Request for an Appeal of an Aetna Medicare Advantage (Part C) Plan Authorization Denial

Because Aetna Medicare (or one of our delegates) denied your request for coverage of a medical item or service or a Medicare Part B prescription drug, you have the right to ask us for an appeal of our decision. You have 65 calendar days from the date of your denial to ask us for an appeal. This form may be sent to us by mail or fax:

Have questions?
Call Member Services at the number on your ID card.

Representation documentation for appeal requests made by someone other than enrollee or the enrollee's doctor: Your doctor may ask us for an appeal on your behalf. If you want another individual (such as a family member or friend) to request an appeal for you, that individual must be your representative. That person may already be your representative if you've filed paperwork with your state, such as Power of Attorney papers. For more information on appointing a representative, contact your plan or 1-800-Medicare 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.

Y0001_NR_3032_7794b_2020_C 03/2020

Page Last Updated: December 2024