Part D complaints, coverage decisions & appeals

Contracting Provider Disputes

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

The Provider Services Manager assigns the Provider Dispute Form to a Provider Services Representative for research, analysis and review. Claims disputes are delegated to the Claims Investigation Department for research, analysis and review. Aetna Better Health of Ohio will inform the provider by email, fax, telephone or in writing of our 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 of Ohio’s Complaint System policy, as well as the Aetna Better Health of Ohio 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 stating 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 will effectuate the decision within thirty (30) calendar days of receipt of IRE’s notification of decision.

Provider Grievances
Both network and out-of-network providers may make a grievance verbally or in writing directly with Aetna Better Health of Ohio 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 grievances, and for disseminating information to the Provider about the status of the grievance. 

An acknowledgement letter will be sent within three (3) business days summarizing the grievance and will include instruction on how to:

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

If the grievance 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 grievance using applicable statutory, regulatory, and contractual provisions and Aetna Better Health of Ohio’s written policies and procedures, collecting pertinent facts from all parties. The grievance, along with all research, will be presented to the Grievance Committee for a decision. if the grievance is related to a clinical issue, the Grievance Committee will include a provider with the same or a similar specialty. The Grievance Committee will consider the additional information and will resolve the grievance within forty-five (45) calendar days.  The Appeals and Grievance Manager will send written notification within ten (10) calendar days of the resolution.

Provider Appeals Untimely Decision Making
Both network and out-of-network providers may file an appeal when Aetna Better Health denies a request for coverage untimely or does not issue a decision on a request for coverage timely.

Upon denial of coverage in whole or in part for an item/service that is covered by Medicaid only the provider will also have the option to request an appeal through the State Agency after completion of the Aetna Better Health Appeal process.  When the provider is filing an appeal on behalf of the member or requests and expedited appeal the appeal will be processed as a member appeal and subject to the requirements of the member appeal policy.

The Appeals and Grievance Department assumes primary responsibility for coordinating and managing Provider grievances.

Provider Appeals for untimely decision making are acknowledged within three (3) business days and processed within forty-five (45) calendar days of receipt of the appeal request. Notification of decision is made via telephone, email, fax or in writing within 2 business days of decision.

Provider complaints

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

We inform enrollees and providers of the complaints, appeals, 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 customer service . 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 DHS.

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.

Aetna Better Health of Ohio 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 of Ohio 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 representatives, if designated, are informed of their right to request a fast complaint in the Enrollee Handbook. The handbook also contains information about 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, 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 a State Fair Hearing as applicable.

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 Member Handbook. 

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 1-855-364-0974, TTY/TDD 7-1-1, 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 of Ohio.  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 Ohio, the QIO is Ohio KePro, which is located at:

Ohio KePro
Rock Run Center, Suite 100
5700 Lombardo Center Dr.
Seven Hills, OH 44131
webmaster@ohiokepro.com 
8 a.m. - 4:30 pm, Monday - Friday
216-447-9604

See chapter 9, section 11 for information about complaints in the Member Handbook

For items/services standardly covered by Medicaid only, an enrollee or their designated representative may submit complaints directly to the State, primarily through the Ombudsman’s office at 1-800-282-1206.

For items/services standardly covered by Medicare only, an enrollee or their designated representative may submit complaints directly to CMS through 1-800-MEDICARE.

For items/services standardly covered by both Medicaid and Medicare an enrollee or their designated representative may submit complaints directly to the State, primarily through the Ombudsman’s office at 1-800-282-1206, or to CMS through 1-800-MEDICARE.

Enrollee Appeals in the Member Handbook.

Aetna Better Health of Ohio members have the right to make an appeal, also called a “redetermination,” 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 seven (7) calendar days from the date the appeal was received. For payment decisions, we will notify the member in writing not later than 14 calendar days.

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

Aetna Better Health of Ohio
Appeals Department
7400 West Campus Road
Mail Code: F494
New Albany, OH 43054

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

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

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 his or her 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 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 of Ohio
  2. Reconsideration by the Independent Review Entity (IRE)
  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, with a clinical expert when necessary. Aetna Better Health of Ohio will notify the member in less than seven (7) calendar days.

If Aetna Better Health of Ohio agrees with the original denial, in whole or in part, the member or their authorized representative may request consideration through the IRE.

The IRE will review the appeal and notify all parties of their decision within seven (7) calendar days.  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 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 whom to contact and what to do next if the member chooses to continue with the appeal.

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, and include 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. 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 the appeal.

If Aetna Better Health of Ohio agrees with the original denial, in whole or in part, the member or their authorized representative may request reconsideration through the IRE.

The IRE will review the appeal and notify all parties of their decision within 72 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 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 whom to contact and what to do next if he or she chooses to continue with the appeal.