Process for Medicare coverage requests, appeals & complaints
We want to be your first stop if you have a concern about your coverage or care. Call us at the number on your member ID card.
As an Aetna 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.
- Appoint someone else to act on your behalf.
How to appoint a representative
Choose a topic to help us find the right process for you
Request a coverage decision(collapsed)
Request a medical appeal(collapsed)
Results for > Medical care benefits or coverage
How to ask for medical coverage or request an appeal for a service
If you have a Medicare Advantage plan and you’re requesting a medical service, you’ll ask for a coverage decision (organization determination).
Results for > Prescription drug benefits or coverage
How to ask for prescription drug coverage or request an appeal
If you're requesting coverage of a medication under your Medicare Advantage or prescription drug plan, or if you’re asking for advance approval to fill a prescription, you'll ask for a coverage decision or exception request (determination).
Request a drug coverage decision (determination)(collapsed)
Requesting a drug appeal(collapsed)
Results for > 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.
Results for > Home health, skilled nursing facility or rehabilitation facility care
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.
When you'll hear back
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.
Results for > Complaint about quality of care or any other services
You can file a complaint about the quality of care or other services you get from us or from a Medicare provider.
How to submit a complaint (grievance)(collapsed)
Results for > All other topics or concerns
- If you have questions about the status of your request or complaint, call us.
- PDP members should call us at 1-877-238-6211 (TTY: 711), 7 days a week, 24 hours a day.
- Medicare Advantage members should call us at 1-800-282-5366 (TTY: 711), 7 days a week, 8 a.m. to 8 p.m.
- If you'd like to get a total for the number of appeals, grievances and exceptions filed with Aetna Medicare, call us at 1-800-282-5366 (TTY: 711), 7 days a week, 8 a.m. to 8 p.m.
Aetna Medicare is a PDP, HMO, PPO plan with a Medicare contract. Our SNPs also have contracts with State Medicaid programs. Enrollment in our plans depends on contract renewal.
See Evidence of Coverage for a complete description of plan benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by service area.
Aetna Medicare’s pharmacy network offers limited access to pharmacies with preferred cost sharing in: Suburban NY and TX; and Rural ME, NY, UT and WY. The lower costs advertised in our plan materials for these pharmacies may not be available at the pharmacy you use. For up-to-date information about our network pharmacies, including pharmacies with preferred cost sharing, members please call the number on your ID card, non-members please call 1-855-338-7027 (TTY: 711) or consult the online pharmacy directory at http://www.aetnamedicare.com/pharmacyhelp.