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Coverage Decisions, Appeals and Grievances

Process for Medicare coverage requests, appeals & grievances

 

We want to be your first stop if you have a concern about your coverage or care. So if you do, please call us at the number on your member ID card. 
 

As ${anCompany} 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.

There are different steps to take based on the type of request you have.

Choose a topic to find the information you need

 

Are you a Special Needs Plan member?

 

Get information specific to Aetna Medicare Longevity and Supportive Care Health Plans (I-SNP) here.

 

Don’t have an I-SNP? Get your information below.

How to ask for medical coverage or request an appeal for a service

 

If you have a Medicare Advantage plan and you’re requesting coverage of a medical service, you’ll ask for a coverage decision (organization determination). If you receive a denial and are requesting an appeal, you’ll “request a medical appeal.” 

 

You can call us, fax or mail your information.

 

Call: 1-800-245-1206 ${tty}, ${hours}.

 

Fax: 1-859-455-8650

 

Mail: Aetna Medicare Precertification Unit
P.O. Box 14079
Lexington, KY 40512-4079

 

When 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)
  • 30 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.

If we don't cover or pay for your medical benefits or services (Medicare Part C), you can appeal our decision. To do so, submit the online form, or fax or mail your request to us.

Submit an authorization appeal online

Submit a claim denial appeal online


To get a printable form or our contact information, select whether your plan was obtained:
 

  • As an individual Medicare Advantage member 
  • Through a Medicare Advantage Employer Group in the Select Plan field


To 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 if you submit your appeal before the service is performed 
  • 72 hours if you request a faster decision (ONLY applies to services not yet received)
  • 60 days after a claim denial (there’s no option for a faster decision)

Your doctor can request coverage on your behalf.

 

Your doctor can call us at 1-800-414-2386 ${tty}, 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.

 

Or you can use one of these methods:

 

You or your appointed representative can call us at 1-800-414-2386 ${tty} 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 14088
Lexington, KY 40512

 

3. You can also request coverage online.

Request coverage online

 

Print our drug coverage determination request form

 

Print the hospice drug coverage request under Part D form

Your doctor can call Customer Care at 1-866-235-5660 ${tty}, 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 1-855-633-7673.

 

Coverage Determination Request Form


Or, you can complete and send a form yourself by fax, mail, or this website.

 

Download and print an English form

 

Download and print a Spanish form

 

Fax option:

1-855-633-7673

 

Mail option:

SilverScript Insurance Company

Appeals and Coverage Determination

P.O. Box 52000 MC109

Phoenix, AZ 85072-2000

 

Online option:

Request coverage online

 

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:

Appeal a denial online

 

Mail: Aetna Medicare Part D Appeals
PO Box 14579
Lexington, KY 40512

 

 

Choose your state, county and plan to find your appeals form.

 

Fax: 1-724-741-4954

 

 

Choose your state, county and plan below to find your phone number.

 

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). 

If we deny your prescription drug request, you can appeal our decision. You can file your standard or expedited appeal using one of the four methods below:

 

Online option:

Appeal a denial online


Phone option:

1-866-235-5660 ${tty}, 7 days a week, 24 hours a day

 

Or, download, print, and send completed forms by fax or mail:

 

 


Fax option:

1-855-633-7673

 

Mail option:

SilverScript Insurance Company

Appeals and Coverage Determination

P.O. Box 52000 MC109

Phoenix, AZ 85072-2000

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.  

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.

 

When you'll hear back

The Quality Improvement Organization will respond to you within 48 hours after receiving your request.

 

Level 2 Appeal

You may ask for this review immediately, but you need to 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.

 

If you have a complaint about the quality of care or any other services you received through your Medicare plan, you may file a grievance. A grievance is the Medicare term for a formal complaint. If your complaint involves a broker or agent, be sure to include the name of the person when filing your grievance.

 

Call us.

 

Medicare Advantage Plan

Call us at 1-800-282-5366 ${tty}

${hours}

 

Dual Eligible Special Needs Plan (D-SNP)

1-866-409-1221 ${tty}

${hours}

 

Aetna Medicare Prescription Drug Plan (PDP)*

1-866-235-5660 ${tty}

7 days a week, 24 hours a day

 

*Formerly known as SilverScript PDP

 


Other ways to file a complaint

 


You will receive a response within 30 days.

 

Helpful Information

 

  • If you have questions about the status of your request or complaint, call us at 1-800-282-5366 ${tty}, ${hours}.
  • If you'd like to get a total for the number of appeals, grievances and exceptions filed with ${company} Medicare, call us at 1-800-282-5366 ${tty}. Calls are answered ${hours}.
  • Members have a right to suggest changes in the plan’s policies and services, including our Member Rights and Responsibilities policy