[PDF] Directory - Aetna Medicare

3. Aetna will notify you and/or the physician of itsdecision as expeditiously as your health conditionrequires, but no later than 72 hours after receivingthe request. We may extend this time frame by upto fourteen (14) calendar days if you request theextension or if we need additional information, andthe extension of time benefits you.4. To request an expedited appeal, you may call1-800-932-2159. You may fax, mail or handdeliver your written request to Aetna. If you write,the 72-hour review time will not begin until yourrequest is received. Please call us for fax/deliveryinformation.5. If Aetna determines that your request is not timesensitive,where your health is not seriouslyjeopardized, Aetna will notify you verbally and inwriting and will automatically begin processingyour request under the standard reconsiderationprocess. If you disagree and believe the reviewshould be expedited, you may file a expeditedgrievance with Aetna. The written notice willinclude instructions on how to file a grievance.Hospital DischargesWhen you are first admitted to the hospital, you willreceive a document entitled, "An Important Messagefrom Medicare". Please read this document carefully. Itwill describe your rights if you believe you are beingasked to leave the hospital too soon. You have theright to request a review by a Quality ImprovementOrganization (QIO) of any discharge decision. If yourequest the review by noon of the first workday afteryou receive the discharge decision, you do not have topay for your hospital care until the QIO makes itsdecision.If you ask for immediate review by the QIO, you willbe entitled to QIO process instead of the MedicareAdvantage appeals process. If you choose to utilizeyour Medicare Advantage appeal rights, you wouldfollow the process described above.Quality-of-Care ComplaintsYou also have the right to complain about the qualityof medical services provided by network providers notmeeting professionally recognized standards of care bywriting to the QIO. The organization must review thecomplaint and inform you or your representative ofthe results of the investigation. They can provideinformation about its review time frames and the stepsinvolved in the process.Refer to your plan documents for the QIO in yourarea.Medicare Fast Track Appeal Procedure forSkilled Nursing Facility (SNF), HomeHealth Agency (HHA) or CertifiedOutpatient Rehabilitation FacilityTerminations (CORF)When these services are no longer covered by theplan, you will receive a written notice from theprovider at least 2 calendar days in advance oftermination of coverage. You or your authorizedrepresentative may be asked to sign and date thenotice, which outlines your rights. Signing the noticedoes not mean that you agree that coverage shouldend. It only means that the notice was provided.As explained in the advance written notice, you havethe right to request a fast appeal of the termination ofcoverage. The fast appeal will be performed by theQuality Improvement Organization (QIO). The advancewritten notice you receive from the provider will givethe name and telephone number of the QIO.When the QIO reviews your case, they will look at themedical information. The QIO will then give anopinion whether your coverage for services will beterminated on the date that has been provided in theadvance written notice. The QIO will make thisdecision within one full day after they receive theinformation needed to make a decision.If you ask for a fast track appeal from the QIO, theymust make the request according to the following:■ If the notice is given 2 days before the coverageends, the request should be made no later thannoon of the day after the provider gave the notice.www.aetna.comXI