Aetna - Member Complaint and Appeal Form

1 1 Member Complaint and Appeal form NOTE: Completion of this form is voluntary. To obtain a review, you or your authorized representative may also call our Member Services Departmentusing the telephone number displayed on the Member ID card or submit arequest in writing to the address listed at the end of your Explanation ofBenefits (EOB) or other correspondence received from Aetna . Please provide the following information for the primary Insured/ Member . (This information may be found on the front of your ID card.) Today s DateMember s ID Number Plan Type Medical Dental Member s Group Number (Optional) Member s First Name Member s Last Name Member s Birthdate (MM/DD/YYYY) Member s E-mail Address Please provide the following information for the person you are submitting the request for. First Name Last Name Birthdate (MM/DD/YYYY) Relationship to person requesting the Appeal : Self Spouse Child Other Note: If your selection is spouse, child (18 years of age or older) or other, please complete and include the attached Authorized Representative form with your request.

2 Please advise if the Appeal is related to: Pre-Service Post Service To help Aetna review and respond to your request, please provide the following information. (This information may be found on correspondence from Aetna .) Claim ID Number (If Post Service selected above.)Reference Number (If Pre-Service selected above.)Service Date (If Post Service insert date of services, if Pre-Service insert date of denial.) Explanation of Your Request (Please use additional pages if necessary.) Member s Signature Note: When submitting this form with your request please include: - Bills and/or correspondence for these services. - Any other helpful information. You may mail your request to: Aetna PO Box 14463 Lexington, KY 40512 Or use our National Fax Number: 859-425-3379 CRTM GR-68192 (10-18) GR-POD GR-68192 (10-18) G 2 Aetna complies with applicable Federal civil rights laws and does not unlawfully discriminate, exclude or treat people differently based on their race, color, national origin, sex, age, or disability.

3 We provide free aids/services to people with disabilities and to people who need language assistance. If you need a qualified interpreter, written information in other formats, translation or other services,call the number on your ID card. If you believe we have failed to provide these services or otherwise discriminated based on a protected class noted above, you can also file a grievance with the Civil Rights Coordinator by contacting: Civil Rights Coordinator, Box 14462, Lexington, KY 40512 (CA HMO customers: PO Box 24030 Fresno, CA 93779), 1-800-648-7817, TTY: 711, Fax: 859-425-3379 (CA HMO customers: 860-262-7705), You can also file a civil rights Complaint with the Department of Health and Human Services, Office for Civil Rights Complaint Portal, available at , or at: Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, or at 1-800-368-1019, 800-537-7697 (TDD).

4 Aetna is the brand name used for products and services provided by one or more of the Aetna groupof subsidiary companies. GR-68192 (10-18) G 3 TTY:711 English To access language services at no cost to you, call the number on your ID card. Albanian P r sh rbime p rkthimi falas p r ju, telefononi n numrin q gjendet n kart n tuaj t identitetit. Amharic Arabic . Armenian Bantu-Kirundi Kugira uronke serivisi z'indimi ata kiguzi, hamagara inomero iri ku karangamuntu kawe Bengali Burmese Catalan Per accedir a serveis ling stics sense cap cost per a vost , telefoni al n mero indicat a la seva targeta d identificaci.

5 Cebuano Aron maakses ang mga serbisyo sa lengguwahe nga wala kay bayran, tawagi ang numero nga anaa sa imong kard sa ID. Chamorro Para un hago' i setbision lenggu hi ni dib tde para h gu, gang i numiru gi iyo-mu kard aidentifikasion. Cherokee , ID . Chinese Traditional Choctaw Anumpa tosholi i toksvli ya peh pilla ho ish i payahinla kvt chi holisso kallo iskitini holhtena takanli ma i payah Chuukese Ren omw kopwe angei aninisin eman chon awewei (ese kam ), kopwe k ri ewe nampa mei mak won noum ena katen ID Cushitic-Oromo Tajaajiiloota afaanii gatii bilisaa ati argaachuuf,lakkoofsa fuula waraaqaa eenyummaa (ID) kee irraa jiruun bilbili. Dutch Voor gratis taaldiensten, bel het nummer op uw ziekteverzekeringskaart. French Pour acc der gratuitement aux services linguistiques, veuillez composer le num ro indiqu sur votre carte d'assurance sant.

6 French Creole (Haitian) Pou ou jwenn s vis gratis nan lang ou, rele nimewo telef n ki sou kat idantifikasyon asirans sante ou. German Um auf den f r Sie kostenlosen Sprachservice auf Deutsch zuzugreifen, rufen Sie die Nummer auf Ihrer ID-Karte an. Greek , . Gujarati Hawaiian No ka wala au ana me ka lawelawe lelo e kahea aku i ka helu kelepona ma k u k leka ID. K ki ole ia k ia k kua Hmong Yuav kom tau kev pab txhais lus tsis muaj nqi them rau koj, hu tus naj npawb ntawm koj daim npav ID. Igbo Inweta enyemaka as s na akwughi gw ob la, kp n mba n na kaadi njirimara g Ilocano Tapno maakses dagiti serbisio ti pagsasao nga awanan ti bayadna, awagan ti numero nga adda ayan ti ID kardmo. Indonesian Untuk mengakses layanan bahasa tanpa dikenakan biaya, silakan hubungi nomor telepon di kartu asuransi Anda. Italian Per accedere ai servizi linguistici senza alcun costo per lei, chiami il numero sulla tessera identificativa.

7 Japanese ID Karen Korean ID . Kru-Bassa I nyuu kosna mahola ni language services ngui nsaa wogui wo, sebel i nsinga i ye ntilga i kat yong matibla Kurdish (ID ) .Lao , . Marathi Marshallese an b k jipan k n kajin ilo an ejje k w ean nan kwe, kw n kallok n ba eo ilo kaat in ID eo a . Micronesian-Ponapean Pwehn alehdi sawas en lokaia kan ni sohte pweipwei, koahlih nempe nan amhw doaropwe en ID. Mon-Khmer, Cambodian Navajo Nepali Nilotic-Dinka T k r y n ran de w r de thokic ke c n w u k r keek t n y n. Ke y n c l ran ye k c ku ny n namba de abac t n ID kard du n de t t de nyin de panakim k u. Norwegian For tilgang til kostnadsfri spr ktjenester, ring nummeret p ID-kortet ditt. Pennsylvanian-Dutch Um Schprooch Services zu griege mitaus Koscht, ruff die Nummer uff dei ID Kaart.

8 Persian Farsi .Polish Aby uzyska dost p do bezp atnych us ug j zykowych, nale y zadzwoni pod numer podany na karcie Para aceder aos servi os lingu sticos gratuitamente, ligue para o n mero indicado no seu cart o de identifica GR-68192 (10-18) G 4 5 Romanian Pentru a accesa gratuit serviciile de limb , apela i num rul de pe cardul de Для того чтобы бесплатно получить помощь переводчика, позвоните по телефону, приведенному на вашей идентификационной карте. Samoan M le mauaina o 'au'aunaga tau gagana e aunoa ma se totogi, vala'au le numera i luga o lau pepa ID. Serbo-Croatian Za besplatne prevodila ke usluge pozovite broj naveden na Va oj identifikacionoj kartici. Spanish Para acceder a los servicios ling sticos sin costo alguno, llame al n mero que figura en su tarjeta de identificaci n.

9 Sudanic Fulfulde Hee a a naasta nder ekkitol jaangirde woldeji walla yo ugo, ewnu lamba je on windi ha do erowol maa a. Swahili Kupata huduma za lugha bila malipo kwako, piga nambari iliyo kwenye kadi yako yakitambulisho. Syriac-Assyrian Tagalog Upang ma-access ang mga serbisyo sa wika nang walang bayad, tawagan ang numero sa iyong ID card. Telugu Thai Tongan Kapau oku ke fiema u ta et t ngi a e ngaahi s vesi kotoa p he ngaahi lea kotoa, telefoni ki he fika oku h atu i ho o ID kaati. Turkish Dil hizmetlerine cretsiz olarak eri mek i in kimlik kart n zdaki numaray aray n. Ukrainian Щоб безкоштовнj отримати мовн послуги, задзвон ть за номером, вказаним на ваш й дентиф кайн й картц . Urdu Vietnamese s d ng c c d ch v ng n ng mi n ph , vui l ng g i s i n tho i ghi tr n th ID c a qu v . Yiddish . ID , Yoruba L ti r y s w n i d f n l f , pe n mb t w l r k d d nim r.

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