Non-Part D complaints, coverage decisions & appeals

Provider Complaint System: Complaints & Appeals

Contracting Provider Disputes

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 and there will be no disruption or interference with the provision of services to enrollees as a result of disputes.

Aetna Better Health Premier Plan will inform providers through the Provider Handbook and other methods, including newsletters, training, provider orientation, the website and by the provider calling their Provider Services Representative about the provider dispute process. Aetna Better Health Premier Plan’s 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 Aetna Better Health Plan’s Provider Services Manager. The Provider Dispute Form is accessible on Aetna Better Health Plan’s website, via fax or by mail. 

The Provider Services Manager assigns the Provider Dispute Form to a Provider Services Representative to research, analysis and review. Claims disputes are delegated to Claims Investigation Department to research, analysis and review. Aetna Better Health will contact the provider by email, fax, telephone or in writing of its decision.

In the event the provider remains dissatisfied with the dispute determination the Provider is notified that a complaint may be initiated. Aetna Better Health Premier Plan’s Complaint System policy, as well as the Aetna Better Health Premier Plan Provider Handbook, includes the process by which the provider can submit a complaint.

Non-Contracting Provider Claim Appeals
Upon denial of payment on a claim 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 (WOL) form within sixty (60) calendar days of the remittance advice.

Non-Contracting Provider Payment Disputes
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 Non-Contracting Provider Payment Dispute.   Non-Participating Provider Payment Disputes must be submitted in writing with the supporting documentation that they should receive a different payment under original Medicare within sixty (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 IRE review within one-hundred-eighty (180) calendar days of the remittance advice.   The IRE will process the request within sixty (60) calendar days of receipt and will notify all parties to the appeal of their decision.  If the decision is overturned Aetna Better Health Premier Plan will effectuate the decision within thirty (30) calendar days of receipt of IRE’s notification of decision.

Provider Complaints
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. 

An acknowledgement letter will be sent within three (3) business days summarizing the complaint and will include 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 Aetna Better Health Premier Plan’s written policies and procedures, collecting pertinent facts from all parties. The complaint with all research will be presented to the Grievance Committee for decision. The Grievance Committee will include a provider with same or 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 forty-five (45) calendar days. The Appeals and Grievance Manager will send written notification within ten (10) calendar days of the resolution.

Enrollee Complaint System: Complaints, coverage decisions & appeals

Overview

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

Contracting providers can file disputes about any aspect of our administrative functions and their contractual provisions, inclusive of claim disputes. Non-contracting providers can file a non-contracting provider claim appeal and a non-contracting provider payment dispute. Both contracting and non-contracting providers may file a provider complaint.

We inform enrollees and providers of the complaints, appeals, External Independent Review and 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 make a complaint if they have a problem or concern about the care or services they have received. The complaint process is used for certain types of problems. This includes problems related to quality of care, waiting times and the customer service you receive. A complaint 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 complaint is reached within thirty (30) calendar days of the date the complaint was made. If we are unable to resolve a complaint within thirty (30) calendar days, we may ask to extend the complaint decision date by fourteen (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 HFS.

Enrollees are advised in writing of the outcome of the investigation of the complaint within two (2) 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 an External Review or State Fair Hearing as applicable.

Fast Complaint Resolution

Aetna Better Health Premier Plan resolves complaints 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, known as fast complaints, 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 enrollee’s request for fast prior authorized or fast appeal decision making does not meet criteria and has transferred the request to a standard request

Enrollees and their representative if designated are informed of their right to request an fast complaint in the Enrollee Handbook and in the extension and denial of fast processing prior authorization and appeal letters.

In most cases, a decision on the outcome of a fast complaint is reached within twenty-four (24) hours of the date the complaint was made. Enrollees are advised orally of the resolution within the twenty-four (24) hours followed by a written notification of resolution within two (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 an External Review or State Fair Hearing as applicable.

Appointment of Representative (AOR)

An enrollee 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.  Enrollees should complete an AOR form to designate a representative to act on their behalf. The form is available on the CMS website, on this site and by calling Member Services and requesting 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

See chapter 9, section 6 for information about Coverage Decisions and Appeals in the Evidence of Coverage

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. If there is anything else you need to do, Member Services will let you know. You can contact Member Services at 1-866-600-2139, TTY/TDD 1-800-526-0857, 24 hours a day, 7 days a week.
  • If you do not 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 an enrollee you will need to submit a completed AOR form designating you as the representative.  The AOR must be signed by both the enrollee and you.

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.

Enrollees can also make complaints about quality of care to the Quality Improvement Organization
An enrollee may make a complaint regarding concerns of the quality of care received with Aetna Better Health Premier Plan.  For items or services covered by Medicare an enrollee or their authorized representative may also make a quality of care concern with the CMS contracted Quality Improvement Organization (QIO).  In Illinois, the QIO is Telligen, which is located at:

Telligen
711 Jorie Boulevard
Oak Brook, IL 60523
630-928-5800

See chapter 9, section 11 for information about complaints in the Evidence of Coverage - English

Regulatory Complaints

For items/services covered by Medicaid only an enrollee or their designated representative may submit complaints direct to the State, primarily through the Ombudsman’s office at 312-814-2121.  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 direct to the State, primarily through the Ombudsman’s office at 312-814-2121 or to CMS through 1-800-MEDICARE.

Enrollee Appeals in the Evidence of Coverage - English

Appeals

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

  • Aetna Better Health of Premier Plan denied payment for renal dialysis services a member received while temporarily outside of the Aetna Better Health Premier Plan service area
  • Aetna Better Health Premier Plan denied payment for emergency services, post-stabilization care or urgently needed services a member received while temporarily outside of the Aetna Better Health Premier Plan service area
  • Aetna Better Health Premier Plan denied payment for any other health services furnished by a provider that a member believes should be covered
  • Aetna Better Health Premier Plan 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 Premier Plan 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 Premier 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 member in writing of the results of our reconsideration not later than 15 business 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 1-866-600-2139 to make an appeal or send it to:

Aetna Better Health Premier Plan
Appeals Department
333 West Wacker Drive
Mailstop F646
Chicago, IL 60606

Members can also fax the appeal to: 1-855-545-5196

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.

The fast appeal process

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 Premier Plan 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 Premier Plan, and the member’s doctor may need to provide oral or written support for the request for a fast appeal.

2. Aetna Better Health Premier Plan must provide a fast appeal if it determines 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 his or her life or health or the ability to regain maximum function.

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

There are five levels to the Aetna Better Health Premier 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, Illinois Department of Healthcare and Family Services or both.  The coverage decision letter will explain the appeal options for the item or service being denied,

Appeal levels

  1. Reconsideration by Aetna Better Health Premier Plan
  2. Reconsideration by the Independent Review Entity (IRE)
    Reconsideration by the Illinois Department of Healthcare and Family Services Bureau of Administrative Hearings
    Reconsideration by an Illinois External Independent Reviewer
  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 Premier Plan will send the member a letter to confirm the basis of the appeal. The reconsideration will be evaluated by an Appeals specialist, with a clinical expert when necessary. Aetna Better Health Premier Plan will notify the member in less than 15 business 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 Premier Plan agrees with the original denial, in whole or in part, for a service that is standardly covered only by Illinois Department of Healthcare and Family Services the enrollee can request a reconsideration by the Illinois Department of Healthcare and Family Services Bureau of Administrative Hearings and / or an Illinois External Independent Review.

The Illinois External Independent Review organization will review the appeal and notify all parties of their decision within 5 calendar days of receipt of all information not to exceed 45 calendar days from receipt of the appeal.

The Illinois Department of Healthcare and Family Services Bureau of Administrative Hearings will review the appeal and notify all parties of their decision within 90 calendar days from the Level 1 Appeal requests to Aetna Better Health Premier Plan.

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 Medicare the file is automatically forwarded for reconsideration to the IRE.  

If Aetna Better Health Premier Plan agrees with the original denial, in whole or in part, for a service that is standardly covered by both Medicare and Illinois Department of Healthcare and Family Services the file is automatically forwarded for reconsideration to the IRE and the member can also request a reconsideration by the Illinois External Independent Review. 

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 Illinois Department of Healthcare and Family Services the member may also request a reconsideration by the Illinois Department of Healthcare and Family Services Bureau of Administrative Hearings. Aetna Better Health Premier Plan will notify the member of this right and how to request a Bureau of Administrative 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, which reviews ALJ's decisions.

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.

Fast review

Only available for reconsiderations for services not yet received. Upon receipt of the appeal, Aetna Better Health 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, 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 timeframes. Aetna Better Health Premier Plan will notify the member of the reconsideration decision as fast as his or her condition requires, but not later than 24 hours after receiving your 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 Illinois Department of Healthcare and Family Services the enrollee can request a reconsideration by the Illinois Department of Healthcare and Family Services Bureau of Administrative Hearings and / or an Illinois External Independent Review.

The Illinois External Independent Review organization will review the appeal and notify all parties of their decision within 72 hours.

The Illinois Department of Healthcare and Family Services Bureau of Administrative Hearings will review the appeal and notify all parties of their decision within 3 business days.

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 Medicare the file is automatically forwarded for reconsideration to the IRE.

If Aetna Better Health Premier Plan agrees with the original denial, in whole or in part, for a service that is standardly covered by both Medicare and Illinois Department of Healthcare and Family Services the file is automatically forwarded for reconsideration to the IRE and the member can also request a reconsideration by the Illinois External Independent Review. 

The IRE will review the appeal and notify all parties of their decision within 24 hours 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 Illinois Department of Healthcare and Family Services the member may also request a reconsideration by Illinois Department of Healthcare and Family Services Bureau of Administrative Hearings.  Aetna Better Health Premier Plan will notify the member of this right and how to request a Bureau of Administrative 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, which reviews ALJ's decisions.

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.

Appointment of representative

An enrollee may designate someone they know, a friend, relative, lawyer or provider to act on their behalf on an appeal.  This person is known as their representative.  Enrollees should complete an AOR form to designate a representative to act on their behalf. The form is available on the CMS website, on this site and by calling Member Services and requesting 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. You can also click here to print a copy of the Appointment of Representative form. The completed and signed form is valid for one (1) year unless the enrollee requests a shorter timeframe

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.

See chapter 9, section 6 for information about Coverage Decisions and Appeals in the Evidence of Coverage

Step-by-Step: Filing an appeal on behalf of an enrollee

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

  • Appeals must be made within 60 calendar days of the coverage decision notice
  • Usually, calling Member Services is the first step. If there is anything else you need to do, Member Services will let you know. You can contact Member Services at 1-866-600-2139, TTY/TDD 1-800-526-0857, 24 hours a day, 7 days a week.
  • If you do not wish to call (or you called and were not satisfied), you can put your appeal in writing and send it to us. If you do this, it means that we will use our formal procedure for answering appeals.  You can complete the Request for Appeal form.
  • Whether you call or write to submit a complaint on behalf of an enrollee you will need to submit a completed AOR form designating you as the representative.  The AOR must be signed by both the enrollee and you.

Step 2: We will process

  • We will acknowledge your appeal
  • We will look into your appeal
  • We will process the appeal as quickly as the enrollee’s health condition requires not to exceed 15 business days.
  • We will send all parties to the appeal a copy of the appeal decision letter

If you would like to learn how many appeals and complaints Aetna Better Health Premier Plan has processed, please contact our representatives at 1-866-600-2139 Hearing Impaired call (TTY/TDD: 1-800-526-0857), 24 hours a day, 7 days a week. Or you may write to us at:

Aetna Better Health Premier Plan
333 West Wacker Drive
Mailstop F646
Chicago, IL 60606