Non-Part D complaints, coverage decisions and appeals

Complaints

Examples of complaints

If you have any of the problems below, you can file a complaint.

Quality of your medical care

• Are you unhappy with the quality of care you received (including care in the hospital)?

Respecting your privacy

• Do you believe that someone did not respect your right to privacy or shared information about you that you feel should be confidential?

Disrespect, poor customer service or other negative behaviors

• Has someone been rude or disrespectful to you?
• Are you unhappy with Aetna Better Health Premier Plan MMAI Member Services?
• Do you feel you are being encouraged to leave our plan (disenroll)?

Complaints about physical accessibility

• You cannot physically access the health care services and facilities in a doctor or provider’s office.

Complaints about language access

• Your doctor or provider does not provide you with an interpreter during your appointment.

Cleanliness

• Are you unhappy with the cleanliness or condition of a doctor's office, provider’s site, clinic or hospital?

Waiting times

• Did you have trouble getting an appointment, or wait too long to get it?
• Have you been kept waiting too long (examples: waiting too long on the phone, in the waiting room, in the exam room, or getting a prescription)?
• Have you waited too long for Member Services or other staff at our plan?

Information you get from our plan

• Do you believe we haven't given you a notice that we're required to give?
• Do you think written information we gave you is hard to understand?

Timeliness of actions related to coverage decisions and appeals

You can make a complaint:

• If you have asked us for a "fast response" for a coverage decision or appeal within 72 hours, and we said we will not provide a fast response.
• If you believe we are not meeting deadlines for a standard coverage decision or an answer to an appeal within 14 calendar days.
• When we do not give you a decision within the timeframes above, we are required to forward your case to the Independent Review Organization. If we don't do that, you can make a complaint.
• Deadlines apply when a coverage decision we make is reviewed and the Independent Review Organization says we must cover or reimburse you for certain medical services. We must provide the approved coverage within 72 hours after we receive the decision, or send payment to you within 30 calendar days if you already paid for the service. If you think we are not meeting these deadlines, you can make a complaint.

How to make a complaint

Follow this process for making a complaint. If you have questions, please give Member Services a call at 1‑866‑600-2139 (TTY: 711), 24 hours a day, 7 days a week. The call is free.

Step 1: Contact us
Whether you call or write, you should contact Member Services right away. The complaint can be made at any time unless you are requesting remedial action, then it must be made within 60 calendar days after you had the problem that you want to complain about.

• Start by calling Member Services. We will let you know what you need to do.

24 hours a day, 7 days a week
1‑866‑600-2139 (TTY: 711)

• If you don’t want to call (or you called and were not satisfied), send your complaint to us in writing:

Aetna Better Health Premier Plan MMAI
PO Box 818070

Cleveland, OH 44181
Fax: 1-855-883-9555

 

Formal complaint procedure
If you write us, it means that we will use our formal procedure for answering grievances. Here's how it works:

• Whether you call or write, you should contact Member Services right away. You can make your complaint at any time unless you are requesting remedial action then it must be made within 60 days after you have the problem you want to report.
• If we cannot resolve your complaint over the phone, we will respond to your complaint within 30 calendar days.
• If you asked us to give you a "fast response" for a coverage decision or appeal, and we said we will not, you can make a complaint. If we extend the time to review a coverage decision or an appeal, you can make a complaint.  These complaints are fast complaints.  If you have a "fast" complaint, it means we will give you an answer within 24 hours.
• If you ask for a written response, file a written grievance, or your complaint is related to quality of care, we will respond to you in writing.

 Step 2: We look into your complaint and give you our answer

• If possible, we will answer you right away. If you call us with a complaint, we may be able to give you an answer during the phone call. If your health condition requires us to answer quickly, we will do that.
• The longest time we can take to answer a complaint is 30 days. If we need more information and the delay is in your best interest, or if you ask for more time, we can take up to 14 more days (44 days total) to answer your complaint.
• If we do not agree with some or all of your complaint or don't take responsibility for the problem you are complaining about, we will let you know. Our response will include our reasons for this answer.

Complaints about quality of care
You also can make complaints about quality of care to the Quality Improvement Organization. You can make your complaint about the quality of care you received to our plan by using the step-by-step process outlined above.

When your complaint is about quality of care, you have two extra options:

• You can make your complaint directly to the Quality Improvement Organization. You don’t have to make the complaint with Aetna Better Health Premier Plan. If you make a complaint to the Quality Improvement Organization, Aetna Better Health Premier Plan MMAI will work with them to resolve your complaint.
• You can make your complaint about quality of care to Aetna Better Health Premier Plan MMAI and to the Quality Improvement Organization.

Livanta is Illinois’ Quality Improvement Organization. You may contact Livanta at 1-888-524-9900, or by Toll-Free TTY, 1-888-985-8775 or by writing:

Livanta

10820 Guilford Rd., Suite 202

Annapolis Junction, MD 20701

Website: www.livantaqio.com

Complaints about disability access or language assistance
If you have a complaint about disability access or about language assistance, you can file a complaint with the Office of Civil Rights at the Department of Health and Human Services.

Celeste Davis, Regional Manager
Office for Civil Rights
U.S. Department of Health and Human Services
233 N. Michigan Ave., Suite 240
Chicago, IL 60601
Voice Phone 1-800-368-1019
FAX 312-886-1807
TDD 1-800-537-7697

You may also have rights under the Americans with Disability Act. You can contact the Senior HelpLine for assistance. The phone number is 1-800-252-8966, TTY: 1-888-206-1327.

Complaints to Medicare
You can send your complaint to Medicare. The Medicare Complaint Form is available.

Medicare takes your complaints seriously and will use this information to help improve the quality of the Medicare program.
If you have any other feedback or concerns, or if you feel the plan is not addressing your problem, please call 1-800-MEDICARE (1-800-633-4227). TTY/TDD users can call 1-877-486-2048. The call is free.

See chapter 9, section 11 for information about complaints and grievances in the Evidence of Coverage - English / Spanish.

Coverage decisions

What is a Coverage Decision?
A coverage decision is an initial decision we make about your benefits and coverage or about the amount we will pay for your medical services or drugs. We are making a coverage decision whenever we decide what is covered for you and how much we pay.

If you or your doctor are not sure if a service is covered by Medicare or Medicaid, either of you can ask for a coverage decision before the doctor gives the service.

Who can I call for help asking for Coverage Decisions?

You can ask any of these people for help:

• You can call us at Member Services at 1-866-600-2139 (TTY: 711), 24 hours a day, 7 days a week to ask for a coverage decision or an appeal.
• You can request a coverage decision or appeal in writing.
• Call the Illinois Health Benefits Hotline for free help. The Illinois Health Benefits Hotline helps people enrolled in Medicaid with problems. The phone number is 1-800-226-0768, TTY: 1-877-204-1012.
• Call the Senior HelpLine for free help. The Senior Helpline will help anyone at any age enrolled in this plan. The Senior HelpLine is an independent organization. It is not connected with this plan. The phone number is 1-800-252-8966, TTY: 1-888-206-1327.
• Talk to your doctor or other provider. Your doctor or other provider can ask for a coverage decision or appeal on your behalf.
• Talk to a friend or family member and ask him or her to act for you. You can name another person to act for you as your "representative" to ask for a coverage decision or make an appeal.
• If you want a friend, relative, or other person to be your representative, call Member Services and ask for the "Appointment of Representative" form. You can also get the Appointment of Representative form on the Medicare website. The form will give the person permission to act for you. You must give us a copy of the signed form.
• You also have the right to ask a lawyer to act for you. You may call your own lawyer, or get the name of a lawyer from the local bar association or other referral service. Some legal groups will give you free legal services if you qualify. If you want a lawyer to represent you, you will need to fill out the Appointment of Representative form.
• However, you do not have to have a lawyer or a representative to ask for any kind of coverage decision or to make an appeal.

Appeals

When to file an appeal

You have the right to file an appeal, also called a fast reconsideration,” with Aetna Better Health Premier Plan MMAI if you receive written notice of any of the following:

• Aetna Better Health Premier Plan MMAI denied payment for renal dialysis services you received while temporarily outside of the Aetna Better Health Premier Plan MMAI service area.
• Aetna Better Health Premier Plan MMAI denied payment for emergency services, post-stabilization care or urgently needed services you received while temporarily outside of the Aetna Better Health Premier Plan MMAI service area.
• Aetna Better Health Premier Plan MMAI denied payment for any other health services furnished by a provider that you believe should be covered.
• Aetna Better Health Premier Plan MMAI refused to authorize, provide or reimburse you for services, in whole or in part, that you believe should be covered.
• Aetna Better Health Premier Plan MMAI failed to approve, furnish, arrange for, or provide payment for health care services in a timely manner.

How the appeals process works
Once you receive a written notice, you may file an appeal within 60 days from the date of the notification letter. You can call or write a letter to Aetna Better Health Premier Plan MMAI to file an appeal. A special team will review your appeal to determine if we made the right decision.

We will notify you in writing of the results of our appeal not later than 15 business days from the date your appeal was received.

How to file an appeal
To file an appeal, call 1‑866‑600-2139, or send your appeal in writing by mail or fax.  You can complete Request for Appeal form.

Aetna Better Health Premier Plan MMAI
Appeals Department
PO Box 818070
Cleveland, OH 44181

Fax your appeal to: 1-855-545-5196

If more time is needed to gather medical records from your physicians, we may file a 14-day extension. You also may request an extension if you need more time to present evidence to support your appeal. We will notify you in writing if an extension is required.

Expedited appeals
You may file a request for an expedited appeal, also called a redetermination, if you believe that applying for the standard appeals process could jeopardize your life or health. If Aetna Better Health Premier Plan MMAI decides that the timeframe for the standard process could seriously jeopardize your life or health, or ability to regain maximum function, the review of your appeal will be expedited. 

1. You, your appointed representative or your doctor can request an expedited appeal. An expedited request can be submitted orally or in writing to Aetna Better Health Premier Plan MMAI. Your doctor may need to provide oral or written support for your request for an expedited appeal.
2. Aetna Better Health Premier Plan MMAI must provide an expedited appeal if it determines that applying the standard timeframe for making a determination may seriously jeopardize your life or health or your ability to regain maximum function.
3. A request made or supported by your doctor will be expedited if he/she tells us that applying the standard timeframe for making a determination may seriously jeopardize your life or health or your ability to regain maximum function.

Appeals levels and timelines

There are five levels to the Aetna Better Health Premier Plan MMAI appeals process for denied services and payment:

Appeal level		Standard review	Expedited (fast) review
1	Reconsideration by Aetna Better Health Premier Plan MMAI	Upon receipt of your appeal, Aetna Better Health Premier Plan MMAI will send you a letter to confirm the basis of the appeal. The reconsideration will be evaluated by an Appeals specialist, with a clinical expert when necessary.   Aetna Better Health Premier Plan MMAI will notify you in less than 15 business  (plus 14 calendar days if an extension is filed)	Only available for reconsiderations for services not yet received. Subject to expedited review criteria. Aetna Better Health Premier Plan MMAI will notify you if the appeal does not meet expedited review criteria.   Aetna Better Health Premier Plan MMAI will notify you of the reconsideration decision as fast as your condition requires, but not later than 24 hours after receiving all information for your appeal
2	Reconsideration by the Independent Review Entity (IRE)	If Aetna Better Health Premier Plan MMAI agrees with the original denial, in whole or in part, the file is automatically forwarded for reconsideration to the IRE for items/services that are standardly covered by Medicare.   The IRE will review the appeal and notify of you of their decision within 30 days from the day it is received by the IRE.	If Aetna Better Health Premier Plan MMAI agrees with the original denial, in whole or in part, your file is automatically forwarded to the IRE for reconsideration within 24 hours for items/services that are standardly covered by Medicare. The IRE will review your appeal and notify you of their decision within 24 hours of receipt of the appeal file from Aetna Better Health Premier Plan MMAI.
	Reconsideration by the Medicaid External Independent Review	If Aetna Better Health Premier Plan MMAI agrees with the original denial, in whole or in part, you can request a Medicaid External Independent Review items/services that are standardly covered by Medicaid. It must be requested within 30 calendar days of the Level 1 Appeal.    The Medicaid External Independent Review organization will review the appeal and notify of their decision within 45 days from the day it received your request.	If Aetna Better Health Premier Plan MMAI agrees with the original denial, in whole or in part, you can request a Medicaid External Independent Review items/services that are standardly covered by Medicaid. It must be requested within 30 calendar days of the Level 1 Appeal.  The Medicaid External Independent Review organization will review the appeal and notify of their decision within 72 hours from when it received your request.
	Reconsideration by the Illinois Department of Health Care and Family Services (HFS) Bureau of Administrative Hearings   Also called a State Fair Hearing.	If Aetna Better Health Premier Plan MMAI agrees with the original denial, in whole or in part, you can request an HFS State Fair Hearing through HFS Bureau of Administrative Hearings.    For items/services that are standardly covered by Medicaid it must be requested within 30 calendar days of the Level 1 Appeal.    For items/services that are standardly covered by both Medicaid and Medicare it must be requested within 30 calendar days of the Level 2 Reconsideration by the Independent Review Entity (IRE).   HFS Bureau of Administrative Hearings will review the appeal and notify of their decision within 90 days from the date of your Level 1 appeal request.	If Aetna Better Health Premier Plan MMAI agrees with the original denial, in whole or in part, you can request an HFS State Fair Hearing through HFS Bureau of Administrative Hearings.  For items/services that are standardly covered by Medicaid it must be requested within 30 calendar days of the Level 1 Appeal.    For items/services that are standardly covered by both Medicaid and Medicare it must be requested within 30 calendar days of the Level 2 Reconsideration by the Independent Review Entity (IRE).   HFS Bureau of Administrative Hearings will review the appeal and notify of their decision within 3 business days from the day it received your request.
3	Administrative Law Judge (ALJ)	If the IRE decision is unfavorable and the amount in dispute meets the appropriate threshold, you may request a hearing with the ALJ. You must follow the instructions on the notice from the IRE.	Same as standard appeal.
4	Medicare Appeals Council (MAC)	If the ALJ decision is unfavorable, you may appeal to the MAC, which is within the Department of Health and Human Services, which reviews ALJ's decisions.	Same as standard appeal.
5	Judicial Review	If you do not want to accept the decision, you might be able to continue to the next level of the review process. It depends on your situation including if the amount in dispute meets the appropriate threshold. Whenever the reviewer says no to your appeal, the notice you get will tell you whether the rules allow you to go on to another level of appeal. If the rules allow you to go on, the written notice will also tell you who to contact and what to do next if you choose to continue with your appeal.	Same as standard appeal.

 

Your doctor or other provider can make a request for you. Your doctor or other provider can request a coverage decision on your behalf. To request any appeal, your doctor or other provider must be appointed as your representative. If your representative holds durable power of attorney or guardianship papers, an Appointment of Representative form is not required.

For information about Coverage Determinations and Appeals see the Evidence of Coverage .