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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)

Legal notices

Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates (Aetna).

Health benefits and health insurance plans contain exclusions and limitations.