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. You have the right to get information about appeals, complaints, and exceptions that other members have filed against our plan. Call Member Services at 1-866-600-2139 (TTY: 711), 24 hours a day, 7 days a week. The call is free.
If you don’t want to call (or you called and were not satisfied), send your complaint to us in writing:
See Part D complaints, coverage decisions and appeals for information on these processes for Part D prescription drugs.
To speak with the Office of the Medicare Ombudsman (OMO) for help with a complaint or information request, visit the website of the Ombudsman on Medicare.gov.
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 for certain types of problems only. The information you provide us will be held in confidence.
The complaint process is for certain types of problems only. This includes problems related to quality of care, waiting times and customer service.
If you have any of the problems below, you can file a complaint.
Quality of your medical care
Respecting your privacy
Disrespect, poor customer service or other negative behaviors
Complaints about physical accessibility
Complaints about language access
Cleanliness
Waiting times
Information you get from our plan
You can make a complaint:
Follow this process for making a complaint. If you have questions, please give Member Services a call at 1‑866‑600-2139 (TTY: 711), 24 hours a day, 7 days a week. The call is free.
Step 1: Contact us
Whether you call or write, you should contact Member Services right away. The complaint can be made at any time unless you are requesting remedial action, then it must be made within 60 calendar days after you had the problem that you want to complain about.
24 hours a day, 7 days a week
1‑866‑600-2139 (TTY: 711)
Formal complaint procedure
If you write us, it means that we will use our formal procedure for answering grievances. Here's how it works:
Step 2: We look into your complaint and give you our answer
Complaints about quality of care
You also can make complaints about quality of care to the Quality Improvement Organization. You can make your complaint about the quality of care you received to our plan by using the step-by-step process outlined above.
When your complaint is about quality of care, you have two extra options:
Livanta is Illinois’ Quality Improvement Organization. You may contact Livanta at 1-888-524-9900, or by Toll-Free TTY, 1-888-985-8775 or by writing:
Livanta
10820 Guilford Rd., Suite 202
Annapolis Junction, MD 20701
Website: www.livantaqio.com
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 1-800-252-8966, TTY: 1-888-206-1327.
Complaints to Medicare
You can send your complaint to Medicare. The Medicare Complaint Form is available.
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 users can call 1-877-486-2048. The call is free.
See chapter 9, section 11 for information about complaints and grievances in the Evidence of Coverage - English / Spanish.
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:
When to file an appeal
You have the right to file an appeal, also called a fast reconsideration,” with Aetna Better Health Premier Plan MMAI if you receive written notice of any of the following:
How the appeals process works
Once you receive a written notice, you may file an appeal within 60 days from the date of the notification letter. You can call or write a letter to Aetna Better Health Premier Plan MMAI to file an 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 our appeal not later than 15 business days from the date your appeal was received.
How to file an appeal
To file an appeal, call 1‑866‑600-2139, or send your appeal in writing by mail or fax. You can complete Request for Appeal form.
Aetna Better Health Premier Plan MMAI
Appeals Department
PO Box 818070
Cleveland, OH 44181
Fax your appeal to: 1-855-545-5196
If more time is needed to gather medical records from your physicians, we may file a 14-day extension. You also may request an extension if you need more time to present evidence to support your appeal. We will notify you in writing if an extension is required.
Expedited appeals
You may file a request for an expedited appeal, also called a redetermination, if you believe that applying for the standard appeals process could jeopardize your life or health. If Aetna Better Health Premier Plan MMAI decides that the timeframe for the standard process could seriously jeopardize your life or health, or ability to regain maximum function, the review of your appeal will be expedited.
Appeals levels and timelines
There are five levels to the Aetna Better Health Premier Plan MMAI appeals process for denied services and payment:
Appeal level |
Standard review |
Expedited (fast) review |
|
1 |
Reconsideration by Aetna Better Health Premier Plan MMAI |
Upon receipt of your appeal, Aetna Better Health Premier Plan MMAI will send you 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 MMAI will notify you in less than 15 business (plus 14 calendar days if an extension is filed) |
Only available for reconsiderations for services not yet received. Subject to expedited review criteria. Aetna Better Health Premier Plan MMAI will notify you if the appeal does not meet expedited review criteria.
Aetna Better Health Premier Plan MMAI will notify you of the reconsideration decision as fast as your condition requires, but not later than 24 hours after receiving all information for your appeal |
2 |
Reconsideration by the Independent Review Entity (IRE) |
If Aetna Better Health Premier Plan MMAI agrees with the original denial, in whole or in part, the file is automatically forwarded for reconsideration to the IRE for items/services that are standardly covered by Medicare.
The IRE will review the appeal and notify of you of their decision within 30 days from the day it is received by the IRE. |
If Aetna Better Health Premier Plan MMAI agrees with the original denial, in whole or in part, your file is automatically forwarded to the IRE for reconsideration within 24 hours for items/services that are standardly covered by Medicare. The IRE will review your appeal and notify you of their decision within 24 hours of receipt of the appeal file from Aetna Better Health Premier Plan MMAI. |
|
Reconsideration by the Medicaid External Independent Review |
If Aetna Better Health Premier Plan MMAI agrees with the original denial, in whole or in part, you can request a Medicaid External Independent Review items/services that are standardly covered by Medicaid. It must be requested within 30 calendar days of the Level 1 Appeal.
The Medicaid External Independent Review organization will review the appeal and notify of their decision within 45 days from the day it received your request. |
If Aetna Better Health Premier Plan MMAI agrees with the original denial, in whole or in part, you can request a Medicaid External Independent Review items/services that are standardly covered by Medicaid. It must be requested within 30 calendar days of the Level 1 Appeal. The Medicaid External Independent Review organization will review the appeal and notify of their decision within 72 hours from when it received your request. |
|
Reconsideration by the Illinois Department of Health Care and Family Services (HFS) Bureau of Administrative Hearings
Also called a State Fair Hearing. |
If Aetna Better Health Premier Plan MMAI agrees with the original denial, in whole or in part, you can request an HFS State Fair Hearing through HFS Bureau of Administrative Hearings.
For items/services that are standardly covered by Medicaid it must be requested within 30 calendar days of the Level 1 Appeal.
For items/services that are standardly covered by both Medicaid and Medicare it must be requested within 30 calendar days of the Level 2 Reconsideration by the Independent Review Entity (IRE).
HFS Bureau of Administrative Hearings will review the appeal and notify of their decision within 90 days from the date of your Level 1 appeal request. |
If Aetna Better Health Premier Plan MMAI agrees with the original denial, in whole or in part, you can request an HFS State Fair Hearing through HFS Bureau of Administrative Hearings. For items/services that are standardly covered by Medicaid it must be requested within 30 calendar days of the Level 1 Appeal.
HFS Bureau of Administrative Hearings will review the appeal and notify of their decision within 3 business days from the day it received your request. |
3 |
Administrative Law Judge (ALJ) |
If the IRE decision is unfavorable and the amount in dispute meets the appropriate threshold, you may request a hearing with the ALJ. You must follow the instructions on the notice from the IRE. |
Same as standard appeal. |
4 |
Medicare Appeals Council (MAC) |
If the ALJ decision is unfavorable, you may appeal to the MAC, which is within the Department of Health and Human Services, which reviews ALJ's decisions. |
Same as standard appeal. |
5 |
Judicial Review |
If you do not want to accept the decision, you might be able to continue to the next level of the review process. It depends on your situation including if the amount in dispute meets the appropriate threshold. Whenever the reviewer says no to your appeal, the notice you get will tell you whether the rules allow you to go on to another level of appeal. If the rules allow you to go on, the written notice will also tell you who to contact and what to do next if you choose to continue with your appeal. |
Same as standard appeal. |
Your doctor or other provider can make a request for you. Your doctor or other provider can request a coverage decision on your behalf. To request any appeal, your doctor or other provider must be appointed as your representative. If your representative holds durable power of attorney or guardianship papers, an Appointment of Representative form is not required.
For information about Coverage Determinations and Appeals see the Evidence of Coverage .
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