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    • Medicare appeals

    Appeals for non-participating providers

     

    Non-participating Medicare Advantage providers can appeal decisions regarding payment. This appeal process applies to all of our medical benefits plans. (State requirements take precedence when they differ from our policy.)

     

    Medicare non-contracted provider appeal process (PDF)

     

    Medicare member payment appeal post service  (PDF)

     

    If you have a dispute around a payment you would have received under original Medicare please send your dispute, documentation of what original Medicare would have paid, applicable copies of medical records, and an explanation of why you disagree with the decision, to:

     

    Medicare Provider Disputes

    P.O, Box 14067

    Lexington, KY 40512

     

    Payment appeals for Contracted provider requests

     

    If you have a dispute around the rate used for payment you have received, please visit Health Care Professional Dispute and Appeal Process.

     

    Hospital discharge appeals

     

    All Medicare patients can appeal an inpatient hospital discharge decision. This includes members in our Medicare Advantage plans. This process is called a Quality Improvement Organization (QIO) review. The QIO in the state in which services are provided reviews the hospital discharge decision. The result is binding (final).


    If a Medicare member asks for this review before leaving the hospital:

     

    • The QIO will contact hospital staff to get medical records for review.
    • The hospital may be asked to share clinical information with a member of Aetna's Medicare Advantage team to complete the CMS-required Detailed Notice of Discharge.

    If a Medicare member asks for the review after midnight on the day of discharge or after leaving the hospital, we will use the Medicare expedited grievance and appeal process.


    For more information regarding the appeal process, please call 1-866-269-3692 (TTY: 711)

     

    Hospital discharge appeal notices (CMS website)

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