[PDF] Directory - Aetna Medicare

■ We do not encourage denials of coverage. In fact,our utilization review staff is trained to focus on therisks of members not adequately using certainservices.Where such use is appropriate, our UtilizationReview/Patient Management staff uses nationallyrecognized guidelines and resources, such as TheMilliman Care Guidelines ® to guide theprecertification, concurrent review and retrospectivereview processes. To the extent certain UtilizationReview/Patient Management functions are delegatedto IDSs, IPAs or other provider groups ("Delegates"),such Delegates utilize criteria that they deemappropriate. Utilization Review/Patient Managementpolicies may be modified to comply with applicablestate law.Only medical directors make decisions denyingcoverage for services for reasons of medical necessity.Coverage denial letters for such decisions delineateany unmet criteria, standards and guidelines, andinform the provider and you of the appeal process.For more information concerning utilizationmanagement, you may request a free copy of thecriteria we use to make specific coverage decisions bycontacting Member Services.You may also visitwww.aetna.com/about/cov_det_policies.html tofind our Clinical Policy Bulletins and some utilizationreview policies. Doctors or health care professionalswho have questions about your coverage can write orcall our Patient Management department. The addressand phone number are on your ID card.Concurrent ReviewThe concurrent review process assesses the necessityfor continued stay, level of care, and quality of care formembers receiving inpatient services. All inpatientservices extending beyond the initial certificationperiod will require concurrent review.Discharge PlanningDischarge planning may be initiated at any stage ofthe patient management process and beginsimmediately upon identification of post-dischargeneeds during precertification or concurrent review. Thedischarge plan may include initiation of a variety ofservices/benefits to be utilized by you upon dischargefrom an inpatient stay.Retrospective Record ReviewThe purpose of retrospective review is toretrospectively analyze potential quality and utilizationissues, initiate appropriate follow-up action based onquality or utilization issues, and review all appeals ofinpatient concurrent review decisions for coverage ofhealth care services. Aetna's effort to manage theservices provided to you includes the retrospectivereview of claims submitted for payment, and ofmedical records submitted for potential quality andutilization concerns.Medicare Advantage Grievance ProcessAetna is committed to addressing members' coverageissues, complaints and problems. If you have acoverage issue or other problem, call Member Servicesat the toll-free number on your ID card. You can alsocontact Member Services through the Internet atwww.aetnamedicare.com. If Member Services isunable to resolve your issue to your satisfaction, youcan request that your concern be forwarded to theMedicare grievance unit, or you may write to theaddress in your area listed in the Evidence ofCoverage.If your issue is regarding a denial of a claim ordenial of coverage for a health care service,please refer to the Medicare Advantage AppealsRights below for more information.Medicare Advantage Appeal RightsAs a member of an Aetna Medicare Advantage plan,you have the right to appeal any decision resulting inAetna's failure to provide coverage for or pay for whatyou believe are covered benefits and services. Theseinclude:■ Reimbursement for coverage of emergency orurgently needed services, or out-of-area dialysisservices.■ A denied claim for coverage of health care servicesthat you believe should have been reimbursed byAetna.VIII