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Coverage decisions, appeals and grievances

Process for Medicare coverage requests, appeals and complaints

We want to be your first stop if you have a concern about your coverage or care. So, if you do, please call us at the number on your member ID card.

 

As an Allina Health | Aetna Medicare member, you have the right to:

 

  • Ask for coverage of a medical service or prescription drug. In some cases, we may allow exceptions for a service or drug that is normally not covered.
  • File an appeal if your request is denied. An appeal is a formal way of asking us to review and change a coverage decision we made.
  • File a complaint about the quality of care or other services you get from us or from a Medicare provider.

There are different steps to take based on the type of request you have.

Choose a topic to help us find the right process for you

How to ask for medical coverage or request an appeal for a service

 

If you have a Medicare Advantage plan and you're requesting a medical service, you'll ask for a coverage decision (organization determination). If you receive a denial and are requesting an appeal, you'll "request a medical appeal"

 

You can call us, fax or mail your information.

 

Call: 1-855-577-4436 ${tty}, Monday to Friday, 8 AM to 8 PM.

 

Fax: 1-859-455-8650

 

Mail: Allina Health | Aetna Medicare Precertification Unit

P.O. Box 14079

Lexington, KY 40512-4079

 

When you'll hear back

 

We'll get back to you within:

 

  • 14 days if you submit your request before the service is performed (72 hours if you request a faster decision)
  • 30 days if you submit your request after the service (there's no option for a faster decision after service)

If we don't cover or pay for your medical benefits or services, you can appeal our decision.

If we don't cover or pay for your medical benefits or services (Medicare Part C), you can appeal our decision. To do so, submit the online form, or fax or mail your request to us.

 

Submit an authorization appeal online

 

Submit a claim denial appeal online

 

Print an authorization appeal form

 

Print a claim denial appeal form

 

Fax: 1-724-741-4953

 

Mail: Allina Health | Aetna Medicare Part C Appeals

PO Box 14067

Lexington, KY 40512

 

An expedited appeal can only be requested for a service that has not been completed.

If you or your doctor believe the standard review timeframe could seriously harm your life, health, or ability to regain maximum function, you can ask for an expedited (fast) decision. If you do not obtain your doctor's support for an expedited appeal, we will decide if your case requires a fast decision. A claim denial is not eligible for an expedited (fast) decision.

 

If you need a faster (expedited) decision, you can call or fax us.

 

  • Expedited phone line: 1-833-570-6671 ${tty}, Monday to Friday, 8 AM to 8 PM.
  • Expedited fax line: 1-724-741-4958

 

When you’ll hear back

 

We’ll get back to you within:

 

  • 30 days if you submit your appeal before the service is performed (72 hours if you request a faster decision) (Only applies to service not yet received)
  • 60 days after a claim denial (there’s no option for a faster decision)

You can contact the Medicare Beneficiary Ombudsman (MBO) for help with a complaint, grievance or information request.

 

Learn more about the ombudsman

 

 

For Quality Improvement Organization (QIO)

 

Inpatient hospital discharge

During your inpatient hospital stay you’ll get a notice called “An Important Message from Medicare about Your Rights”. You’ll have to sign it to show that you understand your rights as a hospital patient, including:

 

  • Your right to receive Medicare-covered services during and after your hospital stay, as ordered by your doctor. This includes the right to know what these services are, who will pay for them and where you can get them.
  • Your right to be involved in any decisions about your hospital stay, and know who will pay for it.
  • Where to report any concerns you have about quality of your hospital care.
  • Your right to appeal your discharge decision if you think you're being discharged from the hospital too soon.

 

Home health, skilled nursing facility or rehabilitation facility care

You have the right to keep getting your covered services for as long as the care is needed to diagnose and treat your illness or injury if you’re getting:

 

  • Home health care
  • Skilled nursing care as a patient in a skilled nursing facility
  • Rehabilitation care as an outpatient at a Medicare-approved Comprehensive Outpatient Rehabilitation Facility (CORF). (Usually, this means you’re getting treatment for an illness or accident, or you're recovering from a major operation.)

You’ll receive a "Notice of Medicare Non-Coverage (NOMNC)" in writing at least 2 days before we decide it’s time to stop covering your care. When your coverage for that care ends, we'll stop paying our share of the cost for your care. You can ask to change this decision so you're able to continue coverage.

 

 

Level 1 Appeal

 

You must contact the Quality Improvement Organization to start your appeal no later than noon of the day after you receive the written notice telling you when we will stop covering your care.

 

If you miss the deadline for contacting the Quality Improvement Organization about your appeal, you can make your appeal directly to us instead. (Please refer to above directions regarding filing an expedited appeal)

 

When you'll hear back from the Quality Improvement Organization (QIO)

 

Within 2 days the reviewers will tell you their decision.

 

 

Level 2 Appeal

 

You may ask for this review immediately but must ask within 60 days after the day the Quality Improvement Organization said no to your Level 1 Appeal.

 

When you'll hear back

 

The Quality Improvement Organization will respond to you as soon as possible, but no later than 14 days after receiving your request for a second review.

 

You will receive directions from the Quality Improvement Organization (QIO) regarding additional appeal options.

How to ask for prescription drug coverage or request an appeal

 

If you're requesting coverage of a medication under your Medicare Advantage plan, or if you’re asking for advance approval to fill a prescription, you'll ask for a coverage decision or exception request (determination).

 

Your doctor can request coverage on your behalf

 

Your doctor can call us at 1-800-414-2386 ${tty}, 7 days a week, 8 AM to 8 PM, to request drug coverage. Or your doctor can fax a completed, signed form with a statement of medical necessity to 1-800-408-2386.

 

Prescription Drug Prior Authorization and Exception Request Forms for Prescribers

 

Or you can use one of these methods

 

You or your appointed representative can call us at 1-800-414-2386 ${tty}, 7 days a week, 8 AM to 8 PM, to request drug coverage.

 

If you prefer, you can print and complete the appropriate forms below. Forms can be sent to us in one of three ways:

 

1. By fax: 1-800-408-2386

 

2. By mail:

 

Allina Health | Aetna Medicare

Coverage Determinations

P.O. Box 7773

London, KY 40742

 

3. You can also request coverage online.

 

Request coverage online

 

Print our drug coverage determination request form

 

Print the hospice drug coverage request under Part D form

 

You'll leave Allina Health | Aetna Medicare and go to the CMS website if you select the link below.

 

Print the Medicare program drug coverage determination request form

 

When you’ll hear back

 

We’ll get back to you within 72 hours (24 hours if you request a faster decision).

 

If your request is denied, you can file an appeal.

If we deny your prescription drug request, you can appeal our decision. You can file your standard or expedited appeal using one of the below:

 

Online:

 

Appeal a denial online

 

Mail:

Allina Health | Aetna Medicare Part D Appeals and Grievances

PO Box 14579

Lexington, KY 40512

 

Download our appeals form

 

Download our appeals form – Spanish

 

You'll leave Allina Health | Aetna Medicare and go to the CMS website if you select the link below.

 

Download the Medicare program appeals form

 

Fax: 1-724-741-4954

 

Phone: 1-833-620-8809 ${tty}, 7 days a week, 24 hours a day

 

When you’ll hear back

 

We’ll get back to you within 7 days (72 hours if you request a faster decision).

During your inpatient hospital stay you’ll get a notice called “An Important Message from Medicare about Your Rights”. You’ll have to sign it to show that you understand your rights as a hospital patient, including:

 

  • Your right to receive Medicare-covered services during and after your hospital stay, as ordered by your doctor. This includes the right to know what these services are, who will pay for them and where you can get them.
  • Your right to be involved in any decisions about your hospital stay, and know who will pay for it.
  • Where to report any concerns you have about quality of your hospital care.
  • Your right to appeal your discharge decision if you think you're being discharged from the hospital too soon.

You have the right to keep getting your covered services for as long as the care is needed to diagnose and treat your illness or injury if you’re getting:

 

  • Home health care
  • Skilled nursing care as a patient in a skilled nursing facility
  • Rehabilitation care as an outpatient at a Medicare-approved Comprehensive Outpatient Rehabilitation Facility (CORF). (Usually, this means you’re getting treatment for an illness or accident, or you're recovering from a major operation.)

You’ll receive a "Notice of Medicare Non-Coverage (NOMNC)" in writing at least 2 days before we decide it’s time to stop covering your care. When your coverage for that care ends, we'll stop paying our share of the cost for your care. You can ask to change this decision so you're able to continue coverage.

 

Level 1 Appeal

 

You must contact the Quality Improvement Organization to start your appeal no later than noon of the day after you receive the written notice telling you when we will stop covering your care.

 

If you miss the deadline for contacting the Quality Improvement Organization about your appeal, you can make your appeal directly to us instead. (Please refer to above directions regarding filing an expedited appeal)

 

When you'll hear back from the Quality Improvement Organization (QIO)

 

Within 2 days the reviewers will tell you their decision.

 

Level 2 Appeal

 

You may ask for this review immediately but must ask within 60 days after the day the Quality Improvement Organization said no to your Level 1 Appeal.

 

When you'll hear back

 

The Quality Improvement Organization will respond to you as soon as possible, but no later than 14 days after receiving your request for a second review.

 

You will receive directions from the Quality Improvement Organization (QIO) regarding additional appeal options.

You can file a complaint about the quality of care or other services you get from us or from a Medicare provider.

 

How to submit a complaint (Grievance)

 

Call us

 

  • For complaints about medical care: Call us at ${membersPhone} ${tty}, ${membersHours}.
  • For complaints about Part D prescription drugs: Call us at 1-833-620-8809 ${tty}, 7 days a week, 24 hours a day.

 

You can fax or mail us your complaint. You can download our form or use your own paper. Be sure to sign your complaint and use the fax number or address shown on the form.

 

Print our complaint form

 

You can also submit your complaint online.

 

Submit a complaint online

 

To send a complaint to Medicare, complete the Medicare Electronic Complaint form.

 

When you’ll hear back

 

We’ll get back to you within 30 days (24 hours if you request a faster response).

Helpful Information

 

If you have questions about the status of your request or complaint, call us.

 

  • Pharmacy questions call 1-866-471-9374 ${tty}, 7 days a week, 24 hours a day
  • Medical questions call ${membersPhone} ${tty}, ${membersHours}

If you'd like to get a total for the number of appeals, grievances and exceptions filed with Allina Health | Aetna Medicare, call us at ${membersPhone} ${tty}, ${membersHours}.