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Coverage decisions, appeals and grievances

Process for Medicare coverage requests, appeals & complaints

Let us know if you have a concern about your coverage or care. Call us at the number on your member ID card to discuss your concern.

 

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 we deny your request. 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. 

If you're asking for a medical service under your Medicare Advantage plan, that's called a coverage decision (organization determination). 

You can call us, fax or mail your information.

 

Call: 1-800-245-1206 (TTY: 711), Monday to Friday, 8 AM to 8 PM ET.

 

Fax: 1-859-455-8650

 

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

 

When you’ll hear from us

 

We’ll get back to you within:

 

  • 14 days if you submit your request before you receive the service (72 hours if you request a faster decision)
  • 60 days if you submit your request after you receive the service (There’s no option for a faster decision after the 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 (under your Medicare Part C), you can appeal our decision. Submit the online form, fax or mail your request to us.

 

Submit an authorization appeal online

 

Submit a claim denial appeal online

 

Print an authorization appeal form (PDF)

 

Print a claim denial appeal form (PDF)

 

Fax: 1-724-741-4953

 

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

 

An expedited appeal can only be requested for a service that has not been completed. If you or your doctor believe the standard review timeframe could seriously harm your life, health, or ability to regain maximum function, you can ask for an expedited (fast) decision. If you do not obtain your doctor's support for an expedited appeal, we will decide if your case requires a fast decision. A claim denial is not eligible for an expedited (fast) decision.

 

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

 

  • Expedited phone line: 1-800-932-2159 (TTY: 711), Monday to Friday, 8 AM to 8 PM.
  • 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)

 

To send a complaint to Medicare, complete the Medicare Electronic Complaint form.

 

If you’re admitted to the hospital, you’ll get a notice called “An Important Message from Medicare about Your Rights”. You’ll have to sign it to show 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 two 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

 

We’ll tell you our decision within 48 hours.

 

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.

For complaints about medical care, you can:

 

  • Call us at the number on your member ID card, ${memberhours}

  • Submit your claim online

  • Fax or mail us your complaint (Download and print our complaint form (PDF). Be sure to sign your complaint and use the fax number or address shown on the form.)

 

When you’ll hear back

 

We’ll get back to you within 30 days (24 hours if you request a faster response). 

If you have questions about the status of your request or complaint, call us at1-800-282-5366 (TTY: 711), Monday to Friday, 8 AM to 8 PM.

 

If you'd like to get a total number of appeals, grievances and exceptions filed with Aetna Medicare, call us at1-800-282-5366 (TTY: 711). Calls are answered seven days a week from 8 AM to 8 PM.

 

You can contact Medicare

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

 

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