Medicare Advantage Choices | Available Plans | Prescription Coverage | What Sets Aetna Apart? | Eligibility | Enrollment | Grievance

The Grievance Process

Our grievance process is designed to address member coverage issues, complaints and problems. If you have a coverage issue or other problem, please call Member Services at the toll-free number on your ID card. If Member Services is unable to resolve your issue, complaint or problem to your satisfaction, you can request that your concern be forwarded to the regional grievance unit or you may write to the Grievance and Appeals address listed in the Evidence of Coverage you received.

Grievances can be filed orally or in writing and must be filed within 60 days of the event or incident. A quality of care grievance can be filed with Aetna or the Quality Improvement Organization (QIO). Grievances will be resolved as expeditiously as the case requires based on the enrollee's health status, but no later than 30 days from the date of receipt. Aetna or the enrollee can take up to a 14 day extension. If Aetna initiates an extension, the enrollee must be notified in writing and the letter must provide the reason for the delay.

Aetna will track all oral and written grievances received, including the date received, type of grievance and final disposition of the grievance, and the date the enrollee was notified of the final outcome or resolution.

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Medicare Advantage Appeal Rights

As a member of the Aetna Golden Medicare Plan, the Aetna Golden Choice Plan or the Aetna Medicare Open Plan, you have the right to appeal any decision resulting in Aetna's failure to provide coverage for or pay for what you believe are covered benefits and services. These include:

1. Reimbursement for coverage of emergency or urgently needed services.
2. A denied claim for coverage of health care services that you believe should have been reimbursed by Aetna.
3. Coverage for an item or service that you have not received but which you believe should be covered.
4. Any decision to discharge you from the hospital if you believe it is too early to do so. (Note: In this case, a notice will be given to you with information about how to appeal to a Medicare Quality Improvement Organization (QIO). You will remain in the hospital while the QIO immediately reviews the decision. You will not be held liable for charges incurred during this period regardless of the outcome of the review. Refer to your Evidence of Coverage for the QIO in your area.)
5. Reductions or terminations of coverage for what you feel are medically necessary covered services.

Aetna has a Medicare Standard Appeals Process and a Medicare Expedited Appeals Process. Following is a general explanation of these important processes.

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Appointment of Representation

If you need assistance understanding or following the appeals or grievance process, you can get assistance from a friend, lawyer or someone else. There are groups such as legal aid services that can help you find a lawyer or give you free legal services, if you qualify.

• The individual can be a relative, provider, friend, or someone else. (Note: A physician may request an expedited appeal on your behalf without being appointed as your representative.)

If you would like to appoint a representative to assist you with the appeals or grievance process, please print, complete and sign the following CMS Appointment of Representative form (CMS-1696) and include it with your written request.

CMS Appointment of Representative form (CMS-1696) 

If you would like to initiate an appeal or grievance request, please print and complete this form   and fax or mail it to Aetna. If you feel your appeal needs to be handled expeditiously, you may also contact Aetna directly at the toll free number indicated in your Evidence of Coverage or on the back of your Member Identification Card.

Medicare Advantage Standard Appeals Process

Aetna must notify you in writing of any decision (partial or complete) to deny a claim or service. The notice must state the reasons for the denial and also must inform you of your right to a file an appeal. If you decide to proceed with the Medicare Standard Appeals Process, the following steps will occur:

1. You must submit a written request for reconsideration to Aetna. Please refer to the Evidence of Coverage for the appropriate address and fax information. You must submit your written request within sixty (60) calendar days of the date of the notice of the adverse organization determination. The sixty (60) day limit may be extended for good cause. Please include in your written request the reason why you could not file within the sixty (60) day timeframe.
2. Aetna will conduct the reconsideration and notify you in writing of the decision, using the following timeframes:
   • Request for Services. If the appeal is for a denied service, we must notify you of the reconsidered decision as expeditiously as your health requires, but no later than thirty (30) calendar days from receipt of your request. We may extend this timeframe by up to fourteen (14) calendar days if you request the extension or if we need additional information and the extension of time benefits you. If you disagree with our decision not to expedite, you have the right to request an expedited grievance. Aetna's written notification will provide instructions and the timeframes associated to the expedited grievance process.
   • Request for Payment. If the appeal is for a denied claim, Aetna must notify you of the reconsidered decision no later than sixty (60) calendar days after receiving your request for a reconsidered decision. Our reconsidered decision will be made by a person(s) not involved in the initial decision. You may present or submit relevant facts and/or additional evidence for review either in person or in writing to Aetna.
3. If we decide fully in your favor on a request for a service, we must provide or authorize the requested service within thirty (30) calendar days of the date we received your request for reconsideration. If we decide fully in your favor on a request for payment, we must make the requested payment within sixty (60) calendar days of the date we received your request for reconsideration.
4. If we decide to uphold the original adverse decision, either in whole or in part, we will automatically forward the entire file to the Maximus Federal Services for a new and impartial review. Maximus Federal Services is CMS's independent contractor for appeal reviews involving Medicare Advantage managed care plans. We must send Maximus Federal Services the file within thirty (30) calendar days of a request for services and within sixty (60) calendar days of a request for payment.
5. For cases submitted for review, Maximus Federal Services will make a reconsidered decision and notify you in writing of the reasons for the decision. If Maximus Federal Services upholds our decision, their notice will inform you of your right to a hearing before an Administrative Law Judge of the Social Security Administration.
6. If Maximus Federal Services decides in your favor, we must:
   • Authorize the disputed service within 72 hours from the date we receive notice from Maximus Federal Services reversing the decision; or
   • Provide the disputed service as expeditiously as your health condition requires, but no later than fourteen (14) calendar days from the date we receive notice from Maximus Federal Services reversing the decision; or
   • Pay for the disputed service within thirty (30) calendar days from the date we receive notice from Maximus Federal Services reversing the decision.
7. If Maximus Federal Services does not rule fully in your favor, there are further levels of appeal:
   • If the amount in dispute meets the established CMS dollar threshold, you may request a hearing before an Administrative Law Judge (ALJ) by submitting a written request to Aetna, Maximus Federal Services or the Social Security Administration. The request must be sent within sixty (60) calendar days of the date of Maximus Federal Services notice that the reconsidered decision was not in your favor. This sixty (60) day notice may be extended for good cause.
   • Either you or Aetna may request a review of an ALJ decision by the Medicare Appeals Council (MAC), which may either review the decision or decline review.
   • If the amount in dispute meets the established CMS dollar threshold, either you or Aetna may request that a decision made by the MAC, or the ALJ, if the MAC has declined review, be reviewed by a Federal district court.
   • Any initial or reconsidered decision made by Aetna, Maximus Federal Services, the ALJ, or the MAC can be reopened by any party (a) within twelve months, (b) within four (4) years for just cause, or (c) at any time for clerical correction of an error or in cases of fraud.

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Medicare Advantage Expedited Appeals Process

1. You may file a request for an expedited appeal for the denial of coverage for services you believe you need and where you feel that applying the standard reconsideration process could jeopardize your health. If Aetna decides that the timeframe for the standard process could seriously jeopardize your life, health or ability to regain maximum function, the review of your request will be expedited. If you disagree with a decision to discharge you from the hospital, see the next section.
2. A physician may file a request for an expedited appeal on your behalf. Aetna must provide an expedited reconsideration if the physician indicates that applying the standard reconsideration process could seriously jeopardize your life, health or ability to regain maximum function.
3. Aetna will notify you and/or the physician of its decision as expeditiously as your health condition requires but no later than 72 hours after receiving the request. We may extend this timeframe by up to fourteen (14) calendar days if you request the extension or if we need additional information, and the extension of time benefits you.
   • If you disagree with our decision not to expedite, you have the right to request an expedited grievance. Aetna's written notification will provide instructions and the timeframes associated to the expedited grievance process.
4. To request an expedited appeal, you may call 1-800-932-2159. You may fax, mail or hand deliver your written request to Aetna. If you write, the 72-hour review timeframe will not begin until your request is received. Please refer to your Evidence of Coverage for the appropriate address and fax information.
5. If Aetna determines that your request is not time-sensitive, where your health is not seriously jeopardized, Aetna will notify you verbally and in writing and will automatically begin processing your request under the standard reconsideration process.
   • If you disagree and believe the review should be expedited, you may file a grievance with Aetna. The written notice will include instructions on how to file an expedited grievance.

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Number of Grievances and Appeals

If you would like to learn how many grievances and appeals Aetna processed, please contact Member Services, 7 days a week, from 8 a.m. - 8 p.m., at 1-800-282-5366 (TTY/TDD 1-800-628-3323).

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Contact Us
Questions? Call us at 1-800-529-5586 (TTY/TDD 1-800-628-3323), Monday - Friday, 8:00 a.m. - 6:00 p.m.

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Updated 2/2008