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 will be settled according to the terms of our contractual agreement. There will be no disruption or interference with the provision of services to members as a result of disputes.

Aetna Better Health℠ Premier Plan informs providers about the provider dispute process in our provider manual. You’ll also get more information in our newsletters, training, provider orientation and website updates. Our Provider Services representatives are available to discuss a provider’s dissatisfaction with a decision based on this policy and contractual provisions, inclusive of claim disputes.

In the case of a claim dispute, the provider must complete and submit the Provider Dispute form and any appropriate supporting documentation to their Provider Services manager. You may download the Provider Dispute form or request by fax or mail.

The Provider Services manager assigns the Provider Dispute form to a Provider Services representative to research, analyze and review. Claims disputes are delegated to the Claims Investigation department to research, analyze and review. We will contact the provider by email, fax, telephone or mail of our decision.

In the event the provider remains dissatisfied with the dispute determination, we will advise that a complaint may be initiated. Our Complaint System policy, as well as our provider manual, instructs how to submit a complaint.

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 call your Provider Relations rep for a copy.

Upon disagreement with a payment on a submitted claim for an item/service that is covered by Medicare only, or by both Medicare and Medicaid, non-participating providers have the right to request a Non-Contracting Provider Payment Dispute. Non-Contracting Provider Payment Disputes must be submitted in writing within 60 calendar days of the remittance advice. Providers should include documentation to support the claim that they should receive a different payment under original Medicare.

If the provider disagrees with the Non-Participating Provider Payment Dispute decision, the provider can submit a request in writing for IRE review within 180 calendar days of the remittance advice. The IRE will process the request within 60 calendar days of receipt and will notify all parties of their decision. If the decision is overturned, Aetna Better Health Premier Plan will effectuate the decision within 30 calendar days of receipt of IRE’s notification of decision.

 

Both network and out-of-network providers may make a complaint 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 manager assumes primary responsibility for coordinating and managing provider complaints, and for disseminating information to the provider about the status of the complaint.

We will send an acknowledgement letter within three business days summarizing the complaint, with instruction on how to:

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

If the complaint requires research or input by another department, the Appeals and Grievance manager will forward the information to the affected department and coordinate with the affected department to thoroughly research each complaint using applicable statutory, regulatory, and contractual provisions and our written policies and procedures, collecting pertinent facts from all parties. The complaint, along with all relevant research, will be presented to the Grievance Committee for decision.

The Grievance Committee will include a provider with the same or a similar specialty if the complaint is related to a clinical issue. The Grievance Committee will consider the additional information and will resolve the complaint within 45 calendar days. The Appeals and Grievance manager will send written notification within 10 calendar days of the resolution.

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, request an appeal, or ask for a State Fair Hearing. You can also ask for review by an Independent Review Entity (IRE), an Administrative Law Judge (ALJ), a Medicare Appeals Council (MAC) 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 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, including 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 to the enrollee in writing, describing the reason for the delay. Upon request, we will also send a letter to the State Agency.

Enrollees are advised in writing of the outcome of the grievance investigation within two calendar days of its resolution. The Notice of Resolution includes the decision reached, the reasons for the decision, and the telephone number and address where the enrollee can contact 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 Premier Plan resolves grievances effectively and efficiently, as the member'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 Health Premier Plan has:

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

Members and/or their designated representative are informed of their right to request expedited grievances in the member handbook. They are also informed of their rights in letters they receive concerning 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. Members 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, the reasons for the decision, and the telephone number and address where the enrollee can speak to someone regarding the decision. The notice also tells an enrollee how to get information on filing a State Fair Hearing, if this applies.

A 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. The member can also call Member Services and ask that an AOR be mailed to them. The member and the person they designate to act on their behalf must sign the form and by .

If you are acting as the representative, and are the prescribing or treating provider, you don’t need to fill out an Appointment of Representative form.

Step by step: Making a complaint on behalf of a member

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.

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 member 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. A member can also make complaints about quality of care to the Quality Improvement Organization.

For items or services covered by Medicare, a member or the authorized representative may also make a quality-of-care concern with the CMS contracted Quality Improvement Organization (QIO). The QIO in 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 directly to CMS through 1-800-MEDICARE (1-800-633-4227).

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 (1-800-633-4227).

What is a coverage decision?
A coverage decision is an initial decision we make about a member’s benefits and coverage or about the amount we will pay for his or her medical services or drugs. We’re making a coverage decision whenever we decide what is covered for the member and how much we pay.

If you are acting as your patient’s representative and are not sure if a service is covered by Medicare or Medicaid, you or your patient can ask for a coverage decision before you provide the service.

Who can I call with questions about coverage decisions?

Any of the below can help you.

  • To ask for a coverage decision or an appeal, just call Member Services at 1-855-676-5772 (TTY: 711), 24 hours a day, 7 days a week. You also can request a coverage decision or appeal in writing.
  • You can also get free help by calling the Beneficiary Help Line at 1-800-642-3195. This hotline helps Medicaid enrollees with problems.
  • The member can also ask a friend or family member to act for him or her. This person will act as the member’s representative to ask for a coverage decision or make an appeal.

If the member denotes another person to be his or her representative, he or she needs to call Member Services and ask for the Appointment of Representative form. The form is also available on the Medicare website. The form gives the person permission to act for your patient. He or she must also send us a copy of the signed form.

The member also has the right to ask a lawyer to act for him or her. This may be his or her own lawyer, a lawyer from the local bar association or another referral service. Some legal groups will provide 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, the member does not have to have a lawyer or a representative to ask for any kind of coverage decision or to make an appeal.

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

Please see the Aetna Better HealthSM 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 HealthSM Better Health has processed, please contact us at 1-855-676-5772 (TTY: 711), 24 hours a day, 7 days a week.

How the appeals process works
If you are notified of a coverage decision denial by Aetna Better Health℠ Premier Plan, you or the member 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. 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.

If you are notified of a coverage decision denial by Aetna Better Health℠ Premier Plan, you or the member 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. Or, you can complete a coverage redetermination form online. 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.

Coverage redetermination form
You can ask Member Services to mail you a coverage determination form. You can download and print it to send by mail or fax. Or, you can submit it online.

Coverage Redetermination form - submit online

Coverage Redetermination form - download and print

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

Mail

Aetna Better Health Premier Plan
Part D Appeals
Pharmacy Department
4500 E. Cotton Center Blvd.
Phoenix, AZ  85040
 
Fax
1-844-242-0914