If you have any questions, please feel free to call our Customer. , the claim number ending in A1, A2, A3, etc. To make a verbal complaint Call our Provider Service Center at 1-888-632-3862. With the enrollees written consent, the provider may make a complaint or request an appeal, an Independent Review Entity (IRE), an Administrative Law Judge (ALJ), a Medicare Appeals Council (MAC,) or a Judicial Review, as applicable. Related to aetna appeal form for providers aetna appeal forms Practitioner and Provider Compla int and Appeal Sequestrate Completion of this form is voluntary. You may mail your request to Aetna-Provider Resolution Team PO Box 14597. Last Name. File a complaint (grievance) Find out how to file a complaint (also called a "grievance") if you have a concern about the quality of care or other services you get from a Medicare provider. It is mandatory. All appeals must be submitted in writing, using the Aetna Provider Complaint and Appeal form. By mail. You also have the right to appeal an apparent lack of activity on a claim you submitted. California grievance forms. File a complaint (grievance) Find out how to file a complaint (also called a "grievance") if you have a concern about the quality of care or other services you get from a Medicare provider. To obtain a review, you or your authorized representative https member aetna com membersecure assets pdfs forms 68192 pdf Member Complaint and Appeal Form NOTE Completion. PO Box 14067. Thing makes the aetna provider complaint and file enter legally commit Because the society moats office work, the completion of paperwork other and more steals place online. The form is used to submit a request for a review and reconsideration of an adverse decision. Then, send it to Aetna Better Health of Maryland Attn Appeal and Grievance Department PO Box 81040 5801 Postal Road Cleveland, OH. Or use our National Fax Number 859-455-8650. Non-Par Provider Appeal Form. The aetna medicare provider complaint and appeal form isnt an exception. I, Print the name of the member who is receiving the service or supply. Discover other resources, information and more. NOTE Completion of this form is voluntary. Who may make a request If you want another individual (such as a family member, your doctor or friend) to request an appeal for you, that individual must be your representative. All appeals must be submitted in writing, using the Aetna Provider Complaint and Appeal form. On a scale of 1 to 5 how satisfied are you with the following. GR-67938-39 (7-22) MEDICARE -Aetna. Waiver of Liability (WOL) Form CMS 1500 Form. This includes Have questions Call Member Services at the number on your ID card. Aetna Better Health of Virginia Attn Appeal and Grievance Department PO Box 81040 5801 Postal Road Cleveland, OH 44181 Fax 1-866-669-2459 Providers should always refer to the provider manual and their contract for further details. 1-888-632-3862 (TTY 711) Medicare plans 1-800-624-0756 (TTY 711) Precertification Information Request Form. Are board certified (if applicable) Are in the same profession or in a similar specialty as normally manages the. to 4 p. With this Claims Adjustment Request Form include A copy of the EOPEOB(s) with claim(s) to be reviewed clearly circled. Legal notices. Cleveland, OH 44181. However, to make things easier for you, weve gathered a few of them together in one place. You can also file your grievance in writing via mail or fax at Aetna Better Health. Provide appropriate documentation to support your payment dispute (i. A complaint is about the quality of care you got or are getting. HEALTH LINK. You can call 1-844-362-0934 (TTY 711) between 8 AM and 5 PM, Monday through Friday. Print the name of the person who is being authorized to act on the members behalf. Sacramento, CA 94244-2430. TTY 651-296-2860. To contact an ombudsman, call Medicare and ask the representative to send your question or compliant to the ombudsman. You can also get free help by calling the Beneficiary Help Line at 1. To submit your request in writing you can print and mail the following form Member complaint and appeal form (PDF) You may appeal on your own. Prior Authorization please fill out the form to get authorization for services. Please submit the form within 365 days of receiving the service or item. Clinical appeals and complaints reviews are completed by health professionals who Hold an active, unrestricted license to practice medicine or another health profession. Cleveland, OH 44181. The Oregon Health Authority Ombudsman at 503-947-2346 or toll-free at 877-642-0450. Send us an email. Edit Provider complaint and appeal form. Download the PDF to learn how to administer Aetna plans and services effectively. To facilitate the handling of an issue, you should. TTY users should call 1-877-486-2048. Print the name of the person who is being authorized to act on the members behalf. View your claims, check your coverage, refill prescriptions and more. Sections 3 and 7 of the Standard OptionValue Plan brochure, or Sections 3 and 7 of the Consumer Option brochure explain how to file a claim with us. You can call 1-844-362-0934 (TTY 711) between 8 AM and 5 PM, Monday through Friday. You must be notified of the decision generally no later than 30 days after the plan gets the complaint. Section 1 Provide the following general information for all requests Typed responses are preferred. Medicare Provider Complaint and Appeal Request NOTE You must complete this form. You have 180 days from the date of the initial decision to submit a dispute. You can also submit a complaint directly to Medicare by using the Medicare Grievance Form. If the request does not qualify for a reconsideration as defined below, the request must be submitted in writing Medicare Advantage Aetna Provider Complaint and Appeal Form. There, you can use your Message Center or find the answers you need. Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance Company and its affiliates (Aetna). appropriate supporting documentation. You can also print out the complaint form, fill it out, and mail or fax it to the company Mail Aetna, PO Box 14463, Lexington, Kentucky. Materials and forms. 1-Requirements for Provider Claim Appeals (Part C Only) of the Parts-C-and-D-Enrollee-Grievances-Organization-Coverage-Determinations-and-Appeals-Guidance. This form is for your representative&39;s use in making suggestions or filing formal complaints or appeals regarding any aspect of the Aetna Health Plan or any physician, hospital, or other health care professional or health services organization providing your care as an enrolleemember of Aetna. File a complaint (grievance) Find out how to file a complaint (also called a "grievance") if you have a concern about the quality of care or other services you get from a Medicare provider. Complete this form to file a complaint about your Medicare health or drug plan. You may mail your request to Aetna-Provider Resolution Team PO Box 14597 Lexington, KY 40512 Or use our National Fax Number 859-455-8650. Medicare Advantage (MAMAPD) Members with Aetna Medicare Advantage (MA) and Aetna Medicare Advantage with Prescription Drug (MAPD) plans can log in or register for an account below. You can find this form, which is called the Medicare Provider Complaint and Appeal Request Form, by going to the forms for health care professionals page and scrolling to the Dispute and appeals drop-down menu. As an Aetna Medicare member, you can cannot ask for a coverage decision, file the appeal if get claim is denied, alternatively file a complaint about the quality of care you've received from a Medicare provider. Submit by following the instructions provided at the bottom of the form. You have the right to lodge a. Box 14094 Lexington, KY 40512-4094. The line is open 24 hours a day, 7 days a week. As an Aetna Medicare member, you can can ask for a coverage decision, file an appeal if your claim is denied, or file a complaint about the quality of care you've received from a Medicare provider. You may also ask us for an appeal through our website at www. Section 1 Provide the following general information for all requests Typed responses are preferred. Note If you are acting on the members behalf and have a signed authorization from the member or you are appealing a preauthorization denial and the services have yet to be rendered, use the member complaint and appeal form. The provider appeal process is for provider complaints that. A RETROSPECTIVE AUTHORIZATION DISPUTE to. Members can request that their provider or a caregiver, friend or family member file a grievance on their behalf. Make sure to include any information that will support your appeal. Medicare Complaint Form. You also can request a coverage decision or appeal in writing. Aetna Provider Complaint and Appeal Form. See below for some of the most common forms and important information as you work with us. You will need to provide your contact information, the member&39;s information, the reason for your complaint or appeal, and any supporting documents. Attn Grievance and Appeals Dept. Contact us at 1-800-282-5366, (TTY 711. On a scale of 1 to 5 how satisfied are you with the following. You have 180 days from the date of the initial decision to submit a dispute. Medicare Advantage (MAMAPD) Members with Aetna Medicare Advantage (MA) and Aetna Medicare Advantage with Prescription Drug (MAPD) plans can log in or register for an account below. Medicare medical and dental plans - 1-800-624-0756 (TTY 711) Non-Medicare plans, including individual and family plans - 1-888-MD AETNA (1-888-632-3862) (TTY 711) Dental for non-Medicare plans - 1-800-451-7715. Name and Dates of Service or Proposed Service. Suite 1300. Whats the form called Medicare Reconsideration Request (CMS-20033) Whats it used for Requesting a 2nd appeal (reconsideration) if youre not satisfied with the outcome of your first appeal. To obtain a review, you or your authorized representative may also call our Member Services Department using the telephone number displayed on the member ID card or submit a request in writing to the address listed at the end of your Explanation of Benefits (EOB) or. or it may include one of our network providers or pharmacies or the quality of your care. Or you may write to us at Aetna Better Health Premier Plan MMAI. Aetna Dental works with ClaimConnect TM offered by EDI Health Group (EHG) to provide easy access to check patient eligibility, file a claim, check claim status, view patient rosters and Electronic Remittance Advice. To file a grievance in writing, members should write to Aetna Better Health. Aetna Medicare member ID. Claims disputes. To obtain a review, you or your authorized representative may also call our Member Services Department using the telephone number displayed on the member ID card or submit a request in writing to the address listed at the end of your Explanation of Benefits (EOB) or. Cleveland, OH 44181. ATTN Complaints and Appeals Department. First Name. Appeals and Grievances Aetna Medicare;. We can resolve complaints outside the formal complaints and appeals process. Explanation of Your Request (Please use additional pages if necessary. By fax. Annual Medicare compliance program requirements. A claim appeal is a written request by a provider to give further consideration to a claim reimbursement decision based on the original and or additionally submitted information. For full details, refer to the appropriate Amerigroup provider manual. 55 West 125th Street. Shop Aetna Medicare plans. A grievance can be filed verbally or in writing. Like certain Aetna Medicare member, you can capacity ask for a coverage decision, file in appeal when your claim are denied, or open adenine complaint about the quality the support you've received from a Medicare provider. Rhode Island residents Confidential communications. Where should I send a claim dispute if I am submitting by mail. The enrollee must file the grievance either verbally or in writing no later than 60. That person may already be your representative if you&x27;ve filed paperwork with your state, such as Power of Attorney papers. By mail. You can send your grievance or appeal to Aetna Better Health&174; of Virginia. Help ensure member payment appeals and medical records go tothe right place. By mail. All appeals must be submitted in writing, using the Aetna Provider Complaint and Appeal form. Note If your selection is spouse, child (18 years of age or older) or other, please submit a completed an Authorized Representative Form with your request. You are now leaving the Aetna Dental Web site and linking to ClaimConnect. Just complete the authorization release for standard appeal form (PDF). 1-888-MD-Aetna (TTY 711). To obtain a review, youll need to submit this form. Rhode Island residents Confidential communications. 5801 Postal Rd. If the request does not qualify for a reconsideration as defined below, the request must be submitted in writing using the Provider complaint and Appeal Form. Fax the request to 1-866-455-8650. Submit an authorization appeal online. File a complaint (grievance) Find out how to file a complaint (also called a "grievance") if you have a concern about the quality of care or other services you get from a Medicare provider. Download the PDF to learn how to administer Aetna plans and services effectively. To file a grievance or to appeal a plan action, please call 1-855-456-9126 or write to Aetna Better Health of New York. An expedited appeal can only be requested for a. Representatives are available 24 hours a day, 7 days a week. Cleveland, OH 44181. ETCT and Sat, 10 a. Youll find many of the forms you need on this website. You may mail your request to Aetna -Provider Resolution Team PO Box 14597 Lexington, KY 40512 Or use our National Fax Number 859-455-8650. First, you can request participation in the Aetna network by completing our online request for participation form. NYC, NY 10027. An expedited appeal can only be requested for a. Box 14067 Lexington, KY 40512. appeal form and indicate you are acting on the member&39;s behalf. File a complaint about the quality of care or other. Health care providers - get answers to the most. This form may be sent to us by mail or fax Aetna Medicare Advantage Plan Aetna Medicare Part C Appeals & Grievances PO Box 14067 Lexington, KY 40512. Please provide details of the complaint or appeal in the fields below. Fax the request to 1-866-455-8650. primarily through the Ombudsmans office at 312-814-2121 or to CMS through 1-800-MEDICARE. Lexington, KY 40512. 5801 Postal Road. Fair treatment. Mailstop OH0102-B325. Print a claim denial appeal form. Maternal Child Health. File a complaint. Attn Grievance and Appeals Dept. Last Name. The manual states A non-contract provider, on his or her. Fax Number 1-724-741-4956. I am filing a complaint. Fax number 1-833-596-0339. You can call 1-844-362-0934 (TTY 711) between 8 AM and 5 PM, Monday through Friday. NOTE Completion of this form is voluntary. Legal notices. Get a Provider Complaint and Appeal form As of March 1, 2017, the change affected all Aetna medical plans. Please enter your member ID and date of birth to get started. That person may already be your representative if you&x27;ve filed paperwork with your state, such as Power of Attorney papers. NOTE Completion of this form is voluntary. Box 81040. mail your complaint and all attachments to Illinois Department of Insurance 320 W. Enter your official contact and identification details. , a remittance advice from a Medicare carrier, medical records, office notes, etc. These changes do NOT affect member appeals. On a scale of 1 to 5 how satisfied are you with the following. You can send your complaint or appeal to Aetna Better Health&174; of West Virginia. Medicare Complaint Form. By mail. Make sure to include any information that will support your appeal. , a remittance advice from a Medicare carrier, medical records, office notes, etc. The Complaint Appeal Panel will review and discuss your case. Log In Now. Talk to a health plan consultant 877-683-0203 (TTY 711) Mon-Fri, 8 a. The website is www. The Oregon Health Authority Ombudsman at 503-947-2346 or toll-free at 877-642-0450. The appeal must include the reasons why the member believes the decision is incorrect. Please follow timely processingrequirements. Authorized Representative Request. The line is open 24 hours a day, 7 days a week. If you have any questions, please feel free to call our Customer. Expedited, urgent, and pre-service appeals are considered member appeals and are not affected. See all legal notices. Medicare Provider Complaint and Appeal Request NOTE You must complete this form. Massachusetts residents health insurance mandate. box listed on the EOB statement, denial letter or overpayment letter related to the issue being disputed. There are two ways to do this Call Member Services at the phone number on your member ID card. Submit the online form, fax or mail your request to us. to act as my authorized representative in requesting (check one) a complaint or an appeal from Aetna regarding the above. Washington Street Springfield, IL 62767-0001; A separate complaint form must be completed for each patient. You can also get free help by calling the Beneficiary Help Line at 1. Then, send it to Aetna Better Health of Maryland Attn Appeal and Grievance Department PO Box 81040 5801 Postal Road Cleveland, OH. Incorrect denial of claim or claim line(s) Incorrect rate payment. Employee Assistance Program (EAP). If you decide to appeal, ask your doctor, health care provider, or supplier for any information that may help your case. Fax the request to 1-866-455-8650. Who may make a request If you want another individual (such as a family member, your doctor or friend) to request an appeal for you, that individual must be your representative. They must request this in writing. You can file a verbal dispute any time. Related to aetna appeal form for providers aetna appeal forms Practitioner and Provider Compla int and Appeal Sequestrate Completion of this form is voluntary. Cleveland, OH 44181. PO Box 81040. Cleveland, OH 44181. One South Wacker Drive, Mail Stop F646. Then, send it to Aetna Better Health of Maryland Attn Appeal and Grievance Department PO Box 81040 5801 Postal Road Cleveland, OH. Aetna Medicare Advantage Plan or Aetna Medicare Prescription Drug Plan Grievance Form. It is mandatory. 365 days. For non-participating health care professionals. Send your form or letter to Aetna Better Health&174; of Virginia Attn Appeals Department PO Box 81139 5801 Postal Road Cleveland, OH 44181 Fax 866-669-2459 Is your provider filing on your behalf If yes, be sure they use this address, not the provider address. Relationship to person requesting the appeal Self Spouse Child Other. Box 81040. Your doctor can file a grievance or request an appeal on your behalf after you give them your written permission. To make a verbal complaint Call our Provider Service Center at 1-888-632-3862. You can also get free help by calling the Beneficiary Help Line at 1. You may mail your request to Aetna-Provider Resolution Team PO Box 14020 Lexington, KY 40512. Cleveland, OH 44181. CALIFORNIA ALAMEDA SAN FRANCISCO Aetna Medicare Value Plus Plan (HMO-POS)H0523-076. Aetna Better Health of Floridas Provider Relations Department will make reasonable efforts to. Medicare members 1-860-900-7995. Request for an Appeal of an Aetna Medicare Advantage (Part C) Plan Claim Denial Because Aetna Medicare (or one of our delegates) denied your request for payment of. Many issues, including denials related to timely filing, incomplete claim submissions, and contract and fee schedule disputes may be quickly resolved through a real-time adjustment by providing requested. Call our Provider Service Center using the phone number on the back of the members ID Card. Redetermination form you have 60 days from the date of our Notice of Denial. It is mandatory. appealing adenial and the services have yet to be rendered, use the member complaint and appeal form and indicate you are acting on the member&39;s behalf. You have 180 days from the date of the initial decision to submit a dispute. As part of our continued effort to provide a high quality user experience while also ensuring the integrity of the information of those that we service is protected, we will be implementing changes to evicore. Every year, all providers who participate in our MA plans are required to meet the Centers for Medicare & Medicaid Services (CMS) compliance program requirements for first-tier, downstream and related entities (FDR). shadbase incredibles, 890 cad to usd
Apr 15, 2022 Find the Aetna Medicare forms you need to help you get started with claims reimbursements, Aetna Rx Home Delivery, filing an appeal and more. . Aetna medicare provider complaint and appeal form
Medicare takes your complaints seriously and will use this information to help improve the quality of the Medicare program. If the request does not qualify for a reconsideration as defined below, the request must be submitted in writing Medicare Advantage Aetna Provider Complaint and Appeal Form. Retro authorization requests can also be submitted electronically, again marked as FILING. to 4 p. On a scale of 1 to 5 how satisfied are you with the following. Behavioral HealthMedical Provider Communication Form; Provider Demographic Updates. In order to ensure the integrity of the Provider Dispute Resolution (PDR) process, we will re-categorize issues sent to us on a PDR form which are not true provider disputes (e. First Name. File a complaint with OHP Client Services by calling 800-273-0557. Medicare takes your complaints seriously and will use this information to help improve the quality of the Medicare program. Case ID or member ID. By fax. 5801 Postal Rd. Cleveland, OH 44181. Time to resolve appeal Time it took to resolve the appeal once you submitted it to the appeals department. Cleveland, OH 44181. First Name. Aetna DMO and PPO grievance and appeals. 5801 Postal Road. Full details of your complaint or appeal. You can file your grievance on the phone by calling Member Services at 866-212-2851. Birthdate (MMDDYYYY) Relationship to person requesting the appeal Self Spouse Child Other. Vendors bottle open a complaint on things enjoy policies, procedures, administrative functions, or appeal billing and how decisions. Medicare medical and dental plans - 1-800-624-0756 (TTY 711) Non-Medicare plans, including individual and family plans - 1-888-MD AETNA (1-888-632-3862) (TTY 711) Dental for non-Medicare plans - 1-800-451-7715. Provider appeals. Provider appeals. A RETROSPECTIVE AUTHORIZATION DISPUTE to. Aetna complaints contacts. com Well acknowledge your appeal verbally or in writing within 5 business days of receipt. Note If you are acting on the members behalf and have a signed authorization from the member or you are appealing a preauthorization denial and the services have yet to be rendered, use the member complaint and appeal form. This form is voluntary and does not affect your right to other remedies. You have 180 days from the date of the initial decision to submit a dispute. This document is a complaint and appeal request form for practitioners and providers to use when appealing a claim denial by Aetna. Use the tools we provide to submit your form. Forms & Resources. This material is for information only. You may mail your request to Aetna-Provider Resolution Team PO Box 14020 Lexington, KY 40512. To view the form just select Continue. This may be medical records, office notes, discharge summaries, lab. Submit the online form, fax or mail your request to us. Most of our HMO-POS plans require you to use a network provider for medical care but provide you with flexibility to go to licensed dentists in or out of network for routine dental care. Requesting an appeal (redetermination) if you disagree with Medicares coverage or payment decision. As in Aetna Medicare member, you can cans ask by a coverage ruling, file an appeal if your claim is denied, or file a complaint about that quality of care you've preserve from a Medicare provider. The Centers for Medicare & Medicaid Services (CMS) describes the appeal process for non-contract providers in section 50. Forms & Resources. Speak with the Office of the Medicare Ombudsman (OMO) for help with a complaint, grievance or information request. PO Box 944243, Mail Station 9-17-37. You have 180 days from the date of the initial decision to submit a dispute. Sep 30, 2019 Get help from the federal government. A complaint is about the quality of care you got or are getting. The fillable form is available in the "Downloads" section at the bottom of this page. Learn about the timeframe for appeals and reconsiderations. Birthdate (MMDDYYYY) Relationship to person requesting the appeal Self Spouse Child Other. ) You may mail your request to Or Fax us at 1-860-900-7995 Medicare Provider Appeals PO Box 14835 Lexington, KY 40512. com 1126773-01-02 (823) Resouur ces,policiesandprocedures aat yourfingertips. First Name. or open adenine complaint about the quality the support you've received from a Medicare provider. This may be medical records, office notes, discharge summaries, lab. Chicago, IL 60606. Office Manual for Health Care Professionals is a comprehensive guide for providers who work with Aetna. Fax the request to Non Medicare members 1-866-455-8650. Any of the below can help you. To request a coverage decision or an appeal on a members behalf, just call Member Services at 1-866-316-3784 (TTY 711). How to ask for an appeal. Health benefits and health insurance plans contain exclusions and limitations. It covers topics such as credentialing, contracting, claims, quality management, and more. If the request does not qualify for a reconsideration as defined below, the request must be submitted in writing using the Provider complaint and Appeal Form. Here's how it works Step 1. Aetna Medicare member ID. Authorized Representative Request Complaint and Appeal Request. This form willbe valid for 1 year unless a shorter time period is listed below. Process for Aetna Assure Premier Plus (HMO D-SNP) complaints, coverage decisions and appeals. Box 81040 5801 Postal Road Cleveland, OH 44181 Fax 844-951-2143. appeal form and indicate you are acting on the member&39;s behalf. Aetna Medicare Advantage Plan or Aetna Medicare Prescription Drug Plan Grievance Form. By mail. Request for a Redetermination for an Aetna Medicare Prescription Drug Denial. CALIFORNIA SAN FRANCISCO Aetna Medicare Select Plan (HMO)H0523-070. First Name. First Name. Minnesota Department of Commerce (for fully insured plans) 85 7th Place East, Suite 500. Please use the form below if you would like to provide comments. You may also contact your provider directly to talk about your concerns. If you would like to learn how many appeals and complaints Aetna Better Health Premier Plan MMAI has processed, please contact our representatives at 1-866-600-2139 Hearing Impaired call (TTY 711), 24 hours a day, 7 days a week. There are two ways to do this Call Member Services at the phone number on your member ID card. How to ask for an appeal. Last Name. Make sure to include any information. Effective January 1, 2022, you need to use a new, Medicare-specific form for your post-service appeals. Full details of your complaint or appeal. You can call 1-844-362-0934 (TTY 711) between 8 AM and 5 PM, Monday through Friday. Print the name of the person who is being authorized to act on the members behalf. B Phoenix, AZ 85085-8200. The Provider Dispute Form is accessible on Aetna Better Health Premier Plan MMAIs website, via fax or by mail. Saint Paul, MN 55101. To dispute a UCR denial by telephone, call 1-800-451-7715. Mail It. Retro authorization requests can also be submitted electronically, again marked as FILING. The administrative law hearing is conducted remotely by video or telephonic means, or in cases where good cause is. New Jersey (NJ) All providers treating fully-insured NJ contracted members and submitting their dispute using the "Health Care Provider Application to Appeal a Claims Determination Form" will be eligible for review by New Jersey&39;s Program for Independent Claims Payment Arbitration (PICPA). You can find this form, which is called the Medicare Provider Complaint and Appeal Request Form, by going to the forms for health care professionals page and scrolling to the Dispute and appeals drop-down menu. Handling it utilizing digital means is different from doing this in the physical world. This form is voluntary and does not affect your right to other remedies. Consent form denial. Aetna Dental P. 365 days. Include any other information about your appeal. Health benefits and health insurance plans contain exclusions and limitations. To obtain a review, you&x27;ll need to submit this form. The aetna medicare provider complaint and appeal form isnt an exception. This form is for your use in making suggestions, filing a formal complaint, grievance, or appeal regarding any aspect of the service provided to you. Name and Dates of Service or Proposed Service. This form is voluntary and does not affect your right to other remedies. Or use our National Fax Number 859-455-8650. It covers topics such as policies, programs, claims, benefits, quality management and more. Print the form, complete it and fax it to 225-219-9823. If the responses cannot be typed, they should be printed clearly If submitting request electronically, complete member name, ID and reference. to 4 p. You have the right to file a complaint, grievance or appeal about Texas Health Aetna; Your plan; A health care service, provider or professional; Print and complete the form. Or you may write to us at Aetna Better Health Premier Plan MMAI. You may mail your request to Aetna -Provider Resolution Team PO Box 14597 Lexington, KY 40512 Or use our National Fax Number 859-455-8650. Relationship to person requesting the appeal Self Spouse Child Other. You also may authorize someone to appeal for you. The number for the rest of California is 1-800-927-HELP. Request for an Appeal of an Aetna Medicare Advantage (Part C) Plan Claim Denial Because Aetna Medicare (or one of our delegates) denied your request for payment of. . the cover of the new york post