Directory - Aetna Medicare

3. If we decide fully in your favor on a request for aservice, we must provide or authorize the requestedservice within thirty (30) calendar days of the datewe received your request for reconsideration. If wedecide fully in your favor on a request for payment,we must make the requested payment within sixty(60) calendar days of the date we received yourrequest for reconsideration.4. If we decide to uphold the original adversedecision, either in whole or in part, we willautomatically forward the entire file to theMAXIMUS Federal Services Inc. for a new andimpartial review. MAXIMUS Federal Services Inc. isthe Centers for Medicare & Medicaid Services’independent contractor for appeal reviews involvingMedicare Advantage managed care plans. We mustsend MAXIMUS Federal Services Inc. the file withinthirty (30) calendar days of a request for servicesand within sixty (60) calendar days of a request forpayment.5. For cases submitted for review, MAXIMUS FederalServices Inc. will make a reconsidered decision andnotify you in writing of the reasons for the decision.If MAXIMUS Federal Services Inc. upholds ourdecision, their notice will inform you of your rightto a hearing before an Administrative Law Judge ofthe Social Security Administration. If MAXIMUSFederal Services Inc. decides in your favor, we must:■ Authorize the disputed service within 72 hoursfrom the date we receive notice from MAXIMUSFederal Services Inc. reversing the decision; or■ Provide the disputed service as expeditiously asyour health condition requires, but no later thanfourteen (14) calendar days from the date wereceive notice from MAXIMUS Federal ServicesInc. reversing the decision; or■ Pay for the disputed service within thirty (30)calendar days from the date we receive noticefrom MAXIMUS Federal Services Inc. reversingthe decision.If MAXIMUS Federal Services Inc. does not rule fullyin your favor, there are further levels of appeal:6. If there is at least $110 in controversy, you mayrequest a hearing before an Administrative LawJudge (ALJ) by submitting a written request toAetna, MAXIMUS Federal Services Inc. or the entityspecified in MAXIMUS Federal Services Inc.reconsideration notice. The request must be sentwithin sixty (60) calendar days of the date ofMAXIMUS Federal Services Inc. notice that thereconsidered decision was not in your favor. Thissixty (60) day notice may be extended for goodcause.7. Either you or Aetna may request a review of anALJ’s decision by the Medicare Appeals Council(MAC), which may either review the decision ordecline review.8. If the amount involved is $1090 or more, either youor Aetna may request that a decision made by theMAC, or the ALJ, if the MAC has declined review,be reviewed by a federal district court.9. Any initial or reconsidered decision made by Aetna,MAXIMUS Federal Services Inc., the ALJ or the DABcan be reopened by any party (a) within twelve (12)months, (b) within four (4) years for just cause or(c) at any time for clerical correction of an error orin cases of fraud.Medicare Advantage Expedited AppealsProcess1. You may file a request for an expedited appeal forthe denial of coverage for services you believe youneed and where you feel that applying thestandard reconsideration process could jeopardizeyour health. If Aetna decides that the time framefor the standard process could seriously jeopardizeyour life, health or ability to regain maximumfunction, the review of your request will beexpedited. If you disagree with a decision todischarge you from the hospital, see the nextsection.2. A physician may file a request for an expeditedappeal on your behalf. Aetna must provide anexpedited reconsideration if the physician indicatesthat applying the standard reconsideration processcould seriously jeopardize your life, health or abilityto regain maximum function.X