Grievances & Appeals

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Coverage Decisions, Exceptions, Appeals and Complaints

 
We know it's important to have medical services and prescription drug coverage. 

As a member of one of our Medicare Advantage or Prescription Drug plans, you have the right to the following:

• Ask for coverage of a medical service or prescription drug. This can include those services and prescription drugs that we must approve in advance (also called “prior authorization”). In some cases, we may allow exceptions for coverage that is normally not covered.

  • If you have a Part C plan and you’re requesting a medical service, you’ll ask for an Organization Determination.
  • If your Part C plan includes prescription drug coverage or you have a Part D plan and you’re requesting a medication, you’ll ask for a Coverage Determination.

• File an appeal if your Organization Determination or Coverage Determination request is denied.
• File a complaint about the quality of care or other services you get from a Medicare provider.
• Appoint someone else (an appointed representative) to act on your behalf. For more information on how to appoint a representative, please refer to “How to Appoint a Representative”.

Frequently Asked Questions



How do I submit a Part C Organization Determination to request coverage for medical services?

You, your doctor, or representative can call, fax or mail your request to us.
Phone and Fax: Our contact information (phone number, address, and fax number) is available to you on the contact us page of this website and in the plan’s Evidence of Coverage (EOC). You can also call us using the number on the back of your ID card.
Fax: 855-788-3994
Mail: Part C Appeal & Grievance
P.O. Box 7776
London, KY 40742-7776

What can I do if my Part C Organization Determination request is denied?

If we don't cover or pay for your benefits or services, you, your doctor, or representative can appeal our decision. You need to submit your name, address, member number and reason for appealing. Any evidence you want us to review, such as medical records, doctor’s letter or other information that explains why you need the item or services, can be submitted. Call your doctor if you need this information .

For a standard appeal, mail or fax deliver your appeal to:

Part C Appeal & Grievance
P.O. Box 7776
London, KY 40742-7776
Fax: 855-788-3994

For an expedited appeal:

Phone: 866-613-4977
Fax: 855-788-3994

How do I submit a Coverage Determination for my prescription drug?

If you’re a member, you can request an exception if a drug has a prior authorization, quantity limit or step therapy. Not an Aetna member yet? You can call 1-877-988-3589 (TTY: 711) to get answers to your questions.

You, your doctor, or representative can submit the online form, or download the form for your type of plan, and fax or mail deliver your request to us. You may also call us.

Submit online form

If we don't currently cover your medication or you need prior authorization before we cover your medication, you can ask for this coverage by completing one of the forms below:
First Health Part D Prescription Drug Plans
Medicare Advantage Plans

Fax: 1-800-639-9158

Mail: Part D - Medicare Appeals & Grievances
P.O. Box 7773
London, KY 40742
Phone: Our phone numbers (standard and expedited) are on the contact us page of this website, in the plan’s Evidence of Coverage (EOC), and on your ID card.

What can I do if my Coverage Determination is denied?

If we deny your Prescription Drug request, you can appeal our decision. You, your doctor, or representative can submit the online form, or download the form below and mail or fax deliver it to us.

Submit online form

Download: Request for Redetermination of Medicare Prescription Drug Denial

Fax: 1-800-535-4047

Mail: Part D Medicare Appeals & Grievances – Redeterminations
P.O. Box 7773
London, KY 40742

If your request needs to be “Expedited” you can call or fax us.
Expedited Phone Line: 1-800-536-6167
Expedited Fax Number: 1-800-535-4047

What can I do if I have a complaint (also called a “grievance”)?

If you have a complaint about your medical or pharmacy coverage, you, your representative , or your doctor can call, fax, or write to us.

For Part C Appeal and Grievance:

Phone : Our phone numbers are on the contact us page of the website, in the plan’s Evidence of Coverage (EOC), and on the back of your Member ID card.
Mail: Part C Appeal & Grievance
P.O. Box 7776
London, KY 40742-7776

Fax #: 855-788-3994

For Part D Appeal & Grievance:

Phone : Our phone numbers are on the contact us page of the website, in the plan’s Evidence of Coverage (EOC), and on the back of your Member ID card.
Fax #: 1-800-535-4047
Mail: Part D Appeal & Grievance
P.O. Box 7773
London, KY 40742

You can contact the Office of the Medicare Ombudsman for help with a complaint, grievance, or information request. To learn more, visit https://www.medicare.gov/claims-and-appeals/medicare-rights/get-help/ombudsman.html.

How long does it take to get a decision?

You can request either a “Standard” or “Expedited” (fast) decision process. If your health requires it, you can ask us to give you a "fast coverage decision". A "fast coverage decision" is called an "expedited coverage determination" or an “expedited organization determination”. When we give you our decision, we will use the "standard" deadlines unless we have agreed to use the "fast" deadlines. We will respond to your request no later than the below timeframes.

Request for an Coventry Medicare Advantage Plan (Part C) Organization Determination 
Standard Process = Pre-service: 14 days     Claims: 60 days
Expedited Process = Pre-service: 72 hours     Claims: n/a

Request for a Coventry Medicare Advantage Plan (Part C) Organization Determination Denial
Standard Process = Pre-service: 30 days Claims: 60 days
Expedited Process = Pre-service: 72 hours Claims: n/a

Request for Prescription Drug Coverage Determination
Standard Process= 72 hours
Expedited Process= 24 hours

Request for Redetermination for a Coventry Medicare Prescription Drug Denial

Standard Process= 7 days
Expedited Process= 72 hours

Coventry Medicare Advantage Plan Grievance
Standard Process= 30 days
Expedited Process= 24 hours

Prescription Drug Plan Grievance
Standard Process= 30 days
Expedited Process= 24 hours



If you'd like to get an aggregate number of appeals, grievances and exceptions filed with Coventry or to ask about the status of a previously submitted grievance, appeal or exception, contact us.


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Y0022_PDPCCP_2013_4006_1202b Approved
CMS Approved Date: 02/08/2013
Page Last Updated: 12/08/2015

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Aetna Medicare is a PDP, HMO, PPO plan with a Medicare contract. Our SNPs also have contracts with State Medicaid programs. Enrollment in our plans depends on contract renewal.