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.)
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.