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.
Choose a topic to help us find the right process for you
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Request a coverage decision
You can call us, fax or mail your information.
Call: 1-800-245-1206 (TTY: 711), Monday to Friday, 8 AM to 8 PM.
Fax: 1-859-455-8650
Mail: Aetna Medicare Precertification Unit
P.O. Box 14079
Lexington, KY 40512-4079When 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 authorization appeal online
Submit a claim denial appeal online
Print an authorization appeal form
Print a claim denial appeal form
Fax: 1-724-741-4953
Mail: Aetna Medicare Part C Appeals & Grievances
PO Box 14067
Lexington, KY 40512If 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.
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).
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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 407423. You can also request coverage online.
You'll leave Aetna Medicare and go to the CMS website if you select the link below.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:
Mail: Aetna Medicare Part D Appeals & Grievances
PO Box 14579
Lexington, KY 40512You'll leave Aetna Medicare and go to the CMS website if you select the link below.
Download the Medicare program appeals formFax: 1-724-741-4954
Phone: 1-877-235-3755, Monday to Friday, 8 AM to 8 PM.
Expedited Phone Line: 1-877-235-3755 (TTY: 711), seven days a week, 24 hours a day
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).
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.
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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 AM to 8 PM.
You can also submit your complaint online.
Submit a complaint onlineYou 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 formTo 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 at 1-800-282-5366 (TTY: 711), Monday to Friday, 8 AM to 8 PM.
- 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 AM to 8 PM.
You can contact the Medicare Beneficiary Ombudsman (MBO) for help with a complaint, grievance or information request.
We're here to help
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Y0001_4006_10829 Approved 10/27/2017
Page last updated: Wed Aug 12 14:19:29 UTC 2020