Coverage Decisions, Appeals and Grievances

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

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

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).

Request a coverage decision

You can call us, fax or mail your information.

Call: 1-800-245-1206 (TTY: 711), 7 days a week, 8 a.m. to 8 p.m.

Fax: 1-859-455-8650

Mail: Aetna Medicare Precertification Unit
P.O. Box 14079
Lexington, KY 40512-4079

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)
60 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.

Request a medical appeal

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

Submit an appeal online

Print an appeal form

Fax: 1-724-741-4953

Mail: Aetna Medicare Part C Appeals & Grievances
PO Box 14067
Lexington, KY 40512

If you need a faster (expedited) decision, you can call or fax us.

Expedited phone line: 1-800-932-2159 (TTY: 711), 7 days a week, 8 a.m. to 8 p.m.
Expedited fax line: 1-724-741-4958

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)
60 days after a claim denial (there’s no option for a faster decision)

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): Your doctor can request coverage on your behalf

Your doctor can call us at 1-800-414-2386 (TTY: 711), 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.

Prescription Drug Prior Authorization & Exception Request Forms for Prescribers

Or you can use one of these methods

You or your appointed representative can call us at 1-800-414-2386 (TTY: 711) 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.

Request coverage online

Print our drug coverage determination request form

Print the hospice drug coverage request under Part D form

You'll leave Aetna Medicare and go to the CMS website if you select the link below.

Print the Medicare program drug coverage determination request form

When you’ll hear back

We’ll get back to you within 72 hours (24 hours if you request a faster decision).

If your request is denied, you can file an appeal.
Requesting a drug appeal: 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:

Appeal a denial online

Mail: Aetna Medicare Part D Appeals & Grievances
PO Box 14579
Lexington, KY 40512

Download our appeals form

You'll leave Aetna Medicare and go to the CMS website if you select the link below.
Download the Medicare program appeals form

Fax: 1-724-741-4954

Phone: 1-877-235-3755, 7 days a week, 24 hours a day

Expedited Phone Line: 1-877-235-3755 (TTY: 711), seven days a week, 24 hours a day

When you’ll hear back

We’ll get back to you within 7 days (72 hours if you request a faster decision).

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)

Call us

For complaints about medical care: Call us at 1-800-282-5366 (TTY: 711), Monday to Friday, 8 a.m. to 8 p.m.
For complaints about Part D prescription drugs: Call us at 1-877-238-6211 (TTY: 711), 7 days a week, 24 hours a day.

You can also submit your complaint online.
Submit a complaint online

You can fax or mail us your complaint. You can download our form or use your own paper. Be sure to sign your complaint and use the fax number or address shown on the form.
Print our complaint form

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 (24 hours if you request a faster response).

Results for > All other topics or concerns

Helpful Information

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), Monday to Friday, 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). Calls are answered seven days a week from 8 a.m. to 8 p.m.

You can contact the Medicare Beneficiary Ombudsman (MBO) for help with a complaint, grievance or information request.

Learn more about the ombudsman

Coverage Decisions, Appeals and Grievances

Process for Medicare coverage requests, appeals & complaints

Choose a topic to help us find the right process for you

Results for > Medical care benefits or coverage

How to ask for medical coverage or request an appeal for a service

Request a coverage decision

Request a medical appeal

Results for > Prescription drug benefits or coverage

How to ask for prescription drug coverage or request an appeal

Request a drug coverage decision (determination)

Requesting a drug appeal

Results for > Inpatient hospital discharge

Results for > Home health, skilled nursing facility or rehabilitation facility care

Level 1 Appeal

When you'll hear back

Level 2 Appeal

When you'll hear back

Results for > Complaint about quality of care or any other services

How to submit a complaint (grievance)

Results for > All other topics or concerns

Helpful Information

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