Grievance and Appeals
Members or their authorized representative can file a complaint, grievance or appeal with Aetna Better Health of Maryland orally or in writing. An authorized representative is someone who assists with the appeal on the member’s behalf, including but not limited to a family member, friend, guardian, provider, or an attorney. Representatives must be designated in writing before or within 10 business days of filing.
A network provider, acting on behalf of a member, and with the member’s written consent, may file a a standard appeal or grievance with Aetna Better Health of Maryland. A provider acting on behalf of a member may file an expedited appeal or grievance without written consent of the member. Members and their representatives, including providers with written consent, may also file a request for a Maryland Fair Hearing.
Members or their authorized representative can file an appeal with Aetna Better Health of Maryland orally or in writing. An authorized representative is someone who assists with the appeal on the member’s behalf, including but not limited to a family member, friend, guardian, provider, or an attorney. Representatives must be designated in writing. An appeal is a request to reconsider a decision (e.g., utilization review recommendation, benefit payment, administrative action), with Aetna Better Health of Maryland. Authorized member representatives, including providers, may also file an appeal on the member’s behalf with the written consent of the member.
The member or authorized representative may also appeal directly to Maryland Department of Health through the Maryland fair hearing process after the health plan’s appeal has been exhausted.
Member Appeals must be files with Aetna Better Health of Maryland no later than 60 calendar days from the date on the Aetna Better Health of Maryland Notice of Adverse Benefit Determination letter. The expiration date to file an appeal is included in the Notice of Action.
Maryland Fair Hearing
Members or their authorized representative, including a provider acting on their behalf with written consent, may request a Maryland Fair Hearing through Maryland Department of Health following the exhaustion of the health plan’s appeal. This request must be completed within 120 calendar days of the health plan’s appeal denial notice. Information on how to submit a Maryland fair hearing appeal is included in Aetna Better Health of Maryland Notice of Action (denial) letter.
Denials include reductions in service, suspensions, terminations, and denials. Members and their authorized representatives may also appeal a denial of payment for Medicaid covered services and failure to act on a request for services within required timeframes.
The request for a Maryland Fair Hearing must be submitted in writing within 120 calendar days of Aetna Better Health of Maryland’s notification of adverse action to the following:
Maryland Department of Health (DOH)
Office of Health Services
201 W. Preston Street, 1st Floor
Baltimore, Maryland 21201
If members wish services to continue while their Maryland Fair Hearing is reviewed, they must request a Maryland Fair Hearing within ten calendar days from the adverse action letter. At the Maryland Fair Hearing, members may represent themselves or be represented by a lawyer, their provider or their authorized representative, with the member’s written permission.
The department renders the final decision about services. If the decision agreed with Aetna Better Health of Maryland’s previous decision, and the member continued to receive services, the member may be responsible for cost of services received during the Maryland Fair Hearing. If the Maryland Fair Hearing decision favors the member, then Aetna Better Health of Maryland will commence the services immediately. If the member’s services were continued while the appeal was pending, Aetna Better Health of Maryland will provide reimbursement for those services according to the terms of the final decision rendered by the Department’s Maryland Fair Hearing Appeals Division.
Provider payment disputes
Network providers may file a payment dispute verbally or in writing direct to Aetna Better Health of Maryland to resolve billing, payment, and other administrative disputes for any reason including but not limited to: lost or incomplete claim forms or electronic submissions, requests for additional explanation as to services or treatment rendered by a health care provider, inappropriate or unapproved referrals initiated by the provider, or any other reason for billing disputes.
Provider payment disputes do not include disputes related to medical necessity. Providers can file a verbal dispute with Aetna Better Health of Maryland by calling Provider Services department at 1-866-827-2710. To file a dispute in writing, providers should write to:
Aetna Better Health of Maryland
Claims and Resubmissions
P.O. Box 61538
Phoenix, AZ 85082-1538
The Provider may also be asked to complete and submit the dispute form with any appropriate supporting documentation. If the dispute is regarding claim resubmission or reconsideration, the dispute may be referred to the Claims Inquiry Claims Research (CICR) department. For all disputes, Aetna Better Health of Maryland will notify the Provider of the dispute resolution by phone, email, and fax or in writing.
Both network and out-of-network providers may file a verbal complaint with Aetna Better Health of Maryland. Provider complaints are an expression of dissatisfaction filed with Aetna Better Health of Maryland that can be resolved outside of the formal appeal and grievance process. Provider complaints include but are not limited to dissatisfaction with:
- Policies and procedures
- A decision made by the Aetna Better Health of Maryland
- A disagreement as to whether a service, supply or procedure is a covered benefit, is medically necessary or is performed in the appropriate setting
Provider complaints requesting review of an action, that cannot be resolved through the informal complaint process; or that require a written decision will automatically be transferred to the provider appeal process. In addition, provider complaints about Aetna Better Health of Maryland staff, contracted vendors or other issues, not requesting review of an action, that require a written decision will automatically transferred to the provider grievance process. In cases where the complaint was transferred to the formal appeal or grievance process, they will be transferred with the original received date.
Compliants from a provider on behalf of a member with written consent, with the exception of an expedited request, that does not require written consent from the member, will be transferred to the member complaint process and subject to member complaint processes.
Providers can file a complaint with Aetna Better Health of Maryland by calling the Provider Services at 1-866-827-2710.