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Coverage Decisions, Exceptions, Appeals and Complaints

We know it's important to have medical services and prescription drug coverage.

As a member of one of our Medicare Advantage or Prescription Drug plans, you have the right to the following:

Florida HMO Members should refer here for coverage decisions, exceptions, appeals and complaints information.

Not an Aetna member yet? You can call the number listed at the top of the page to get answers to your questions.

Frequently Asked Questions

How do I submit an Organization Determination to request coverage for medical services?

You can call, fax or mail us.

    Phone: 1-800-245-1206 (TTY: 711), 8 a.m. – 8 p.m., 7 days a week
    Fax: 1-859-455-8650
    Mail: Aetna Medicare Precertification Unit
    P.O. Box 14079
    Lexington, KY 40512-407

What can I do if my Organization Determination request is denied?

If we don't cover or pay for your benefits or services, you can appeal our decision. Submit the online form, fax or mail your request to us.

If your request needs to be “Expedited” you can call or fax  us.

    Expedited Phone Line: 1-800-932-2159
    Expedited Fax Line: 1-860-975-9631

How do I submit a Coverage Determination for my prescription drug?

You can submit the online form, call us, or download the Coverage Determination form, and fax or mail your request to us.

If we don't currently cover your medication or you need prior authorization before we cover your medication, you can submit the online form, download the Coverage Determination form and fax or mail your request to us.

What can I do if my Coverage Determination is denied?

If we deny your Prescription Drug request, you can appeal our decision. You can submit the online form, call us, or download the Coverage Redetermination form, and fax or mail your request to us.

If your request needs to be “Expedited” you can call or fax us.

    Expedited Phone Line: 1-877-235-3755
    Expedited Fax Number: 1-860-907-3984

What can I do if I have a complaint (also called a “grievance”)?

If you have a complaint about your medical coverage, call us at 1-800-282-5366 (TTY: 1-888-760-4748 or 711).

If you have a complaint about your pharmacy coverage, call us at 1-877-238-6211 (TTY:711).

    Fax - Medical Plan: 1-866-604-7092
    Mail - Medical (Part C) Plan:
    Aetna Medicare Grievance & Appeals 
    PO Box 14067 
    Lexington, KY 40512

    Fax - Pharmacy Plan: 1-866-604-7092
    Mail - Pharmacy (Part D) Plan
    Aetna Medicare Grievance & Appeals
    PO Box 14579
    Lexington, KY 40512

Or, you can complete the online Aetna Medicare Advantage Plan or Prescription Drug Plan Grievance Form.

You can contact the Office of the Medicare Ombudsman for help with a complaint, grievance, or information request. To learn more Contact the Office of the Medicare Ombudsman.

How long does it take to get a decision?

You can request either a "Standard" or "Expedited" (fast) decision process. If your health requires it, you can ask us to give you a "fast coverage decision". A "fast coverage decision" is called an "expedited coverage determination" or an "expedited organization determination". When we give you our decision, we will use the "standard" deadlines unless we have agreed to use the "fast" deadlines. We will respond to your request no later than the below timeframes.

 

Request for an Aetna Medicare Advantage Plan (Part C) Organization Determination
Pre-service:
14 days

Claims: 60 days
Pre-service:
72 hours

Claims: n/a

Request to Appeal an Aetna Medicare Advantage Plan (Part C) Organization Determination Denial

Pre-service:
30 days

Claims: 60 days
Pre-service:
72 hours

Claims: n/a

Request for Prescription Drug Coverage Determination

72 hours 24 hours

Request for Redetermination for an Aetna Medicare Prescription Drug Denial

7 days 72 hours

Aetna Medicare Advantage Plan Grievance

30 days 24 hours
Prescription Drug Plan Grievance
30 days 24 hours

 

If you'd like to get an aggregate number of appeals, grievances and exceptions filed with Aetna Medicare, call us at 1-800-282-5366 (TTY: 711), from 8 a.m. to 8 p.m., local time, seven days a week.

If you have questions about the status of your submitted request, call us at 1-877-238-6211 (TTY: 711), from 8 a.m. to 8 p.m., local time, seven days a week.

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LET’S TALK Call us at 1-888-247-1028
(TTY: 711). We are available from
8 a.m. - 8 p.m., local time, 7 days a week, from 10/1 - 2/14,
8 a.m. - 8 p.m., local time, Monday - Friday, from 2/15 - 9/30

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Page last updated January 4, 2016