Coverage Decisions, Appeals and Complaints - Aetna Medicare

http://www.aetnamedicare.com/help_and_resources/downloadable_forms.jsp?tab=4 orby contacting Member Services at the toll free number on your ID card for copies.Aetna Medicare Grievance & Appeals UnitP.O. Box 14067Lexington, KY 40512Fax Number all States: 1-866-604-7092Aetna will conduct the reconsideration and notify you in writing of the determination,using the following timeframes:a. Request for Services. If the appeal is for a denied service, we must notify you ofthe reconsidered determination as expeditiously as your health requires, but nolater than thirty (30) calendar days from receipt of your request. We may extendthis timeframe by up to fourteen (14) calendar days if you request the extensionor if we need additional information and the extension of time benefits you. Ourreconsidered determination will be made by a person(s) not involved in the initialdetermination.b. If you disagree with our determination to extend the time frame, you have theright to request a “fast complaint” also known as an expedited grievance aboutour determination to take extra days. When you file a “fast” or expeditedgrievance, we will give you an answer to your grievance within 24 hours.c. Request for Payment. If the appeal is for a denied claim, Aetna must notify you ofthe reconsidered determination no later than sixty (60) calendar days afterreceiving your request for a reconsidered determination. Our reconsidereddetermination will be made by a person(s) not involved in the initialdetermination. You may present or submit relevant facts and/or additionalevidence for review either in person or in writing to Aetna.2. If we decide fully in your favor on a request for a service, we must provide orauthorize the requested service within thirty (30) calendar days of the date wereceived your request for appeal. If we extended the time needed to make ourdetermination, we will provide the coverage by the end of that extended period. Ifwe decide fully in your favor on a request for payment, we must make the requestedpayment within sixty (60) calendar days of the date we received your request forappeal.3. If we decide to uphold the original adverse determination, either in whole or in part, wewill automatically forward the entire file to an Independent Review Organizationdesignated by CMS for a new and impartial review. We must send the file to theIndependent Review Organization within thirty (30) calendar days of a request forservice and within sixty (60) calendar days of a request for payment.4. If we do not give you an answer by the deadline above (or by the end of the extendedtime period if we took extra days), we are required to send the request on to Level 2 ofthe appeals process where it will be review by an Independent Review Organizationdesignated by CMS.Y0001_M_OT_WB_10925 CMS Approved 10/04/2011