Do you want to file an appeal with Aetna Medicare? If you want to do that, of course you need to know the steps and also everything related to appealing with Aetna Medicare. You are able to read about it here where the information is based on the Aetna Medicare website.
Several Rights as Aetna Medicare Member
Do you have a concern about your coverage or care? If so, Aetna Medicare can be your first stop and you are able to call them at the number that can be found on your member ID card.
If you are a member of Aetna Medicare, you have several rights as you can read below.
- You are able to ask for coverage of a medical service or prescription drug. In some cases, exceptions may be permitted by Aetna Medicare for a service or drug that is normally not covered.
- You are able to file an appeal if your request is denied. What is an appeal? It is a formal way of asking Aetna Medicare to review and change a coverage decision Aetna Medicare made.
- You are able to file a complaint about the quality of care or other services you get from Aetna Medicare or from a Medicare provider.
Asking For Medical Coverage or Requesting an Appeal for a Service
Do you have a Medicare Advantage plan and you are requesting coverage of a medical service? If so, you will ask for a coverage decision. However, in case you get a denial and are requesting an appeal, you will ‘request a medical appeal’.
To request a coverage decision, you are able to call Aetna Medicare, fax or mail your information.
- If you want to call, you can call at 1-800-245-1206 (TTY:711), Monday to Friday, 8 am to 8 pm.
- If you want to fax, it can be done to 1-859-455-8650.
- If you want to mail it, it can be sent to:
Aetna Medicare Precertification Unit
P.O. Box 14079
Lexington, KY 40512-4079
Aetna Medicare will get back to you within 14 days if you submit your request before the service is done (72 hours if you request a faster decision). Aetna Medicare will get back to you within 60 days if you submit your request after the service.
Let’s say that Aetna does not cover or pay for your medical benefits or services (Medicare Part C). If so, you are able to appeal their decision where it can be done by submitting the online form or fax or mail your request to Aetna Medicare.
- Here is the link to request for an appeal of an Aetna Medicare Advantage (Part C) Plan Authorization Denial: https://member.aetna.com/MemberPublic/featureRouter/forms?page=appealsPartCForm
- Here is the link to request for an appeal of an Aetna Medicare Advantage (Part C) Plan Claim Denial: https://member.aetna.com/MemberPublic/featureRouter/forms?page=appealsPartCClaimForm
If you want to get a printable form or Aetna Medicare contact information, you have to choose whether your plan was obtained as an individual Medicare Advantage member or through a Medicare Advantage Employer Group in the Select Plan field.
If your plan was obtained as an individual Medicare Advantage member, you have to choose a state, county and plan to discover printable forms for claim denial appeal or authorization appeal. Choosing those can be done at this page here. Then, there will appear the links to the appeal forms. You are able to fax it to 1-724-741-4953. If you want to mail it, you can send it to:
Aetna Medicare Part C Appeals
Po Box 14067
Lexington, KY 40512
Aetna Medicare will get back to you within 30 days if you submit your appeal before the service is done. If you request a faster decision, it will be 72 hours. Aetna Medicare will get back to you within 60 days after a claim denial and there is no option for a faster decision.
If your plan was obtained as an Employer Group Medicare Advantage, you have to use the forms below.
- A claim denial appeal form: https://www.aetnamedicare.com/documents/group/2022/appeals/aetna_GRP_medicare_appeal_post.pdf
- An authorization appeal form: https://www.aetnamedicare.com/documents/group/2022/appeals/aetna_GRP_medicare_appeal_form.pdf.
You can fax it to 1-724-741-4953. If you want to mail it, it can be sent to:
Aetna Medicare Part C Appeals
PO Box 14067
Lexington, KY 40512
If you need a faster decision, you are able to call at 1-888-267-2637 from Monday to Friday at 8 am to 9 pm ET and for fax, 1-724-741-4958.
Requesting a Drug Appeal with Aetna Medicare
Medical Coverage with Drug (MAPD)
Let’s say that Aetna Medicare denies your prescription drug request. If it happens, you are able to appeal their decision by filing your standard or expedited appeal.
If you want to appeal a denial online, you have to access this here. By using this online form, you can submit it online.
If you want to appeal a denial by mail, you can send it to:
Aetna Medicare Part D Appeals
PO Box 14579
Lexington, KY 40512
The appeals form for being sent by mail can be accessed at here where you have to choose your state, county and plan name. If you want to fax it, you can do it to 1-724-741-4954.
Aetna Medicare will inform you again within 7 days or if you request a faster decision, it can be 72 hours.
Home Health Care, Skilled Nursing Facility or Rehabilitation Facility Care Appealing
You need to keep getting your covered services for as long as the care is needed to diagnose and treat your illness or injury if you are getting home health care, skilled nursing care as a patient in a skilled nursing facility, or rehabilitation care as an outpatient at a Medicare-approved Comprehensive Outpatient Rehabilitation Facility.
At least 2 days before Aetna Medicare decides it’s time to stop covering your care, you will get a ‘Notice of Medicare Non-Coverage (NOMNC)’ in writing. When your coverage for the care ends, Aetna Medicare will stop paying their share of the cost for your care. If it happens, you are able to ask to change this decision so that you can continue coverage.
- Level 1 Appeal
You are able to contact the Quality Improvement Organization if you want to start your appeal no later than noon of the day after you get the notice which tells you when they will stop covering your care. Let’s say that you miss the deadline to contact the Quality Improvement Organization about your appeal. If so, you are able to make your appeal directly to Aetna Medicare. - Level 2 Appeal
You may be able to ask for this review soon, but you need to ask within 60 days after the day the Quality Improvement Organization said no to your Level 1 Appeal.
