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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 ${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.
  • 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

Disclaimers

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.

This information is not a complete description of benefits. Call 1-855-335-1407 (TTY: 711) for more information.

Out-of-network/non-contracted providers are under no obligation to treat Aetna members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.  

Participating physicians, hospitals and other health care providers are independent contractors. They're neither agents nor employees of ${company}. The availability of any particular provider can't be guaranteed. Provider network make-up is subject to change.