Aetna Medicare Plans - Complaint and Appeal Form

IMPORTANT INFORMATION ABOUT YOUR APPEAL RIGHTSFor more information about your appeal rights, call your plan or see your Evidence of CoverageAny issue involvingMedicare Advantage Plan CoverageThere Are Three Kinds of Appeals You CanFile:Any issue involvingPrescription Drug Plan CoverageThere Are Three Kinds of Appeals You CanFile:Standard (30 days) – If the denial is for a service,you can ask for a standard appeal. We must giveyou a decision no later than 30 days after we getyour appeal. (We may extend this time by up to 14days if you request an extension, or if we needadditional information and the extension benefitsyou.)Standard (7 Days) – If the denial is for coverageof a prescription drug, you can ask for a standardappeal. We must give you a decision no later than7 days after it gets your appeal request.Standard (60 days) – If the denial is for a deniedclaim, you can ask for a standard appeal.We must give you a decision no later than 60 daysafter we get your appeal.Standard (7 Days) – If the denial is for payment ofa prescription drug, you can ask for a standardappeal. We must give you a decision no later than7 days after we get your appeal.Expedited (72-hour review) - You can ask for anexpedited appeal if you or your doctor believe thatyour health could be seriously harmed by waitingtoo long for a decision. We must decide on anexpedited appeal no later than 72 hours after weget your appeal. (We may extend this time by up to14 days if you request an extension, or if we needadditional information and the extension benefitsyou.)• If any doctor asks for an expedited appealfor you, or supports you in asking for one,and the doctor indicates that waiting for 30days could seriously harm your health, wewill automatically give you an expeditedappeal.• If you ask for an expedited appeal withoutsupport from a doctor, we will decide if yourhealth requires an expedited appeal. If wedo not give you an expedited appeal, we willdecide your appeal within 30 days.Expedited (72-hour review) – You can ask for anexpedited appeal if you or your doctor believe thatyour health could be seriously harmed by waitingtoo long for a decision. We must decide on anexpedited appeal no later than 72 hours after weget your appeal.• If any doctor asks for an expedited appealfor you, or supports you in asking for one,and the doctor indicates that waiting for 7days could seriously harm your health, wewill automatically give you an expeditedappeal.• If you ask for an expedited appeal withoutsupport from a doctor, we will decide if yourhealth requires an expedited appeal. If wedo not give you an expedited appeal, we willdecide your appeal within 7 days.• Your appeal will not be expedited if you’vealready received the drug you areappealing.M0001_S5810_7B_70135 (01/07) - 3 -