[PDF] Directory - Aetna Medicare

■ Coverage for an item or service that you have notreceived but which you believe should be covered.Any decision to discharge you from the hospital ifyou believe it is too early to do so. (Note: In thiscase, a notice will be given to you with informationabout how to appeal to a Medicare QualityImprovement Organization (QIO). You will remain inthe hospital while the QIO immediately reviews thedecision. You will not be held liable for chargesincurred during this period regardless of theoutcome of the review. Refer to your Evidence ofCoverage for the QIO in your area.)■ Reduction or terminations of coverage for whatyou feel are medically necessary covered services.Aetna has a Medicare Advantage Standard AppealsProcess and a Medicare Advantage Expedited AppealsProcess. Following is a general explanation of theseimportant processes.Assistance With AppealsIf you need assistance understanding or following theMedicare Advantage Appeals Process, you can getassistance from a friend, lawyer or someone else.There are also groups, such as legal aid services thatcan help you find a lawyer or give you free legalservices, if you qualify.You may appoint an individual to act as yourauthorized representative by following the stepsbelow:■ The individual can be a relative, provider, friend orsomeone else. (Note: A physician may request anexpedited appeal on your behalf without beingappointed as your representative.)■ Give us your name, your Medicare claim number,Medicare identification number and a writtenstatement that appoints an individual as yourrepresentative. For example, the followingstatement will suffice as an appointment ofrepresentative: "I {your name} appoint {name ofrepresentative} to act as my authorizedrepresentative in requesting an appeal from Aetnaregarding denial of coverage for requested servicesand/or payment."■ You must sign and date the statement.■■Your representative must also sign and date thestatement unless he/she is an attorney.Include the signed statement with your request.Medicare Advantage Standard AppealsProcessAetna must notify you in writing of any decision(partial or complete) to deny a claim or service. Thenotice must state the reasons for the denial and alsomust inform you of your right to file an appeal. If youdecide to proceed with the Medicare AdvantageStandard Appeals Process, the following steps willoccur:1. You must submit a written request forreconsideration to Aetna. Please refer to theEvidence of Coverage for the appropriate addressin your area. You must submit your written requestwithin sixty (60) calendar days of the date of thenotice of the initial decision. The sixty (60) day limitmay be extended for good cause. Please include inyour written request the reason you could not filewithin the sixty (60) day time frame.2. Aetna will conduct the reconsideration and notifyyou in writing of the decision, using the followingtime frames:■ Request for Services: If the appeal is for a deniedservice, we must notify you of the reconsidereddecision as expeditiously as your health requires,but no later than thirty (30) calendar days fromreceipt of your request. We may extend thistime frame by up to fourteen (14) calendar daysif you request the extension or if we needadditional information and the extension of timebenefits you.■ Request for Payment: If the appeal is for adenied claim, Aetna must notify you of thereconsidered decision no later than sixty (60)calendar days after receiving your request for areconsidered decision.Our reconsidered decision will be made by aperson(s) not involved in the initial decision. Youmay present or submit relevant facts and/oradditional evidence for review either in person or inwriting to Aetna.www.aetna.comIX