How to Fill Out and Submit the Aetna Member Complaint and Appeal Form

The Aetna member complaint and appeal form, numbered GR-68192, is the two-page document you use to challenge a denied claim or file a formal complaint about Aetna’s services. Download the PDF from Aetna’s forms library at aetna.com, or if you have a non-Medicare plan, file the whole thing online through the member portal without printing anything.¹² Group health plan members have 180 days from the date they receive a denial notice to file.³

Where to Get the Form

Two options. Download the printable PDF (form GR-68192) directly from Aetna’s forms library on aetna.com.¹ Or log in to the Aetna member portal and file electronically, which works for all non-Medicare plans.² California HMO and DMO members use a separate online grievance form linked from the same page.

Filling Out the Form

The form is short, but a mismatched ID number or missing signature will slow down the review. Keep your Aetna ID card and your denial letter or Explanation of Benefits in front of you.

Member Information

Start with the primary insured member’s details, taken directly from the ID card:

Member’s ID number — the unique number on the front of your card, and the single most important identifier for your case.
Plan type — check Medical or Dental.
Group number — also on the ID card. The form marks this optional, but including it helps Aetna locate your plan faster.
Member’s name, birthdate, and email — use the name exactly as it appears on the card.

Then indicate who is requesting the appeal. If it’s you, select “Self.” If anyone else is filing for you, see the authorized representative section below; you’ll need an extra form.

Request Details

This is the core of the form. First, mark whether the appeal is pre-service or post-service. Pre-service means Aetna denied authorization before you received the care. Post-service means you already received the care and Aetna denied the claim afterward. The distinction changes which reference number you provide.

Claim ID number — required for post-service appeals. It’s on the Explanation of Benefits Aetna sent you.
Reference number — required for pre-service appeals. It’s on the denial letter or prior authorization correspondence.
Service date — the date you received the care (post-service) or the date of the denial (pre-service).

The “Explanation of Your Request” section is a free-text field. Describe why you believe Aetna’s decision was wrong. Name the treatment or service, state what Aetna denied or what went wrong, and explain why you disagree. The form invites additional pages, so don’t let the space on the PDF constrain you. Sign and date the bottom. An unsigned form is incomplete.¹

What to Attach

The form instructs you to include “bills and/or correspondence for these services” and “any other helpful information.”¹ That second phrase is broad, and strong appeals use it well. The more relevant clinical evidence the reviewer sees, the harder it is to uphold the denial on incomplete information.

At a minimum, include a copy of the denial letter or EOB that triggered the appeal. Consider adding medical records from the treating provider documenting the diagnosis and treatment, along with any lab results or imaging that support why the service was necessary. A letter from your doctor explaining medical necessity in your specific clinical situation can be particularly persuasive. If Aetna denied the service as experimental or investigational, attach peer-reviewed studies or FDA approval documentation supporting the treatment’s accepted use.

Keep copies of everything. If you mail the appeal, send photocopies of medical records, not originals.

How and Where to Submit

Three channels. Pick based on how close you are to the deadline.

Mail

Send the completed form and attachments to:

Aetna
PO Box 14463
Lexington, KY 40512¹

Use certified mail with return receipt requested. That receipt is your proof of the date Aetna received the appeal if a deadline is ever disputed.

Fax

Aetna’s national fax number for member appeals is 859-425-3379.¹ Save the fax confirmation page as timestamped evidence of a timely submission. Faxing is useful when you’re close to a filing deadline.

Online

Non-Medicare members can file through the Aetna member portal at aetna.com. Log in and navigate to the complaint or grievance filing tool.² The portal provides an electronic timestamp, so you don’t need separate delivery proof.

Deadline to File

For group health plans governed by ERISA, you have at least 180 days from the date you receive the adverse benefit determination. For non-group-health plans such as disability or life insurance, the minimum appeal window is 60 days.³ Your denial letter states the exact deadline that applies to your plan. Check it carefully, because some plans set shorter windows than the federal floor.

The clock starts the day you receive the denial, not the day Aetna mailed it. Don’t push it to the last day anyway. A late filing gives Aetna a procedural reason to dismiss the appeal regardless of its merits, and recovering from a missed deadline is extremely difficult.

If Someone Else Is Filing for You

A spouse, an adult child, a doctor, an attorney, or anyone else filing on your behalf needs a separate Authorized Representative Request Form (GR-68910), submitted along with the complaint and appeal form.⁴

That form carries your signature authorizing Aetna to share your protected health information with the representative, including diagnosis, treatment records, behavioral health information, and HIV/AIDS-related records. If you want someone to handle the paperwork without receiving your medical details, the form has a checkbox that restricts PHI disclosure while still letting the representative file for you. Attorneys or other legal representatives must attach a healthcare power of attorney or other document establishing their legal authority. The authorization lasts for the duration of the appeal and can be revoked anytime by notifying Aetna in writing.⁴

If You Need an Urgent Decision

If waiting for a standard appeal would seriously jeopardize your life, health, or ability to regain maximum function, or if a physician determines the standard timeline would leave you in severe pain that can’t be managed without the denied treatment, you can request an expedited review.⁵

Expedited appeals can be filed orally. Call the member services number on your ID card and explicitly request an expedited appeal. Aetna must issue a decision within 72 hours of receiving the request, and communications can happen by phone, fax, or other fast methods.⁵ Don’t rely on the paper form in these situations. Speed matters more than documentation format.

What Happens After You Submit

A peer clinician reviews the appeal along with your supporting documentation.⁶ Federal regulations set firm response deadlines for group health plans:

Pre-service appeals: 30 days.
Post-service appeals: 60 days.
Urgent care appeals: 72 hours.³

The result arrives as a written Notice of Appeal Decision. If Aetna overturns the denial, the claim is reprocessed. If the denial is upheld, the notice explains the reasons, cites the specific plan provisions relied upon, and describes your right to request an external review.

If Aetna Denies the Appeal

When Aetna’s internal appeal ends with a final denial, you can request an independent external review by an Independent Review Organization that has no ties to Aetna. The final denial letter includes a Request for External Review form and filing instructions.⁷ If the IRO overturns the denial, Aetna must comply and cover the service. External review is the final administrative step; after that, the remaining option is legal action.

1
Aetna. Member Complaint and Appeal Form
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Aetna. Help Filing a Complaint, Grievance or Appeal
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eCFR. 29 CFR 2560.503-1 – Claims Procedure
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Aetna. Authorized Representative Request Form
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eCFR. 29 CFR Part 2560 – Rules and Regulations for Administration and Enforcement
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Aetna. Disputes and Appeals Process
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Aetna. Aetna External Review Program