Non-Part D complaints, coverage decisions and appeals

You have rights if you have a problem or complaint about the medical care you receive. Learn more about the complaints, coverage decisions and appeals process for medical care below.

If you are a Medicare-Medicaid participant with Aetna Better Health FIDA Plan, see Part D complaints, coverage decisions and appeals for information on these processes for Part D prescription drugs. Call the Medicaid Beneficiary Help Line at 1-888-692-6116 for help with a complaint or information request.

You have the right to get information about appeals, complaints, and exceptions that other participants have filed against our plan.  Call Participant Services at 1-855-494-9945 or TTY: 711 24 hours a day, 7 days a week.

You have the right to make a complaint if you have a problem or concern about the care or medical services you receive. The formal name for making a complaint is “filing a grievance.” A grievance is a complaint or dispute. The complaint process is used only for certain types of problems such as quality of care, waiting times and customer service. The information you provide us will be held in confidence.

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 FIDA Plan’s Participant Services?
  • Do you feel you are being encouraged to leave our plan (disenroll)?

Complaints about physical accessibility
Is it hard for you to physically access the health-care services and facilities at your doctor’s office?

Complaints about language access
Do you need someone to translate for you during your appointment, and you haven’t received this service?

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

Wait times

  • Did you have trouble getting an appointment, or wait too long to get it?
  • Have you been kept waiting too long (e.g., waiting too long on the phone, in the waiting room, in the exam room or getting a prescription)?
  • Have you waited too long for Participant 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

  • Do you believe we took more time than we said we would to give you an answer on your coverage decision or appeal?
  • Did we take an extension on giving you an answer on your coverage decision or appeal?

Other reasons you can make a complaint

  • You’ve asked us for a "fast response" for a coverage decision or appeal within 72 hours, and we said we wouldn’t provide a fast response.
  • We’ve taken an extension on answering your coverage decision or appeal.
  • You believe we’re not meeting deadlines for a standard coverage decision within 14 calendar days, or an answer to an appeal within 30 calendar days.
  • We didn't give you a decision within the timeframes above. In this case we are required to forward your case to the Integrated Administrative Hearing (IAH) office. If we don't do that, you can make a complaint.
  • Deadlines apply when a coverage decision we make is reviewed and the IAH 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.

Follow the process below for making a complaint.

  • Step 1: Contact us
    Whether you call or write, you should contact Participant Services right away. The complaint must be made within 60 calendar days after you had the problem.
  • Start by calling Participant Services at 1-855-494-9945 (TTY 711). We are available 24 hours a day, 7 days a week. We will let you know what you need to do.
  • If you don’t want to call (or you called and were not satisfied), send your complaint to us in writing. Our address is:

Aetna Better Health FIDA Plan
55 West 125th Street, Suite 1300
New York, NY  10027

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 Participant Services right away. You must make your complaint within 60 days after 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 couldn’t, 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 must 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 don’t agree with some or all of your complaint or don't take responsibility for the problem you are complaining about, we’ll let you know. Our response will include our reasons for this answer.

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

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

Livanta is New York’s Quality Improvement Organization. You may contact Livanta at 1-866-815-5440 or by writing:

Livanta
BFCC-QIO Program, Area 1
9090 Junction Drive, Suite 10
Annapolis Junction, MD 20701
Phone (toll free): 1-866-815-5440
TTY: 1-866-868-2289
Fax number for appeals: 1-855-236-2423
Fax number for all other reviews: 1-844-420-6671
BFCC-QIO

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

Phone 1-800-368-1019 (TDD 1-800-537-7697)
Fax 312-886-1807

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).

If you are a Medicare-Medicaid member, you also can send your complaint to Medicare. The Medicare Complaint form is available online.

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 1-877-486-2048). The call is free.

See information about complaints and grievances in the participant handbook.

What is a coverage decision?
A coverage decision is an initial decision we make about your benefits and coverage. This often concerns 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, you can ask us. Either of you can ask for a coverage decision before you receive the service.

There are many ways to get help about coverage decisions
You can call Participant Services at 1-855-494-9945 (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 Medicaid Beneficiary Hot Line at 1-888-692-6116 for free help.
  • Talk to your doctor or other provider. He or she 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 this person to act for you as your "representative." He or she can ask for a coverage decision or make an appeal on your behalf.
  • If you want a friend, relative, or other person to be your representative, call Participant Services and ask for the Appointment of Representative form. You can also get the 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’ll need to fill out the Appointment of Representative form.

Note: Remember, you don’t have to have a lawyer or a representative to ask for any kind of coverage decision or to make an appeal. You can do it yourself, following the steps above.

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 1-888-692-6116. 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 1-888-692-6116, or to CMS through 1-800-MEDICARE.

Aetna Better Health FIDA Plan participant have the right to make an appeal, also called a “reconsideration,” if they receive notice of any of the following:

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

Once the participant receives a written notification, he or she may make an appeal within 90 days from the date of the notification letter. The participant can call or write a letter to Aetna Better Health FIDA Plan to make an appeal. A special team will review the appeal to determine if we made the right decision. For authorization decisions, we will notify the participant in writing of the results of our reconsideration not later than 30 calendar days from the date the appeal was received. For payment decisions, we will notify the participant in writing no later than 60 calendar days after receiving the appeal.

Participants can call 1-855-494-9945 to make an appeal or send it to:

Aetna Better Health FIDA Plan
55 West 125th Street, Suite 1300
New York, NY  10027

Participants can also fax the appeal to: 1-855-264-3822.

If more time is needed to gather a participant’s medical records from their physicians, we may take a 14-day extension. A participant may also request an extension if he or she needs more time to present evidence to support the appeal. We will notify the participant in writing if an extension is required.

Participants may make a request for a fast appeal, also called an “expedited appeal,” if they believe that applying for the standard appeals process could jeopardize their life or health. If Aetna Better Health FIDA Plan decides that the timeframe for the standard process could seriously jeopardize a participant’s life, health or ability to regain maximum function, the review of that request will be fast.

  1. A participant, a participant’s appointed representative, or his or her doctor can request a fast appeal. A fast request can be submitted orally or in writing to Aetna Better Health FIDA Plan. The participant’s doctor may need to provide oral support to request an expedited appeal but does not need written support.
  2. Aetna Better Health FIDA Plan must provide a fast appeal if we determine that applying the standard timeframe for making a determination may seriously jeopardize a participant’s life or health or the ability to regain maximum function.
  3.  A request made or supported by a participant’s doctor will be fast if he/she tells us that applying the standard timeframe for making a determination may seriously jeopardize the participant’s life or health or the ability to regain maximum function.

There are four levels to the Aetna Better Health FIDA Plan appeals process for denied services and payment. Appeal options are determined by how the item or service being appealed is standardly covered by Medicare, New York Medicaid or both. The coverage decision letter will explain the appeal options for the item or service being denied.

The legal term for “fast appeal” is “expedited reconsideration.

Level 1
Reconsideration by Aetna Better Health FIDA Plan

Level 2
Reconsideration by the Integrated Administrative Hearing Office (IAHO)

Level 3
Medicare Appeals Council (MAC)

Level 4
Judicial Review by a Federal District Judge

Upon receipt of the appeal, Aetna Better Health FIDA Plan will send the participant a letter that we received the 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 your appeal no later than  than 30 calendar days from when it was received or no later than 60 calendar days for payment appeals.

If Aetna Better Health FIDA Plan agrees with the original denial, in whole or in part, the appeal is automatically forwarded for reconsideration to the Integrated Administrative Hearing Office (IAH) for review.

The IAHO will review the appeal and notify all parties of their decision within 7 calendar days for Medicaid prescription drug coverage appeals and within 90 calendar days for all other appeals. If the IAHO decision is unfavorable the IAHO decision letter will tell you if you have further appeals rights and how to request that appeal.

For services that are standardly covered by Medicare the next level appeal is a Medicare Appeals Council (MAC) review.  If the MAC decision is unfavorable and the amount in dispute meets the appropriate threshold, the participant may file for Judicial Review through Federal Court.

If the participant 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 participant’s appeal, the notice he or she gets will tell him or her whether the rules allow the participant to go on to another level of appeal. If the rules allow the participant to go on, the written notice will also tell the participant who to contact and what to do next, if the participant chooses to continue with the appeal.

If Aetna Better Health FIDA Plan agrees with the original denial, in whole or in part, the appeal is automatically forwarded for reconsideration to the Integrated Administrative Hearing Office (IAH) for review.

The IAHO will review the appeal and notify all parties of their decision within 72 hours from receipt of the State Fair Hearing request.