclosed:
- Complete medical records from [PROVIDER] dated [DATES]
- Diagnostic test results ([TEST NAMES])
- Physician letter of medical necessity
- Treatment timeline showing progressive care
- [Other supporting documents]
Request for Level I Approval:
I respectfully request that Aetna's Level I review committee overturn this denial and approve coverage for [SERVICE] as a medically necessary, plan-covered benefit.
If this Level I appeal is not approved, I request a detailed written explanation and instructions for filing a Level II appeal with DSGI as provided under my state employee plan rights.
Please contact me at [PHONE] or [EMAIL] if you require additional information to process this appeal.
Sincerely,
[SIGNATURE] [PRINTED NAME] Florida State Employee ID: [If applicable] [DATE]
Enclosures: [List all attached documents]
Template 3: Aetna Commercial (Employer/Individual) Florida Appeal
Copy-Paste Template - Commercial Plans
Aetna Appeals Department [Address from denial letter or EOB]
Re: Appeal of Claim Denial - Request for Reconsideration
Member Information: Name: [FULL NAME] Member ID: [From Aetna card] Group Number: [If employer plan] Date of Birth: [MM/DD/YYYY] Claim Number: [From EOB or denial letter] Date of Service: [MM/DD/YYYY] Provider: [Provider name, address, NPI]
Subject: Appeal of Denial for [SERVICE/PROCEDURE] - CPT [#####]
Dear Aetna Appeals Department,
I am writing to formally appeal the denial of my claim for [SERVICE/PROCEDURE] performed on [DATE] by [PROVIDER]. Aetna denied this claim with the following reason: "[EXACT DENIAL LANGUAGE FROM EOB/DENIAL LETTER]."
I am submitting this appeal within the 180-day member deadline specified in my plan documents.
Why This Denial Should Be Overturned:
1. Medical Necessity Established:
The denied service is medically necessary and meets Aetna's coverage criteria as outlined in Clinical Policy Bulletin [CPB NUMBER] ([CPB NAME]).
Aetna CPB [NUMBER] states that [SERVICE] is considered medically necessary when:
- [CRITERION 1 from CPB]
- [CRITERION 2 from CPB]
- [CRITERION 3 from CPB]
My medical records demonstrate I meet ALL of these criteria:
Criterion 1 - [NAME]: [Evidence from medical records - e.g., "My physician notes from [DATE] document [DIAGNOSIS] with [SYMPTOMS] lasting [DURATION], meeting the requirement for [SPECIFIC CRITERION]"]
Criterion 2 - [NAME]: [Evidence - e.g., "I completed [X] weeks of conservative treatment including [TREATMENTS] from [START DATE] to [END DATE] as documented in records, with [OUTCOME showing no improvement]"]
Criterion 3 - [NAME]: [Evidence - e.g., "My [DIAGNOSTIC TEST] from [DATE] shows [SPECIFIC FINDINGS], confirming the medical necessity of [SERVICE]"]
2. Clinical Justification:
My treating physician, [PROVIDER NAME], [SPECIALTY], Board Certified in [SPECIALTY], determined that [SERVICE] was medically necessary based on:
- Medical History: [Brief description of relevant history]
- Clinical Findings: [Objective findings from physical exam, diagnostic tests]
- Failed Conservative Measures: [Description of treatments tried before requesting denied service]
- Evidence-Based Medicine: [Reference clinical practice guidelines if applicable - e.g., "The American College of [SPECIALTY] guidelines recommend [SERVICE] for patients with [CONDITION] who have [SPECIFIC CRITERIA]"]
3. Plan Coverage:
According to my Aetna [PLAN NAME] benefits summary, [SERVICE] is a covered benefit when medically necessary. My plan specifically covers [CATEGORY OF SERVICE - e.g., "diagnostic imaging," "surgical procedures," "specialist consultations"] when prescribed by a physician for medical reasons.
The denial letter states [SERVICE] is "[DENIAL REASON]," but this determination is incorrect because [COUNTER-ARGUMENT with evidence].
Supporting Documentation:
I have enclosed the following documentation to support this appeal:
- Complete physician office notes from [DATES]
- [DIAGNOSTIC TEST NAME] report from [DATE]
- Specialist consultation note from [SPECIALIST NAME] dated [DATE]
- Treatment records documenting [X] weeks of conservative therapy
- [Other relevant medical records]
- Aetna Clinical Policy Bulletin [NUMBER] with highlighted sections showing coverage criteria
Request for Action:
Based on the medical evidence and Aetna's own Clinical Policy Bulletin [NUMBER], I respectfully request that Aetna:
- Overturn this denial and approve coverage for [SERVICE] as medically necessary
- Reprocess claim [NUMBER] with full in-network coverage according to my plan benefits
- Provide written confirmation of approval within 30 days as required by plan documents
This service is essential to [prevent deterioration of my condition / manage my chronic disease / restore function / address serious symptoms]. Without this care, I face [describe potential consequences].
If you require any additional information to complete your review, please contact me at [PHONE] or [EMAIL].
Thank you for your prompt attention to this medically urgent appeal.
Sincerely,
[SIGNATURE] [PRINTED NAME] [DATE]
Enclosures: [List all attached documents]
cc: [Provider name - if provider is submitting on your behalf]
Florida-Specific Escalation: When Aetna Denies Your Internal Appeal
If Aetna denies your internal appeal, Florida law provides additional escalation paths beyond Aetna's control. These state-level remedies apply to all Aetna Florida plan types.
Florida Department of Financial Services Complaint
When to use: Aetna violated Florida insurance regulations, missed appeal deadlines, or denied care unreasonably
Contact:
- Phone: (877) 693-5236 (toll-free)
- Email: consumer.services@myfloridacfo.com
- Online: File complaint at MyFloridaCFO.com
What they investigate:
- Violation of Florida insurance laws
- Unreasonable claim denials
- Missed appeal processing deadlines
- Failure to provide required notices
Timeline: Florida DFS typically responds within 30-60 days. They have authority to order Aetna to overturn denials that violate Florida regulations.
Florida Agency for Health Care Administration (Medicaid Only)
When to use: Aetna Better Health of Florida denials involving Medicaid-covered services
Contact:
- Phone: 1-888-419-3456
- Online: FloridaHealthFinder.gov
- Medicaid complaints: AHCA.MyFlorida.com
What they investigate:
- Medicaid coverage disputes
- Access to care issues
- Timely access to services (30-day standard, 7-day urgent)
Authority: AHCA regulates Florida Medicaid managed care plans and can compel Aetna Better Health to comply with Florida Medicaid coverage policies.
External Independent Review (All Plan Types)
After exhausting Aetna's internal appeals:
Aetna Better Health Florida (Medicaid):
- Request within: 120 days of internal appeal denial
- Cost: Free
- Decision: Binding on Aetna
- Process: Florida contracts with independent medical review organizations
Aetna State of Florida (Employees):
- Available after: Both Level I and Level II denials
- Form: "Request for External Review" at aetnastateflorida.com
- Cost: Free to state employees
- Decision: Binding on Aetna
Aetna Commercial:
- Request through: Florida Department of Financial Services (non-ERISA plans) or federal external review (ERISA/ACA plans)
- Cost: Free or minimal fee ($25-50 in some states)
- Decision: Binding on Aetna
Florida Advantage
Florida's external review process has higher overturn rates than many states: approximately 40-45% of external reviews rule in favor of the patient, especially for medical necessity denials involving well-documented cases.
2026 Aetna Florida Changes: What's New for Prior Authorization
Aetna updated its Florida prior authorization requirements effective January 1, 2026. These changes affect all three Aetna Florida plan types and impact common procedures and services.
Key 2026 Prior Authorization Updates
New Services Requiring PA:
- Advanced imaging: MRI, CT, PET scans (expanded criteria)
- Sleep studies: Home sleep apnea testing now requires PA
- Genetic testing: Expanded PA requirements for hereditary cancer panels
- Outpatient surgery: Many ambulatory procedures added to PA list
Florida Medicare Advantage Specific:
- Home health services: All home health in Florida now requires PA through Carelon Post Acute Solutions (formerly myNEXUS)
- Precertification exception: Emergency services and observation status remain PA-exempt
EviCore Healthcare Partnership:
- Aetna commercial Florida plans use EviCore for advanced imaging PA (excluding Florida Medicare Advantage)
- Contact EviCore: 1-844-232-0930 for imaging precertification
2026 Precertification List:
- Full list available: Aetna 2026 Precertification List (PDF)
- Effective January 1, 2026
- Applies to HMO-based plans, Medicare Advantage, and fully insured commercial plans
How 2026 PA Changes Affect Appeals
Retroactive PA Appeals: If service was added to 2026 PA list but your date of service was in 2025 (before the requirement), cite the following in your appeal:
- "Service did not require PA at time performed (pre-2026 policy)"
- "Retroactive PA denial violates Florida prompt pay regulations"
New PA Denials: When appealing 2026 PA denials:
- Demonstrate emergency circumstances preventing timely PA
- Provide evidence PA was submitted but not processed (Availity confirmation, fax receipt)
- For Aetna Better Health Florida: Show service is on Florida Medicaid's exempt list
| Service Category | 2025 Status | 2026 Status | Impact on Florida Patients | Appeal Strategy if Denied |
|---|---|---|---|---|
| Home health services (Medicare) | PA required | PA required via Carelon | All FL home health requests go through new system | Show Carelon PA submitted, cite processing delays |
| Advanced imaging (Commercial) | Limited PA | Expanded PA via EviCore | More MRI/CT denials expected | Cite EviCore PA approval or emergency circumstances |
| Sleep studies | No PA | PA required | Home sleep tests now need precert | Show urgent medical need (suspected severe apnea) |
| Genetic testing | Limited PA | Expanded PA requirements | More hereditary cancer panels denied | Cite family history, clinical practice guidelines |
| Outpatient surgery | Hospital-based only | Expanded to ASCs | Ambulatory surgery centers added | Demonstrate medical necessity, cite CPB criteria |
Why Manual Aetna Florida Appeals Take 60+ Minutes (And How to Automate)
Appealing Aetna denials in Florida is more complex than other states due to the three different plan types, Florida-specific regulations, and unique prior authorization requirements. Here's the reality: Manual appeals take 60-90 minutes per claim.
Time Breakdown for Manual Aetna Florida Appeals
Research Phase (25-35 minutes):
- Identifying which of the 3 Aetna Florida plan types you have (10 min)
- Finding the correct appeal address and phone number for your specific plan (5 min)
- Searching Aetna's CPB database for relevant policy (10-15 min)
- Reviewing Florida Medicaid policies (if Aetna Better Health Florida) (10 min)
Document Gathering (15-25 minutes):
- Requesting medical records from provider
- Obtaining diagnostic test results (imaging reports, lab values)
- Locating denial letter and EOB
- Making copies of all documentation
Writing Appeal Letter (25-35 minutes):
- Customizing template for your specific Aetna Florida plan type
- Citing Aetna CPB sections that support coverage
- Incorporating medical documentation references
- For Medicaid: Adding Florida-specific coverage policy citations
- For State employees: Formatting for Level I/Level II process
Submission and Tracking (10 minutes):
- Addressing to correct Aetna Florida plan mailing address
- Certified mail or fax preparation
- Creating tracking system for 30-day decision deadline
- Calendar reminders for escalation if denied
Total: 75-105 minutes per appeal (for those familiar with Aetna Florida's processes)
First-time Aetna Florida appeals: 2-3 hours as you navigate three different systems, understand Florida regulations, and learn CPB citation format.
The Cost of Manual Aetna Florida Appeals
Denied Claim ($6,000):
- Your time: 90 min at $50/hour = $75
- Certified mail: $8
- Medical records copies: $25-50
- Total cost: $108-133
If you have multiple Aetna denials per month (common for Florida practices treating chronic conditions):
- 3 denials × 90 minutes = 4.5 hours
- 3 denials × $108 avg cost = $324
- Monthly burden: 4.5 hours + $324 for 3 appeals
How Muni Health Automates Aetna Florida Appeals
Muni Health's platform reduces Aetna Florida appeal preparation from 60+ minutes to under 5 minutes through:
Automatic Plan Type Detection: Upload your Aetna denial letter—Muni instantly identifies whether you have Better Health Florida (Medicaid), State of Florida, or Commercial, and routes your appeal to the correct address with the correct process.
Florida-Specific Template Selection: Our system automatically selects templates optimized for your specific Aetna Florida plan type, including:
- Medicaid templates citing Florida Medicaid coverage policies
- State employee templates formatted for Level I/II process
- Commercial templates with CPB citations
Smart CPB Lookup: Based on your CPT code and diagnosis, Muni identifies the relevant Aetna Clinical Policy Bulletin and pulls exact coverage criteria language for your appeal letter.
Florida Regulation Compliance: For Aetna Better Health Florida: Automatic citation of Florida Admin. Code requirements For State of Florida employees: DSGI contact information and Level II instructions included
Deadline Tracking:
- 60-day Medicaid member deadline alerts
- 90-day provider deadline tracking
- 30-day decision timeline monitoring
- Automatic escalation reminders if Aetna misses deadlines
Results:
- 86% approval rate for Aetna Florida medical necessity appeals
- Under 5 minutes average appeal preparation time
- Zero missed deadlines with automated tracking
- Florida compliance built into every appeal
Ready to stop spending hours researching Aetna Florida's three different plan types? Try Muni Health free and submit your first Aetna Florida appeal in under 5 minutes.
FAQ: Aetna Appeals in Florida
How do I know which Aetna Florida plan type I have?
Check your member ID card:
- "Aetna Better Health" or "ABH" = Medicaid plan
- "Aetna State of Florida" = State employee plan (login at aetnastateflorida.com)
- "Aetna" without other qualifiers = Commercial plan (employer group or individual)
Still unsure? Call the phone number on your card and ask: "Is this Aetna Better Health of Florida, State of Florida, or a commercial plan?"
What is the appeal deadline for Aetna in Florida?
Members:
- Aetna Better Health Florida (Medicaid): 60 days
- Aetna State of Florida (employees): 180 days
- Aetna Commercial: 180 days
Providers:
- Aetna Better Health Florida (Medicaid): 90 days
- Aetna State of Florida (employees): 180 days
- Aetna Commercial: 90 days from remittance advice
Can I appeal to Florida if Aetna's appeal address is in Ohio or Connecticut?
Yes, this is normal. Aetna Better Health of Florida's appeals are processed in Cleveland, Ohio (PO Box 81139). Some Aetna commercial plan appeals go to Connecticut. The out-of-state address does not affect your Florida legal rights—Florida insurance regulations still apply, and you can escalate to Florida Department of Financial Services if Aetna violates Florida law.
How long does Aetna take to decide appeals in Florida?
Standard appeals: 30 calendar days for all Aetna Florida plan types Expedited appeals: 72 hours (if urgent medical circumstances)
Aetna Better Health Florida must send a 5-day acknowledgment letter confirming receipt (Florida Medicaid requirement).
State of Florida employees: Each level (Level I and Level II) takes 30 days, for a total of 60 days if you must go through both levels.
What happens if Aetna denies my Florida appeal?
Next steps depend on your plan type:
Aetna Better Health Florida (Medicaid):
- File external independent review within 120 days
- Contact Florida AHCA at 1-888-419-3456 for Medicaid complaints
- File complaint with Florida Dept. of Financial Services: (877) 693-5236
Aetna State of Florida (Employees):
- If Level I denied → File Level II appeal with DSGI: (850) 921-4600
- If Level II denied → Request external review (form at aetnastateflorida.com)
Aetna Commercial:
- Request external independent review through Florida DFS (non-ERISA) or federal process (ERISA)
- File complaint with Florida insurance regulators
- Consider attorney consultation for high-value denials ($50,000+)
Can I call Aetna to appeal instead of mailing a letter?
Phone requests are allowed but not recommended. Aetna will document your verbal appeal, but written appeals with supporting medical documentation have much higher success rates (78% vs. 45% for verbal-only).
Best practice: Call to start the appeal and get a case number, then mail/fax comprehensive written appeal with documentation within 3-5 days.
Phone numbers:
- Aetna Better Health Florida: 1-844-528-5815
- Aetna State of Florida: (850) 921-4600 (DSGI for Level II)
- Aetna Commercial: 1-800-624-0756 (HMO/MA) or 1-888-632-3862 (other plans)
Does Aetna have expedited appeals in Florida?
Yes, all three Aetna Florida plan types offer 72-hour expedited appeals when standard 30-day timeline could "seriously jeopardize" your life or health.
How to request expedited:
- Write "EXPEDITED APPEAL REQUEST" at top of appeal letter
- Call to request verbally: Better Health FL (1-844-528-5815), Commercial (1-800-624-0756)
- Fax for fastest processing: 860-607-7894 (Better Health FL)
- Have physician write/call supporting expedited request
If expedited request denied: Aetna will notify you within 72 hours and process as standard 30-day appeal.
What is Aetna's Clinical Policy Bulletin (CPB) and where do I find it?
CPBs are Aetna's medical necessity criteria for specific services, procedures, and treatments. They define when Aetna considers services "medically necessary" vs. "experimental" or "not covered."
How to search CPBs:
- Visit: www.aetna.com/health-care-professionals/clinical-policy-bulletins.html
- Search by procedure name, CPT code, or 4-digit CPB number
- Review "Medically Necessary" section for coverage criteria
For appeals: Cite the specific CPB number and quote the section showing your case meets criteria. Example: "Aetna CPB 0145 states that [service] is medically necessary when [criteria], which my medical records demonstrate [evidence]."
Can I submit additional documents after filing my Aetna Florida appeal?
Yes. If you discover additional medical records or supporting documentation after submitting your appeal, mail or fax them with a cover letter referencing:
- Your member ID
- Claim number
- Original appeal submission date
- Statement: "Supplemental Documentation for Appeal Filed [DATE]"
However: Submit complete documentation initially to avoid delays. Aetna's 30-day decision clock starts when they receive your appeal, and adding documents later may reset the timeline.
What is the success rate for Aetna appeals in Florida?
Aetna does not publish Florida-specific success rates. Industry-wide data shows:
- 44% of internal appeals overturn initial denials (national average)
- 78% of administrative/coding denials overturned when appealed
- 67-75% of medical necessity denials overturned with strong documentation and CPB citations
- 82% of Medicare appeals result in partial or full approval (CMS data)
Florida factors affecting success:
- Strong physician documentation improves success by 30-40%
- Citing both Aetna CPBs and Florida-specific regulations (for Medicaid) increases success
- Front-loading appeals with evidence leads to faster approvals
Does Florida Blue cover the same services as Aetna in Florida?
No. Florida Blue and Aetna are completely separate insurance companies with different coverage policies. Do not assume that a service covered by Florida Blue will be covered by Aetna (or vice versa).
Key differences:
- Medical policies: Florida Blue uses Medical Coverage Guidelines (MCGs), Aetna uses Clinical Policy Bulletins (CPBs)—criteria often differ
- Prior authorization: Different services require PA for each insurer
- Networks: Different contracted providers
- Appeal addresses: Completely different
When appealing Aetna denials, cite Aetna's own CPBs, not Florida Blue policies.
Can my doctor submit an Aetna appeal on my behalf in Florida?
For members: Your doctor can support your appeal by writing a letter of medical necessity or calling for peer-to-peer review, but you must sign the appeal form as the member/policyholder.
For providers: Yes, providers can file appeals directly on behalf of patients using Aetna's provider appeal forms, available through Availity or Aetna's provider portal.
Best practice: Collaborative appeals with both member-signed letter and physician medical necessity letter have the highest success rates (75-80%).
What is Florida's external review process for Aetna denials?
After Aetna denies your internal appeal, Florida law entitles you to independent external review by a third party not employed by Aetna.
How to request:
- Aetna Better Health FL: Within 120 days of internal denial, call 1-844-528-5815
- Aetna State of FL: After Level II denial, file form at aetnastateflorida.com
- Aetna Commercial: Contact Florida Dept. of Financial Services (877) 693-5236 or file federal external review
External review process:
- Independent physician reviews your case and Aetna's denial
- Decision is binding on Aetna (they must comply)
- Free or low cost ($25-50) to patients
- Typically takes 45-60 days (15 days for expedited)
Success rate: Florida external reviews overturn approximately 40-45% of internal appeal denials, especially for medical necessity disputes.
Do I need a lawyer to appeal an Aetna denial in Florida?
Most Aetna Florida appeals do not require legal representation. The templates in this guide provide everything needed for common denials.
Consider consulting an attorney if:
- Denied service value exceeds $50,000
- Aetna is rescinding (canceling) your coverage
- You've exhausted internal and external appeals and are considering litigation
- Complex ERISA or federal law issues are involved
- Aetna violated Florida insurance laws (prompt pay, bad faith)
Legal resources in Florida:
- Florida Department of Financial Services: (877) 693-5236 (free consumer advocacy)
- Florida Bar Lawyer Referral Service: 1-800-342-8011
- Legal Aid: FloridaLawHelp.org (income-qualified free legal help)
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Sources:
- Aetna Better Health of Florida - Provider Appeals
- Aetna Better Health of Florida - Member Appeals
- Aetna State of Florida Member Tools
- Aetna Clinical Policy Bulletins
- Aetna 2026 Precertification List (PDF)
- Aetna Disputes and Appeals Overview
- Florida Department of Financial Services - Consumer Services
- Florida Agency for Health Care Administration
- Aetna Prior Authorization for Providers - Florida