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Process for Medicare coverage requests, appeals & grievances
We want to be your first stop if you have a concern about your coverage or care. So if you do, please call us at the number on your member ID card.
As ${anCompany} Medicare member, you have the right to:
- Ask for coverage of a medical service or prescription drug. In some cases, we may allow exceptions for a service or drug that is normally not covered.
- File an appeal if your request is denied. An appeal is a formal way of asking us to review and change a coverage decision we made.
- File a complaint about the quality of care or other services you get from us or from a Medicare provider.
There are different steps to take based on the type of request you have.
Choose a topic to help us find the right process for you
How to ask for medical coverage or request an appeal for a service
If you have a Medicare Advantage plan and you’re requesting coverage of a medical service, you’ll ask for a coverage decision (organization determination). If you receive a denial and are requesting an appeal, you’ll “request a medical appeal.”
You can call us, fax or mail your information.
California – Aetna Medicare Preferred Plan (HMO D-SNP) – H4982 – 016
Call us at 1-866-409-1221 ${tty}, 7 days a week, 8 AM to 8 PM
Fax: 1-833-596-0339
Mail: Aetna Medicare Precertification Unit
P.O. Box 14079
Lexington, KY 40512-4079
Pennsylvania - Aetna Medicare Longevity Health Plan (HMO I-SNP) – H3959 – 066
Prior authorization requests can be submitted by phone, 1-844-826-5291 ${tty}, 7 days a week, 8 AM to 8 PM or through the Provider portal Availity
Mail: 7400 W. Campus Road New Albany, OH 43054
When you’ll hear back
We’ll get back to you within:
- 14 days if you submit your request before the service is performed (72 hours if you request a faster decision)
- 30 days if you submit your request after the service (there’s no option for a faster decision after service)
If we don't cover or pay for your medical benefits or services, you can appeal our decision.
If we don't cover or pay for your medical benefits or services (Medicare Part C), you can appeal our decision. To do so, fax or mail your request to us.
Fax: 1-959-876-7979
Mail: Aetna Duals Member Appeals
PO Box 14726
Lexington, KY 40512-4726
To send a complaint to Medicare, complete the Medicare Electronic Complaint form.
When you’ll hear back
We’ll get back to you within:
- 30 days if you submit your appeal before the service is performed
- 72 hours if you request a faster decision (ONLY applies to services not yet received)
- 60 days after a claim denial (there’s no option for a faster decision)
Your doctor can request coverage on your behalf
Your doctor can call us at 1-800-414-2386 ${tty}, 7 days a week, 24 hours a day, to request drug coverage. Or your doctor can fax a completed, signed form with a statement of medical necessity to 1-800-408-2386.
Or you can use one of these methods
You or your appointed representative can call us at 1-800-414-2386 ${tty} to request drug coverage.
If you prefer, you can print and complete the appropriate forms below. Forms can be sent to us in one of three ways:
1. By fax: 1-800-408-2386
2. By mail:
Aetna Medicare Coverage Determinations
P.O. Box 7773
London, KY 40742
3. You can also request coverage online.
Print our drug coverage determination request form
Your doctor can call Customer Care at 1-866-235-5660 ${tty}, 7 days a week, 24 hours a day, to request drug coverage. Or, your doctor can fax a completed, signed form with a statement of medical necessity to 1-855-633-7673.
Coverage Determination Request Form
Or, you can complete and send a form yourself by fax, mail, or this website.
Download and print an English form
Fax option:
1-855-633-7673
Mail option:
SilverScript Insurance Company
Appeals and Coverage Determination
P.O. Box 52000 MC109
Phoenix, AZ 85072-2000
Online option:
If we deny your prescription drug request, you can appeal our decision. You can file your standard or expedited appeal using one of the below:
Online:
Mail: Aetna Medicare Part D Appeals
PO Box 14579
Lexington, KY 40512
Fax: 1-724-741-4954
Find your plan’s contact details
California – Aetna Medicare Preferred Plan (HMO D-SNP) – H4982 – 016
Call us at 1-866-409-1221 ${tty}, 7 days a week, 8 AM to 8 PM
Pennsylvania – Aetna Medicare Longevity Health Plan (HMO I-SNP) – H3959 – 066
Call us at 1-844-826-5291 ${tty}, 7 days a week, 8 AM to 8 PM
To send a complaint to Medicare, complete the Medicare Electronic Complaint form.
When you'll hear back
We’ll get back to you within 7 days (72 hours if you request a faster decision).
If we deny your prescription drug request, you can appeal our decision. You can file your standard or expedited appeal using one of the four methods below:
Online option:
Phone option:
1-866-235-5660 ${tty}, 7 days a week, 24 hours a day
Or, download, print, and send completed forms by fax or mail:
Redetermination Request Form – English
Redetermination Request Form – Español
Reconsideration Request Form – English
Fax option:
1-855-633-7673
Mail option:
SilverScript Insurance Company
Appeals and Coverage Determination
P.O. Box 52000 MC109
Phoenix, AZ 85072-2000
Inpatient hospital discharge
During your inpatient hospital stay you’ll get a notice called “An Important Message from Medicare about Your Rights”. You’ll have to sign it to show that you understand your rights as a hospital patient, including:
- Your right to receive Medicare-covered services during and after your hospital stay, as ordered by your doctor. This includes the right to know what these services are, who will pay for them and where you can get them.
- Your right to be involved in any decisions about your hospital stay, and know who will pay for it.
- Where to report any concerns you have about quality of your hospital care.
- Your right to appeal your discharge decision if you think you're being discharged from the hospital too soon.
You have the right to keep getting your covered services for as long as the care is needed to diagnose and treat your illness or injury if you’re getting:
- Home health care
- Skilled nursing care as a patient in a skilled nursing facility
- Rehabilitation care as an outpatient at a Medicare-approved Comprehensive Outpatient Rehabilitation Facility (CORF). (Usually, this means you’re getting treatment for an illness or accident, or you're recovering from a major operation.)
You’ll receive a "Notice of Medicare Non-Coverage (NOMNC)" in writing at least 2 days before we decide it’s time to stop covering your care. When your coverage for that care ends, we'll stop paying our share of the cost for your care. You can ask to change this decision so you're able to continue coverage.
Level 1 Appeal
You must contact the Quality Improvement Organization to start your appeal no later than noon of the day after you receive the written notice telling you when we will stop covering your care.
If you miss the deadline for contacting the Quality Improvement Organization about your appeal, you can make your appeal directly to us instead. (Please refer to above directions regarding filing an expedited appeal)
When you'll hear back from the Quality Improvement Organization (QIO)
Within 48 hours the reviewers will tell you their decision.
Level 2 Appeal
You may ask for this review immediately, but must ask within 60 days after the day the Quality Improvement Organization said no to your Level 1 Appeal.
When you'll hear back
The Quality Improvement Organization will respond to you as soon as possible, but no later than 14 days after receiving your request for a second review.
You will receive directions from the Quality Improvement Organization (QIO) regarding additional appeal options.
If you have a complaint about the quality of care or any other services you received through your Medicare plan, you may file a grievance. A grievance is the Medicare term for a formal complaint. If your complaint involves a broker or agent, be sure to include the name of the person when filing your grievance.
Call us.
California – Aetna Medicare Preferred Plan (HMO D-SNP) – H4982 – 016
Call us at 1-866-409-1221 ${tty}, 7 days a week, 8 AM to 8 PM
Pennsylvania – Aetna Medicare Longevity Health Plan (HMO I-SNP) – H3959 – 066
Call us at 1-844-826-5291 ${tty}, 7 days a week, 8 AM to 8 PM
Don’t have a CA Aetna Medicare Preferred Plan (HMO D-SNP) or a PA Aetna Medicare Longevity Health Plan (HMO I-SNP)? Get your information here.
Other ways to file a complaint
- Fax or mail us your signed complaint using the contact information shown below.
Fax: 959-876-7982
Mail: Aetna Duals Grievances
PO Box 14725
Lexington, KY 40512-4725
- To send a complaint to Medicare, call 1-800-MEDICARE or complete the Medicare Electronic Complaint form.
You will receive a response within 30 days.