Non-Part D complaints, coverage decisions & appeals

Aetna is committed to resolving complaints and appeals promptly and fairly. Contracted providers and Aetna work together to settle disputes according to contractual agreements without disrupting services to enrollees. Providers are informed of dispute processes through the Provider Handbook, newsletters, training, orientation, and our website. If a provider disagrees with a decision, including claim disputes, they may submit a Provider Dispute Form with supporting documentation to the Provider Services Manager. This form is available online, by fax, or mail.

Non-contracting providers may request a claim appeal if payment for a Medicare-covered service is denied. Appeals must include a Waiver of Liability form and be submitted within 65 days of the remittance advice. If a payment dispute persists, providers may request an Independent Review Entity (IRE) review within 180 days. The IRE will issue a decision within 65 days, and if overturned, Aetna will implement the decision within 30 days.

Providers, whether in-network or out-of-network, may file complaints about policies or administrative functions verbally or in writing. The Appeals and Grievance Manager coordinates these complaints and sends an acknowledgment within three business days. Complaints requiring further research are reviewed by the Grievance Committee, which includes a provider of similar specialty for clinical issues. Resolutions are issued within 30 days, followed by written notification within the turn-around-time.

Enrollees also have the right to file complaints or appeals. Complaints address issues such as quality of care, wait times, or customer service and can be submitted orally or in writing. Most complaints are resolved within 30 days, with possible extensions of 14 days if necessary. Fast complaints, or expedited grievances, are handled within 24 hours when health concerns require urgent action. Enrollees receive oral and written notifications of resolutions, including instructions for further review options.

Appeals, also called reconsiderations, may be filed within 65 days of a denial notice. Appeals can be submitted by phone, fax, or mail, and may involve services denied for payment, authorization, or timeliness. Standard appeals are resolved within 14 calendar days for service requests and 65 days for payment decisions. Fast appeals are available when delays could jeopardize health and are processed within 24 hours. There are multiple levels of appeal, including reviews by Aetna, the IRE, Illinois Department of Healthcare and Family Services, External Independent Review, Administrative Law Judge, Medicare Appeals Council, and Federal District Court.

Enrollees may appoint a representative, such as a friend, relative, lawyer, or provider, by completing an Appointment of Representative (AOR) form available on the CMS website or by calling Member Services. If the representative is a treating provider or holds power of attorney, the form is not required.

For assistance, enrollees and providers can contact Member Services at 1-866-600-2139 (TTY: 711), available from 8AM to 8PM EST, 7 days a week. Appeals and complaints may also be mailed to:

Aetna Duals Provider Appeals
PO Box 14727
Lexington, KY 40512-4727
Fax: 959-876-7983

For more information regarding Non-Part D complaints, coverage decisions, and appeals please view our provider handbook.