Non-Part D Complaints, Coverage Decisions & Appeals

Aetna Better Health℠ Premier 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 will be 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 PREMIER PLAN

PO Box 66215

Phoenix, AZ 85082

 

When a claim is denied for an item/service that is covered by Medicare only, or by both Medicare and Medicaid, non-contracted providers have the right to request a Non-Contracting Provider Claim Appeal. Non-contracting provider claim appeals must be submitted in writing with a completed Waiver of Liability form within 60 calendar days of the remittance advice. Please contact your Provider Relations rep for a copy of the form. The non-PAR Claim Appeal form can be located here.

If a non-contracting provider disagrees with a payment on a submitted claim for an item/service that’s covered by Medicare only or by both Medicare and Medicaid, the non-participating provider has the right to request a Non-Contracting Provider Payment Dispute. Non-Participating Provider Payment Disputes must be submitted in writing, with supporting documentation stating that they should receive a different payment under original Medicare, within 60 calendar days of the remittance advice.

If the provider remains in disagreement with the Non-Participating Provider Payment Dispute decision, the provider can submit a request in writing for Independent Review Entity (IRE) review within 180 calendar days of the remittance advice. The Non-Contracting Provider Payment Dispute decision letter gives information on how to request an IRE review. The IRE will process the request within 60 calendar days of receipt and will notify all parties of their decision concerning the appeal. If the decision is overturned, we effectuate the decision within 30 calendar days of receipt of IRE’s notification of decision. The non-PAR Claim Appeal form can be located here.

Both network and out-of-network providers may file a grievance verbally or in writing directly with Aetna Better Health℠ Premier Plan 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 45 business days.

Aetna Better Health℠ Premier Plan will communicate its decision via telephone, email or fax within 2 business days of the decision, or in writing if requested within 10 calendar days from the date of the decision.

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 45 calendar days of receipt of the appeal request. Notification of the decision is made via telephone, email, fax or mail within 2 business days of decision.

Overview
We take complaints and appeals very seriously. We want to know what’s wrong so we can improve our services. Enrollees can file a grievance or make an appeal if they are not satisfied. A network provider may act on behalf of an enrollee with the enrollee’s written consent. With that authorization, the provider may file a grievance, or request an appeal, a State Fair Hearing, an Independent Review Entity (IRE), an Administrative Law Judge (ALJ), a Medicare Appeals Council (MAC) review, or a Judicial Review, as applicable.

We inform enrollees and providers of the complaints, appeals, State Fair Hearing, IRE, ALJ, MAC and Judicial Review procedures. This information is also contained in the enrollee handbook and provider handbook. When requested, we give enrollees reasonable assistance in completing forms and taking other procedural steps. Our assistance includes, but is not limited to, interpreter services, alternate formats and toll-free numbers that have adequate TTY/TTD and interpreter capability.

Enrollee complaints
Enrollees have the right to file a grievance if they have a problem or concern about the care or services they have received. The grievance process is used for certain types of problems. This includes problems related to quality of care, waiting times and the customer service they received. A grievance may be made with us orally or in writing by the enrollee or the enrollee’s authorized representative. That includes providers.

In most cases, a decision on the outcome of the grievance is reached within 30 calendar days of the date the grievance was made. If we are unable to resolve a grievance within 30 calendar days, we may ask to extend the grievance decision date by 14 calendar days. In these cases, we will provide information describing the reason for the delay in writing to the enrollee and, upon request, to the State Agency.

Enrollees are advised in writing of the outcome of the investigation of the grievance within two calendar days of its resolution. 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.

Fast complaint resolution
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. These issues occur in situations where Aetna Better HealthSM Premier Plan has:

  • Taken an extension on prior authorization or appeal decision making timeframe; or
  • Determined that a enrollee’s request for fast prior authorization or fast appeal decision making does not meet criteria and has transferred the request to a standard request

Enrollees and their representatives, if designated, are informed of their right to request expedited grievances in the member handbook. They will also be informed of their rights in letters they will receive about the extension and denial of fast processing, prior authorization and appeals.

In most cases, a decision on the outcome of an expedited grievance is reached within 24 hours of the date the grievance was made. Enrollees are advised orally of the resolution within the 24 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.

Fast review
This is only available for reconsideration for services not yet received. Upon receipt of the appeal, Aetna Better HealthSM Premier Plan will review the request for reconsideration to determine if it meets fast review criteria. The reconsideration will be evaluated by an Appeals specialist, along with a clinical expert when necessary. Aetna Better Health℠ Premier Plan will notify the member in writing if the appeal does not meet fast review criteria within 2 calendar days of receipt, and will transfer the appeal to a standard review timeframe. Aetna Better HealthSM Premier Plan will notify the member of the reconsideration decision as fast as his or her condition requires, but not later than 72 hours after receiving an appeal (plus 14 days if an extension is taken).

If Aetna Better Health℠ Premier Plan agrees with the original denial, in whole or in part, for a service that is standardly covered only by Michigan Department of Community Health, the enrollee can request reconsideration by the State Office of Administrative Hearings and Rules for the Department of Community Health.

The State Office of Administrative Hearings and Rules for the Department of Community Health will review the appeal and notify all parties of their decision within 72 hours from receipt of the State Fair Hearing request.

If the Aetna Better Health℠ Premier Plan Level 1 appeal decision agrees with the original denial, in whole or in part, for a service that is standardly covered only by Medicare, the case is automatically forwarded for reconsideration to the IRE.

If the Aetna Better Health℠ Premier Plan Level 1 appeal decision agrees with the original denial, in whole or in part, for a service that is standardly covered by both Medicare and the Michigan Department of Community Health, the case is automatically forwarded for reconsideration to the IRE.

The IRE will review the appeal and notify all parties of their decision within 24 hours for service requests, and 10 days for payment requests, from the day the request is received by the IRE.  If the IRE decision is unfavorable and the amount in dispute meets the appropriate threshold, the member may request a hearing with the ALJ. The member must follow the instructions on the notice from the IRE.  If the service is standardly covered by both Medicare and the Michigan Department of Community Health, the member may also request a reconsideration by the State Office of Administrative Hearings and Rules for the Department of Community Health. Aetna Better HealthSM Premier Plan will notify the member of this right, and tell the member how to request a State Fair Hearing if he or she has not already done so.

If the ALJ decision is unfavorable, the member may appeal to the MAC, a council within the Department of Health and Human Services that reviews ALJ's decisions.

If the MAC decision is unfavorable and the amount in dispute meets the appropriate threshold, the member may file for Judicial Review through Federal Court.

If the member does not want to accept the decision, he or she might be able to continue to the next level of the review process. It depends on the situation. Whenever the reviewer says no to the member’s appeal, the notice he or she gets will tell him or her whether the rules allow the member to go on to another level of appeal. If the rules allow the member to go on, the written notice will also tell the member who to contact and what to do next if the member chooses to continue with the appeal.

An member may designate someone they know --a friend, relative, lawyer or provider -- to act on their behalf on a complaint.  This person is known as their representative.  Members should complete an AOR form to designate a representative to act on their behalf. The form is available on this site and on the CMS website. Members can also call Member Services and ask that an AOR be mailed to them. The form must be signed by the enrollee and by the person they designate to act on their behalf.

If the representative is the prescribing or other treating provider or holds durable power of attorney or guardianship papers, an Appointment of Representative form is not required.

Appointment of Representative form

Step by step: Making a complaint on behalf of an enrollee

Step 1: Contact us promptly – either by phone or in writing

Usually, calling Member Services is the first step. Member Services will let you know if there is anything else you need to do. You can contact Member Services at 1-855-676-5772 (TTY: 711), 24 hours a day, 7 days a week. The call is free.

If you don’t wish to call (or you called and were not satisfied), you can put your complaint in writing and send it to us. If you do this, it means that we will use our formal procedure for answering grievances.  You can complete the Submit a Grievance form. Whether you call or write to submit a complaint on behalf of a member, you will need to submit a completed Appointment of Representative (AOR) form designating you as the representative. Both you and the enrollee must sign the AOR.

Step 2: We will process

  • We will acknowledge your complaint.
  • We will look into your complaint.
  • If we cannot resolve your complaint over the phone, we will respond to your complaint within 30 calendar days.
  • If you made your complaint in writing or asked for a written response, or your complaint is related to quality of care, we will respond to you in writing within 30 calendar days.

A member may make a complaint to us regarding concerns of the quality of care received. Enrollees can also make complaints about quality of care to the Quality Improvement Organization.

For items or services covered by Medicare, an enrollee or their authorized representative may make a quality-of-care concern with the CMS-contracted Quality Improvement Organization (QIO). The QIO for Michigan is Livanta.

Livanta
10820 Guilford Rd., Suite 202
Annapolis Junction, MD 20701
Phone: 1-888-524-9900
Fax: 1-888-985-8775

Website: www.livantaqio.com

For items/services covered by Medicaid only, an enrollee or their designated representative may submit complaints directly to the state, primarily through the Medicaid Beneficiary Help Line at 1-800-642-3195. For items/services covered by Medicare only an enrollee or their designated representative may submit complaints direct to CMS through 1-800-MEDICARE.

For items/services covered by both Medicaid and Medicare, an enrollee or their designated representative may submit complaints directly to the State, primarily through the Medicaid Beneficiary Help Line at 1-800-642-3195, or to CMS through 1-800-MEDICARE.

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 by Medicare or 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 1-855-676-5772 (TTY: 711), 24 hours a day, 7 days a week. You can ask for a 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.

The member and his or her representative will need to call Member Services and ask for the Appointment of Representative form. The form is also available on the Medicare website. The member must give us a copy of the signed form.

Your patient also has the right to ask a lawyer to act for him or her. Members may call their own lawyers, or get the name of a lawyer from the local bar association or other referral service. Some legal groups will give free legal services if the member qualifies. If the member wants a lawyer to represent him or her, the member will need to fill out the Appointment of Representative form. However, a lawyer or a representative is not necessary to request any kind of coverage decision or appeal.

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

Please see the Aetna Better Health℠ Premier Plan Member Handbook for more information about Part D prescription drug coverage decisions and appeals.

To learn how many appeals and complaints Aetna Better Health℠ Premier Plan has processed, please contact us at 1-855-676-5772 (TTY: 711), 24 hours a day, 7 days a week. The call is free.

If you are notified of a coverage decision denial by Aetna Better Health℠ Premier Plan, the member or you as the appointed representative may submit a redetermination request (1st Level of Appeal). This needs to be done within 60 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.

If you are notified of a coverage decision denial by Aetna Better Health℠ Premier Plan, you as your patient’s appointed representative may submit a redetermination request (1st Level of Appeal). This needs to be done within 60 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.

 

Phone
1-855-676-5772
(TTY: 711), 24 hours a day, 7 days a week.

Mail
Aetna Better Health℠ Premier Plan
PO Box 818070
Cleveland, OH 44181

 

If Aetna Better Health℠ Premier Plan agrees with the original denial, in whole or in part, for a service that is standardly covered only by Michigan Department of Community Health, the enrollee can request a reconsideration by the State Office of Administrative Hearings and Rules for the Department of Community Health within 90 days of the denial and/or they may also request a reconsideration through a Patient’s Right to Independent Review (PRIRA) Organization within 60 days of the appeal denial letter.

The State Office of Administrative Hearings and Rules for the Department of Community Health will review the appeal and notify all parties of their decision within 90 calendar days from receipt of the State Fair Hearing request.

The Patient’s Right to Independent Review (PRIRA) Organization will review the appeal and notify all parties of their decision within 72 hours from receipt of the PRIRA review request.