Non Part D complaints, coverage decisions & appeals

Non-Part D complaints, coverage decisions and appeals

Examples of 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 of Ohio’s 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’s or provider’s office.

Complaints about language access

• Your doctor or provider doesn’t 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

• 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?

Complaints about receiving a bill

• Did you receive a bill from your doctor or provider?

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 we have taken an extension on answering your coverage decision or appeal.
• If you believe we are not meeting deadlines for a standard coverage decision within 14 calendar days or an answer to an appeal within 15 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 for items that are standardly covered by Medicare or by both Medicare and Medicaid. 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 or thet State Fair Hearing decision 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 us a call at 1-855-364-0974 (TTY: 711), 24 hours a day, seven days a week.

Step 1: Contact us
Whether you call or write, you should contact Member Services right away.

• Start by calling Member Services. We will let you know what you need to do.
  24 hours a day, 7 days a week
  1-855-364-0974 (TTY: 711)
• If you don’t want to call (or you called with a question and were not satisfied with our answer), send your complaint to us in writing:
  Aetna Better Health of Ohio
  PO Box 818070
  Cleveland, OH 44181
• Fax: 1-855-883-9555

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.
• If your complaint is about access to services, we will respond in two business days.
• 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’ll 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.
• We will respond, whether we agree with the statement or not.  

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 of Ohio. If you make a complaint to the Quality Improvement Organization, Aetna Better Health of Ohio will work with them to resolve your complaint.
• You can make your complaint about quality of care to Aetna Better Health of Ohio and to the Quality Improvement Organization.

Livanta is Ohio’s Quality Improvement Organization. You may contact Livanta at 1-888-524-9900 (TTY: 1-888-985-8775) or by writing:

Livanta
Attention: Beneficiary Complaints
10820 Guilford Rd., Suite 202
Annapolis Junction, MD 20701

Toll-free Phone: 1-888-524-9900

Toll-free TTY: 1-888-985-8775


 


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 1-800-686-1578, TTY: 1-888-206-1327.

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

Medicare and Ohio Medicaid take your complaints seriously and will use this information to help improve the quality of the Medicare and Medicaid programs.

If you have any other feedback or concerns, or if you feel the plan is not addressing your problem, please call Medicare at 1-800-MEDICARE (1-800-633-4227) and TTY/TDD users can call 1-877-486-2048. Or you can call the Ohio Medicaid Hotline at 1-800-324-8680 and TTY/TDD users can call 1-800-292-3572. The call is free.

For Dual Eligible Members (those with Medicare and Medicaid coverage) See Chapter 9 of the Medicare-Medicaid Member Handbook/Evidence of Coverage in English or Spanish.

For those with Medicaid-Only coverage see page 37 of the Medicaid-Only Member Handbook here.

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 1-855-364-0974 (TTY: 711), 24 hours a day, seven days a week to ask for a coverage decision or an appeal.
• You can request a coverage decision or appeal in writing.
• Talk to your doctor or other provider.
  • For items standardly covered by Medicare of by both Medicare and Medicaid, your doctor or other provider can ask for a coverage decision or appeal on your behalf.
  • For items standardly covered by Medicaid only, you will need to notify us in writing that you want your doctor or other provider to 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 form on the Medicare website in English or Spanish. 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.
• If you have questions or need help with your appeal, including interpreter and translation services at no cost to you, call Aetna Better Health Member Services at 1-855-364-0974 (TTY: 711), 24 hours a day, seven days a week, and Aetna Better Health will assign a staff person who has not been involved in the complaint issue to help you.

Regulatory complaints

For items/services covered by Medicaid only, an enrollee or their designated representative may submit complaints directly to the State, by calling the Ohio Medicaid Hotline at 1-800-324-8680. Enrollees or their designated representative may also call the Ombudsman’s office at 1-800-282-1206. 

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 through Call the Ohio Medicaid Hotline at 1-800-324-8680.  Enrollee’s or their designated representative may also contact the Ombudsman’s office at 1-800-282-1206, or to CMS through 1-800-MEDICARE.

Appeals

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

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

Once the member receives a written notification, he or she may make an appeal within 60 days from the date of the notification letter. The member can call or write a letter to Aetna Better Health of Ohio 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 member in writing of the results of our reconsideration not later than 15 calendar days from the date the appeal was received. For payment decisions, we will notify the member in writing not later than 60 calendar days.

Members can call 1-855-364-0974 (TTY: 711) to make an appeal or send it to:

Aetna Better Health of Ohio

Appeals Department

PO Box 818070

Cleveland, Ohio 44181

Members can also fax the appeal to: 1-855-883-9555.

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

Members 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 of Ohio decides that the timeframe for the standard process could seriously jeopardize a member’s life, health or ability to regain maximum function, the review of that request will be fast. 

1. A member, a member’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 of Ohio. The member’s doctor may need to provide oral support to request an expedited appeal but does not need written support.

2. Aetna Better Health of Ohio must provide a fast appeal if we determine that applying the standard timeframe for making a determination may seriously jeopardize a member’s life or health or the ability to regain maximum function. 

3. A request made or supported by a member’s doctor will be fast if he/she tells us that applying the standard timeframe for making a determination may seriously jeopardize the member’s life or health or the ability to regain maximum function.

There are five levels to the Aetna Better Health of Ohio appeals process for denied services and payment.  Appeal options are determined by how the item or service being appealed is standardly covered by Medicare, Ohio 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.”

Appeal levels

1. Reconsideration by Aetna Better Health of Ohio
2. Reconsideration by the Independent Review Entity (IRE) and/or,
   Reconsideration by the Ohio Department of Job and Family Services Bureau of State Hearings
3. Administrative Law Judge (ALJ)
4. Medicare Appeals Council (MAC)
5. Judicial Review by a Federal District Judge

Standard review
Upon receipt of the appeal, Aetna Better Health of Ohio will send the member a letter to confirm the basis of the appeal. The reconsideration will be evaluated by an Appeals specialist, and with a clinical expert when necessary. Aetna Better Health of Ohio will notify the member in less than 15 calendar days for service requests (plus 14 days if an extension is taken) or in less than 60 calendar days for payment reconsiderations.

If Aetna Better Health of Ohio agrees with the original denial, in whole or in part, for a service that is standardly covered only by Ohio Department of Medicaid, the enrollee can request a reconsideration by the Ohio Department of Job and Family Services Bureau of State Hearings.

The Ohio Department of Job and Family Services Bureau of State Hearings will review the appeal and notify all parties of their decision within 70 calendar days from receipt of the State Fair Hearing request.

If the Aetna Better Health of Ohio 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 Aetna Better Health of Ohio 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 Ohio Department of Medicaid the case is automatically forwarded for reconsideration to the IRE.

The IRE will review the appeal and notify all parties of their decision within 30 days for service requests and 60 days for payment requests, from the day it 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 Ohio Department of Medicaid, the member may also request a reconsideration by the Ohio Department of Job and Family Services Bureau of State Hearings.  Aetna Better Health of Ohio will notify the member of this right, and how to request a State Fair Hearing if they have not already done so.

If the ALJ decision is unfavorable, the member may appeal to the MAC, which is 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.

The fast appeal process

Fast review
This is only available for reconsiderations for services not yet received. Upon receipt of the appeal, Aetna Better Health of Ohio 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 of Ohio will notify the member in writing if the appeal does not meet fast review criteria within two (2) calendar days of receipt, and will transfer the appeal to a standard review timeframe. For fast appeals, Aetna Better Health of Ohio 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 of Ohio agrees with the original denial, in whole or in part, for a service that is standardly covered only by Ohio Department of Job and Family Services, the enrollee can request a reconsideration by the Ohio Department of Medicaid Bureau of State Hearings.

The Ohio Department of Job and Family Services Bureau of State Hearings will review the appeal and notify all parties of their decision within 70 calendar days from receipt of the State Hearing request.

If the Aetna Better Health of Ohio 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 Aetna Better Health of Ohio 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 Ohio Department of Medicaid the case is automatically forwarded for reconsideration to the IRE.

The IRE will review the appeal and notify all parties of their decision within 72 hours for expedited requests and 30 days for standard requests, from the day it is received by the IRE (plus 14 days if an extension is taken).  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 Ohio Department of Medicaid, the member may still request a reconsideration by the Ohio Department of Job and Family Services Bureau of State Hearings.  Aetna Better Health of Ohio will remind the member of this right, and how to request a State Hearing if they have not already done so.

If the ALJ decision is unfavorable, the member may appeal to the MAC, which is 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.