Complaints, coverage decisions and appeals

A coverage decision is the decision (approval or denial) we make about:

• Your benefits and coverage  

• The amount we will pay for your medical care or treatment or services

How to ask for a coverage decision

You, your representative or your doctor can ask for a coverage decision: 

• By phone: Just call 1-844-362-0934 (TTY: 711). We’re here 8 AM to 8 PM, 7 days a week.

• In writing: You can also send us a completed prior authorization form (PDF) by:

   

  • Fax: 1-855-883-9555 

  • Mail: Aetna Assure Premier Plus (HMO D-SNP)

    7400 W. Campus Rd 

    New Albany, OH 43054

Not sure if we cover your service? Just ask before you receive the service. 

How to appoint a representative

Would you like someone else to act for you? This means they can ask for a coverage decision for you. Some examples are: 

• Friends

• Relatives or family members 

• Lawyers

Just complete, download and print the online appointment of representative form. You can choose English, Spanish or large print. This form gives permission to the person you choose to act for you. You’ll need to give us a copy of the signed form. 

Some legal groups will give you free legal services if you qualify. You don’t have to use a lawyer or representative to ask for a coverage decision. You can do this yourself.

You have the right to ask for an appeal or “reconsideration” if we denied services or payment you believe we should have covered. You can do so within 60 days from the date of the coverage determination letter.  

How to ask for an appeal 

Step 1: Contact us. You can ask for an appeal: 

• By phone: Call us at 1-844-362-0934 (TTY: 711) to ask for a medical appeal. You can call 8 AM to 8 PM, 7 days a week. 

• Online: Complete the online complaints and appeals form. 

• In writing:  You can also write to ask for a medical appeal by: 

   

  • Fax: 1-855-883-9555

  • Mail: Aetna Assure Premier Plus (HMO D-SNP) 

    Attn: Grievances & Appeals 

    PO Box 818070 

    Cleveland, OH 44181

Fast appeals (expedited reconsideration) 

You can also ask for a fast appeal if you or your doctor thinks the standard appeals process could put your life, health or function at risk. If we agree, the review of that request will be fast. You, your doctor or your representative can ask for a fast appeal. 

Step 2: Once we receive your appeal, we’ll review it to see if we need to do a fast review.  

• If your appeal doesn’t meet the criteria for fast review: We’ll write to you within 2 calendar days of receiving it. We’ll also transfer the appeal to a standard appeals timeline. 

• If your appeal meets the criteria for fast review: We’ll let you know the decision as fast as your condition requires it. This won’t be later than 72 hours after receiving your appeal (plus 14 days if it needs an extension). 

Standard appeals 

A special team reviews the appeal to see if we made the right decision:  

• For authorization decisions: We’ll write to you with the results no later than 30 calendar days from the date we received the appeal. 

• For Part B drugs: We’ll write to you with the results no later than 7 calendar days from the date we received the appeal. 

• For payment decisions (Medicare covered drugs or services): We’ll write to you with the results no later than 60 calendar days from the date we received the appeal.  

• For payment decisions (Medicaid covered drugs or services): We’ll write to you with the results no later than 30 calendar days from the date we received the appeal.  

Extensions 

• For authorization decisions: We may take a 14-day extension if we need more time to gather your medical records. You can also ask for an extension if you need more time to share proof that supports your appeal. We’ll write to you if we need an extension.   

• For Part B drugs: We will not take an extension for Part B drug appeals. 

• For payment decisions (Medicare and Medicaid): We will not take an extension for payment decision appeals..

How to appoint a representative 

Would you like someone else to act for you? This means they can ask for an appeal for you. Some examples are: 

• Friends 

• Relatives or family members 

• Lawyers 

Just complete, download and print the online appointment of representative form. You can choose English, Spanish or large print. This form gives permission to the person you choose to act for you. You’ll need to give us a copy of the signed form.  

Some legal groups will give you free legal services if you qualify. You don’t have to use a lawyer or representative to ask for a medical appeal. You can do this yourself. 

Additional appeal options

Once you have completed the internal appeal, you have access to request an external review with the Independent Utilization Review Organization (IURO) and New Jersey State Fair Hearings. You can:

• Request an external (IURO) appeal, wait until it is completed, and choose to pursue a State Fair Hearing if the outcome was not in your favor;

• Request an external (IURO) appeal and a State Fair Hearing at the same time; or

• Request a State Fair Hearing without requesting an external (IURO) appeal.

State Fair Hearing

You may ask for a State Fair Hearing only after you have received a decision on your internal appeal. You must request a State Fair Hearing in writing within one-hundred-twenty (120) days of the date of the Appeal Decision letter from your internal appeal.

At the State Fair Hearing, you may represent yourself, or you may legally authorize someone else to represent you. You must ask for a State Fair Hearing in writing by contacting DMAHS at the following address:

State of New Jersey Division of Medical Assistance and Health Services

Fair Hearing Unit

P.O. Box 712

Trenton, NJ 08625-0712

If your appeal was based on a decision to reduce, suspend, or stop an ongoing service or a course of treatment, and you file for a Medicaid State Fair Hearing, you have the right to request to have your services continue while your appeal is pending. You must ask, in writing, for your services to continue:

• Within ten (10) calendar days of the date of the Appeal Decision letter (if you choose to request a State Fair Hearing immediately following your Internal Appeal);

• Within ten (10) calendar days of the date on the letter informing you of the outcome of your External (IURO) Appeal, (if you chose to request an External/IURO Appeal before requesting a State Fair Hearing);

• On or before the final day of the previously approved authorization for the services in question, whichever is later.

You can call Member Services at 1-844-362-0934 (TTY: 711), 8 AM to 8 PM, 7 days a week if you have questions.

External Independent Utilization Review Organization (IURO)

You can request a review by an Independent Utilization Review Organization (IURO).  To request that the IURO review your appeal, you can request a review in writing within 60 days of the Appeal Decision letter:

You can complete your application and submit all required documents online at https://njihcap.maximus.com

If unable to apply electronically, the completed appeal form can be returned to Maximus by fax or mail as set forth below.

 Fax:      585-425-5296

 Mail:   Maximus Federal – NJ IHCAP

3750 Monroe Avenue, Suite 705

Pittsford, NY 14534

Questions about the application process can be directed to Maximus Federal by calling 888-866-6205 or e-mailing Stateappealseast@maximus.com. 

Although you have 60 days to file an appeal to the IURO, if you are receiving these services and want your services to continue automatically during the IURO appeal, you must request your appeal on or before the final day of the previously approved authorization, or within 10 calendar days of the date of the Appeal Decision letter, whichever is later.  If you do not request your appeal within this timeframe, the services will not continue during the appeal.

Please note: There are some services that the IURO will not review. If the Appeal Decision letter you receive about the outcome of your appeal does not include information about your option to request an External (IURO) review, this is probably the reason.

However, if you have questions about your options, you can call Member Services at 1-844-362-0934 (TTY: 711).

A coverage decision is the decision (approval or denial) we make about: 

• Your benefits and coverage  

• Whether to provide or pay for a prescription drug, as well as the amount paid 

How to ask for a coverage decision 

Step 1: Contact us. You, your representative or your doctor can ask for a coverage decision or exception: 

• By phone: Call 1-844-362-0934 (TTY: 711). We’re here 8 AM to 8 PM, 7 days a week. 

• Online: Complete the online request for Medicare prescription drug coverage determination form.  

• In writing: You can also write to ask for a coverage decision or exception. Just download and print the request for Medicare prescription drug coverage determination form — English (PDF) | Spanish (PDF). Or ask Member Services to mail it to you. Then, send your completed form to us by:  

   

  • Fax: 1-844-814-2260 

  • Mail: Aetna Assure Premier Plus (HMO D-SNP)  
    

    Attn: Part D Coverage Determination 
    

    Pharmacy Department 

    4750 S. 44^th Place Suite 150

    Phoenix, AZ 85040-4015

Step 2: We’ll make a coverage decision. You have the right to a timely coverage decision. If we aren’t able to provide one, we’ll forward your case to an Independent Review Entity. Otherwise, we’ll review and process:  

• Standard coverage decisions: as fast as your health condition requires, but no later than 72 hours from receiving your request 

• Fast (expedited) coverage decisions: as fast as your health condition requires, but no later than 24 hours from receiving your request

Part D reimbursement decisions: This is when you ask us to pay you back for a drug you paid for. We’ll let you know our decision within 14 calendar days from receiving your request. If we approve, we’ll make payment to you within 14 calendar days after we receive your request. You can file a fast (expedited) complaint if we don’t let you know our decision within these time frames. 

Approvals and denials 

If we agreed to cover part or all of your request, we’ll let you know. Then, we’ll provide the drug or payment. If we didn’t agree to cover part or all of your request, we’ll write to explain the reasons. We’ll also explain how you can appeal this decision. Here are some common reasons we deny requests: 

• The drug isn’t on the formulary (Drug List).  

• We determined the drug isn’t medically necessary. 

• You haven’t tried a similar drug listed on the Drug List. 

• You haven’t met the requirement for prior authorization (permission). 

Exceptions 

If a drug is not covered in the way you would like it to be covered, you can ask us to make an “exception.”  Some medications have rules you need to follow before we cover them. These include:

• Prior authorization – You or your doctor needs approval from us before we cover the drug.
• Quantity limits – For certain drugs, we limit the amount you can get.
• Step therapy – We require you to try another drug first before we cover your drug.

You and your provider can ask us to make an exception to one of our coverage rules. This includes requesting an exception to a prior authorization, quantity limit or step therapy rule.

You can review our Drug List information to see the list of covered drugs and any rules for the drugs we cover. 

You’ll need to get a supporting statement from your prescriber to ask for an exception. Once you do, we’ll review, process and let you know about: 

• Standard exception requests: after receiving your prescriber’s statement and as fast as your health condition requires, but no later than 72 hours from receiving your prescriber's supporting statement

• Expedited exception requests: after receiving your prescriber’s statement and as fast as your health condition requires, but no later than 24 hours from receiving your prescriber's supporting statement

   

How to appoint a representative

Would you like someone else to act for you? This means they can ask for an appeal for you. Some examples are: 

• Friends 

• Relatives or family members 

• Lawyers 

Just complete, download and print the online appointment of representative form. You can choose English, Spanish or large print. This form gives permission to the person you choose to act for you. You’ll need to give us a copy of the signed form.  

Some legal groups will give you free legal services if you qualify. You don’t have to use a lawyer or representative to file a complaint. You can do this yourself.  

You have the right to ask for an appeal or “redetermination” if we denied services or payment you believe we should have covered. You can do so within 60 days from the date of the denial letter. You can also submit an appeal after this time frame if you have good cause. You’ll need to include a supporting statement from your doctor. This should provide the medical reasons you need this drug. 

How to ask for an appeal 

Step 1: Contact us. You can ask for an appeal: 

• By phone: Call us at 1-844-362-0934 (TTY: 711) to ask for an appeal. You can call 8 AM to 8 PM, 7 days a week.  

• Online: Complete the online request for redetermination of Medicare prescription drug denial form.  

• In writing: You can also write to ask for an appeal. Just send us your completed request for redetermination of Medicare prescription drug denial  — English (PDF) | Spanish (PDF) by: 

   

  • Fax: 1-844-814-2260

  • Mail: Aetna Assure Premier Plus (HMO D-SNP)  
    Attn: Part D Appeals
    Pharmacy Department 
    4750 S. 44th Place Suite 150
    Phoenix, AZ 85040-4015 

No matter how you choose to appeal, remember to include your doctor’s supporting statement. 

Fast appeals (expedited redetermination) 

You can ask for a fast appeal if you believe the standard appeals process could put your life, health or function at risk.  

You, your doctor or your representative can ask for a fast appeal by phone or in writing. Your doctor or other prescriber can also call or write with support for your request for a fast appeal. 

We’ll expedite your appeal if your doctor or prescriber believes the standard time frame for making a decision could put your life, health or function at risk. 

Step 2: Once we receive your appeal:  

• A special team will review your request to see if we made the right decision. They’ll collect support and information from you or your doctors. 

• A new doctor will review your case.  

• We’ll send your case to an Independent Review Entity (IRE) for review if we don’t make a decision and let you and your doctor know within the time frame. If this happens, we’ll let you know. 

You have the right to a timely appeal. You can file a fast complaint if we don’t let you know our decision within the time frame. 

If we deny your appeal and you disagree, you can submit a reconsideration request (Level 2 appeal) to the IRE. If this happens, we’ll send information about how to do this.  

Level 1: Redetermination by Aetna Assure Premier Plus (HMO D-SNP) 

Standard appeal 

After receiving your appeal, we’ll gather information about the denial of the Part D prescription drug from: 

• You or your representative 

• Your prescribing doctor 

Then, a medical expert will review your appeal. We’ll call you as fast as your health requires, but no later than 7 calendar days from receiving the appeal. 

Fast (expedited) appeal 

You or your doctor can ask for a fast appeal if you or your doctor believes the standard time frame will cause you serious harm. We’ll call you as fast as your health requires, but no later than 72 hours from receiving the appeal. 

If we don’t agree that your appeal needs a fast review, we’ll let you know we’re using the standard time frame.  

Level 2: Redetermination by the IRE 

Standard appeal 

You can send your appeal to the Centers for Medicare & Medicaid Services (CMS)-contracted IRE if we uphold the original denial for your prescription drug. You must do so within 60 calendar days of our notice. The IRE will review your appeal and decide within 7 calendar days. 

Fast (expedited) appeal 

You can file a fast appeal with the IRE if you or your doctor believes the standard time frame will cause you serious harm. The IRE will review your appeal, and: 

• If they don’t agree your appeal needs a fast review: They’ll let you know they’re using the standard time frame.  

• If they agree your appeal needs a fast review: They’ll let you know their decision within 72 hours from the time they received your appeal. 

Level 3: Hearing with administrative law judge (ALJ) 

Standard appeal 

You can ask for a hearing with the ALJ if the: 

• IRE decision goes against you  

• Amount in dispute meets the requirements 

Follow the instructions on the notice from the IRE. 

Fast (expedited) appeal 

Same as standard appeal. 

Level 4: Review by Medicare Appeals Council (MAC) 

Standard appeal 

You can appeal to the MAC if the ALJ decision goes against you. MAC is within the Department of Health and Human Services. The MAC oversees the ALJ decisions. 

Fast (expedited) appeal 

Same as standard appeal. 

Level 5: Federal district judge 

Standard appeal 

You may be able to go on to the next level of the review process if you don’t accept the decision. It depends on your situation. If the reviewer says no to your appeal, the notice tells you whether you can go to the next level of appeal. If the rules allow you to go on and you choose to continue your appeal, the written notice also tells you: 

• Who to contact  

• What to do next  

Fast (expedited) appeal 

Same as standard appeal. 

How to appoint a representative 

Would you like someone else to act for you? This means they can ask for an appeal for you. Some examples are: 

• Friends 

• Relatives or family members 

• Lawyers 

Just complete, download and print the online appointment of representative form. You can choose English, Spanish or large print. This form gives permission to the person you choose to act for you. You’ll need to give us a copy of the signed form.  

Some legal groups will give you free legal services if you qualify. You don’t have to use a lawyer or representative to file a complaint. You can do this yourself.