Complaints, Coverage Decisions & Appeals

Aetna Better Health℠ of Michigan (Premier Plan & Medicaid Plan) and our contracted providers are responsible for timely resolution of any disputes between both parties. Disputes are settled according to the terms of our contractual agreement. There will be no disruption or interference with the provision of services to enrollees as a result of disputes.

Your Provider Services representative is available to discuss any dissatisfaction with a decision based on this policy and contractual provisions, inclusive of claim disputes.

In the case of a claim dispute, you may will be asked required to complete and submit the Provider Dispute form  and any appropriate supporting documentation to the Provider Services department. Incomplete Disputes lacking all required forms and documentation will be returned to the provider unprocessed.  Please ensure you include all required information as identified on the form.  Disputes must be mailed to:

 
AETNA BETTER HEALTH OF MICHIGAN

Medicaid & Premier Plans

PO BOX 66215

Phoenix, AZ 85082

You may download the Provider Dispute form or request one via fax or mail. After reviewing your dispute, we’ll inform you of our decision via email, fax, telephone or mail.

In the event you remain dissatisfied with the dispute determination, we will notify you that a grievance or appeal may be initiated as appropriate. Our Grievance and Appeal policies (also in our provider manual) instruct how you can submit a grievance or appeal.

Both network and out-of-network providers may file a grievance verbally or in writing directly with Aetna Better Health of Michigan in regard to our policies, procedures or any aspect of our administrative functions. 

The Appeals and Grievance department assumes primary responsibility for coordinating and managing provider grievances. 

An acknowledgement letter will be sent within three business days summarizing the grievance and will include instructions on how to:

  • Revise the grievance within the timeframe specified in the acknowledgement letter
  • Withdraw a grievance at any time until Grievance Committee review. 

If the grievance requires research or another department’s input, the Appeals and Grievance department will forward the information to the affected department and coordinate with the affected department to thoroughly research each grievance using applicable statutory, regulatory, and contractual provisions and Aetna Better Health’s written policies and procedures, collecting pertinent facts from all parties. The grievance, with all research included, will be presented to the Grievance Committee for decision. If the grievance is related to a clinical issue, the Grievance Committee will include a provider who has the same or a similar specialty. The Grievance Committee will consider the additional information and will resolve the grievance within 35 calendar days. 

Aetna Better Health of Michigan will communicate its decision via telephone, email or fax within 2 business days of the decision, and 3 calendar days in writing.

Both network and out-of-network providers may file an appeal when Aetna Better Health℠ Premier Plan is untimely denying a request for coverage or does not issue a decision on a request for coverage in a timely manner.

Upon denial of coverage in whole or in part for an item/service that is covered by Medicaid only, the provider will also have the option to request an appeal through the State agency after completion of the plan appeal process.

When the provider is filing an appeal on behalf of the member, or requests an expedited appeal, the appeal will be processed as a member appeal and subject to the requirements of the member appeal policy.

The Appeals and Grievance department assumes primary responsibility for coordinating and managing provider grievances.

Provider appeals for untimely decisions are acknowledged within 3 business days, and processed within 35 calendar days of receipt of the appeal request. Notification of the decision is made via telephone, email, fax or mail within 3 business days of decision.

Aetna Better Health resolves grievances effectively and efficiently as the enrollee’s health requires. Fast complaints are also called "expedited grievances." On occasion, certain issues may require a quick decision.

In most cases, a decision on the outcome of an expedited grievance is reached within 72 hours of the date the grievance was made. Enrollees are advised orally of the resolution within the 72 hours, followed by a written notification of resolution within 2 calendar days of the oral notification. The Notice of Resolution includes the decision reached and the reasons for the decision, and the telephone number and address where the enrollee can speak with someone regarding the decision. The notice also tells an enrollee how to obtain information on filing a State Fair Hearing if applicable.

What is a coverage decision?

A coverage decision is the initial decision we make about a member’s benefits and coverage. It also determines the amount we will pay for the member’s medical services or drugs. We make a coverage decision whenever we decide what is covered for an enrollee and how much we will pay.  If you are not sure if a service is covered Medicaid, you or your patient can ask for a coverage decision before the service is provided.

Who can I call with questions about coverage decisions?

Any of the below can help you.

To request a coverage decision or an appeal on a member’s behalf, just call Member Services at 1-866-316-3784 (TTY 711). The line is open 24 hours a day, 7 days a week. You can ask for coverage decision or appeal in writing.

You can also get free help by calling the Beneficiary Help Line at 1-800-642-3195. The Help Line helps solve problems for Medicaid enrollees.

Your patient can also ask another provider, friend or family member to act on his or her behalf. This person will act as his or her representative to ask for a coverage decision or make an appeal.

Providers may submit a Pre-Service Authorization Member Appeal on the member’s behalf for authorization denials.  The instructions on how to appeal a UM decision on behalf of a member are

included in the Denial Letter sent by Utilization Management.  Please refer to the instructions provided in the Denial Letter.  This Appeal should be done immediately following receipt of the Denial

letter, prior to service,  and prior to any claim submission.  Note: this Appeal is not the same as a Claim Appeal that would be submitted by non-PAR providers, as it precedes the submission of a

claim, and is a Member Appeal, not a Provider Appeal.  Member Appeals are received by our Grievance & Appeals department who will coordinate the request with Utilization Management.

If your patient, or you as your patient’s representative, receives a denial notice for a prescription drug, you have the right to file an appeal, also called a “redetermination” request. 

Please see the Aetna Better Health℠ of Michigan Member Handbook for more information about prescription drug coverage decisions and appeals. 

If you are notified of a coverage decision denial by Aetna Better Health℠ of Michigan, the member or you as the appointed representative may submit a redetermination request (1st Level of Appeal). This needs to be done within 90 calendar days from the date of the written notice. You may submit an appeal after this timeframe if you have good cause. 

You can make a request by phone, fax or in writing. Or, you can complete a coverage decision form. The request needs to include a supporting statement that provides the medical reasons for the drug requested. You also can submit a coverage decision or exception request to CVS Caremark.

Within 90 days of an Adverse Action Notice, the member has the right to request a State Fair Hearing through the Michigan Department of Health and Human Services. Members Services can assist members with completing the Request for State Fair Hearing form by calling 1-866-316-3784 (TTY 711). This request can be submitted during the appeals process. 

Submit request to:
Michigan Administrative Hearing System
For the Department of Health and Human Services
P.O. Box 30763
Lansing, MI 48909
1-877-833-0870