Non-Part D Complaints, Coverage Decisions & Appeals

Non-Part D complaints, coverage decisions and appeals

Complaints

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 only for certain types of problems such as quality of care, waiting times and customer service. The information you provide us will be held in confidence. Please see the Aetna Better Health^SM Premier Plan Member Handbook for detailed information and timelines for filing a grievance.

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^SM Premier Plan’s Member Services?
• Do you feel you are being encouraged to leave our plan (disenroll)?

Complaints about physical accessibility
Is it hard for you to physically access the health-care services and facilities at your doctor’s office?

Complaints about language access
Do you need someone to translate for you during your appointment, and you haven’t received this service?

Cleanliness
Are you unhappy with the cleanliness or condition of a doctor's office, provider’s site, clinic or hospital?

Wait times

• Did you have trouble getting an appointment, or wait too long to get it?
• Have you been kept waiting too long (e.g., 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

• Did we take an extension on giving you an answer on your coverage decision or appeal?

Other reasons you can make a complaint

• You’ve asked us for a "fast response" for a coverage decision or appeal within 72 hours, and we said we wouldn’t provide a fast response.
• We’ve taken an extension on answering your coverage decision or appeal.
• We didn't give you a decision within the timeframes above. In this case we are required to forward your case to the Independent Review Entity. 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 Entity (IRE) 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 the process below for making a complaint.

Step 1: Contact us
Whether you call or write, you should contact Member Services right away. The complaint must be made within 60 calendar days after you had the problem.

Start by calling Member Services at 1-855-676-5772 (TTY: 711), 24 hours a day, 7 days a week. The call is free. We will let you know what you need to do.

If you don’t want to call (or you called and were not satisfied), send your complaint to us in writing. Our address is:

Aetna Better Health Premier Plan

PO Box 818070

Cleveland, OH 44181

Formal 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 must make your complaint within 60 calendar days after the problem you want to report.

If your complaint is about access to services, we will respond in 2 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 must give you an answer within 24 hours.

We respond to all grievances 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 calendar 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 calendar days (44 calendar days total) to answer your complaint.

If we don’t agree with some or all of your complaint or don't take responsibility for the problem you are complaining about, we’ll let you know. Our response will include our reasons for this answer.

Complaints about quality of care

When your complaint is about quality of care, you have two extra options:

1. You can make your complaint directly to the Quality Improvement Organization. You don’t have to make the complaint with Aetna Better Health℠ Premier Plan. If you make a complaint to the Quality Improvement Organization, Aetna Better Health℠ Premier Plan will work with them to resolve your complaint.
2. You can make your complaint about quality of care to Aetna Better Health℠ Premier Plan and to the Quality Improvement Organization.

Livanta is Michigan’s Quality Improvement Organization. You may contact Livanta at 1-888-524-9900 or by writing:

Livanta
10820 Guilford Rd., Suite 202
Annapolis Junction, MD 20701

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

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

Website: www.livantaqio.com

Complaints about disability access or language access

If you have a complaint about disability access or about language assistance, you can file a complaint with:

• Member Services at 1-855-676-5772 (TTY: 711)
• Office of Civil Rights at the Department of Health and Human Services
• Both of us

Office for Civil Rights
U.S. Department of Health and Human Services
233 N. Michigan Ave., Suite 240
Chicago, IL 60601

Phone 1-800-368-1019 (TDD 1-800-537-7697)
Fax 1-312-886-1807

You may also have rights under the Americans with Disability Act. You can call the Senior HelpLine for help at 1-800-252-8966 (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 at Medicare.gov.

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 1-877-486-2048). The call is free.

See information about complaints and grievances in the member handbook.

Coverage decisions

What is a coverage decision?
A coverage decision is an initial decision we make about your benefits and coverage. This often concerns 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, you can ask us. Either of you can ask for a coverage decision before you receive the service.

There are many ways to get help about coverage decisions
You can call Member Services at 1-855-676-5772 (TTY: 711), 24 hours a day, 7 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. He or she can 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 this person to act for you as your "representative." He or she can ask for a coverage decision or make an appeal on your behalf.
• 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 (English | Español) on the Medicare website. 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’ll need to fill out the Appointment of Representative form.

Note: Remember, you don’t have to have a lawyer or a representative to ask for any kind of coverage decision or to make an appeal. You can do it yourself, following the steps above.

 

Complaints to Medicare and Michigan Medicaid

We are here to help you. We take your concerns seriously. To make a complaint, call Members Services at 1-855-676-5772 (TTY: 711), 24 hours a day, 7 days a week. Tell the representative you'd like to make a complaint. If you are still dissatisfied after we help you, you may contact Medicare and Michigan Medicaid.

For items/services covered by Medicaid only, an enrollee or their designated representative may submit complaints directly to the State, primarily through the Medicaid Beneficiary Help Line at 1-800-642-3195. 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, primarily through the Medicaid Beneficiary Help Line at 1-800-642-3195, or to CMS through 1-800-MEDICARE.

Appeals

Aetna Better Health℠ Premier Plan members have the right to make an appeal, also called a “reconsideration.” A member, a member’s appointed representative, or the member’s provider with the members written consent may request a standard appeal on behalf of the member. The following are some examples of appeals. Appeals are not limited to these situations. If you have questions about appeals, please call Member Services at 1-855-676-5772 (TTY: 711), 24 hours a days, 7 days a week. The call is free.

Examples of appeals

• Aetna Better Health 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

If the Aetna Better Health Premier Plan Level 1 appeal decision agrees with the original denial, in whole or in part, for a service that is standardly covered only by Michigan Medicaid the enrollee can request a reconsideration by Michigan Administrative Hearing System (MAHS) within 90 days of the denial. 

Members may also request a reconsideration through Michigan Administrative Hearing System (MAHS) at the time of the prior authorization denial.  If a member has completed an appeal with Aetna Better Health℠ Premier Plan they may also request a reconsideration through a Patient’s Right to Independent Review (PRIRA) Organization within 60 calendar days of the appeal denial letter.”

Members can call 1-855-676-5772 to make an appeal or send it to:

Aetna Better Health Premier Plan

PO Box 818070
Cleveland, OH 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-calendar 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. A member, a member’s appointed representative,  or the member’s provider may request an expedited appeal on behalf of the member. If Aetna Better Health 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. 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℠ Premier Plan 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 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, Michigan Medicaid or both. The coverage decision letter will explain the appeal options for the item or service being denied.

If the prescription drug you are appealing is also covered by Michigan Medicaid, you may want to request a Non-Part D appeal at the same time as when you request a Part D appeal.

The legal term for a fast appeal is “expedited reconsideration."

 

Appeal levels

Level 1 (Medicare or Medicaid services)

• Reconsideration by Aetna Better Health Premier Plan

Level 2 (Medicare or Medicaid services)

• Reconsideration by the Independent Review Entity (IRE) - (Medicare services)
• Reconsideration by Patient’s Right to Independent Review (PRIRA) Organization - (Medicaid-only services)
• Reconsideration by the State Office of Administrative Hearings - (Medicare services)

Level 3 (Medicare services)

• Administrative Law Judge (ALJ)

Level 4 (Medicare services)

• Medicare Appeals Council (MAC)

Level 5 (Medicare services)

• 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, and with a clinical expert when necessary. We will notify the member in less than 30 calendar days for service requests (plus 14 calendar days if an extension is taken).

If the Aetna Better Health Premier Plan Level 1 appeal decision agrees with the original denial, in whole or in part, for a service that is standardly covered only by Michigan Department of Community Health the enrollee can request a reconsideration by Michigan Administrative Hearing System (MAHS) within 90 days of the denial.  Members may also request a reconsideration through Michigan Administrative Hearing System (MAHS) at the time of the prior authorization denial.  If a member has completed an appeal with Aetna Better Health℠ Premier Plan they may also request a reconsideration through a Patient’s Right to Independent Review (PRIRA) Organization within 60 days of the appeal denial letter.

The State Office of Administrative Hearings and Rules for the Department of Community Health will review the appeal and notify all parties of their decision within 90 calendar days from receipt of the State Fair Hearing request.

The Patient’s Right to Independent Review (PRIRA) Organization will review the appeal and notify all parties of their decision within 14 calendar days from receipt of the PRIRA review request.

If the Aetna Better Health℠ Premier Plan 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 Independent Review Entity (IRE).

If the Aetna Better Health℠ Premier Plan 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 the Michigan Department of Community Health, 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 calendar days for service requests and 60 calendar 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 Administrative Law Judge (ALJ). The member must follow the instructions on the notice from the IRE.  If the service is standardly covered by both Medicare and Michigan Medicaid, the member may also request a reconsideration by the Michigan Administrative Hearing System (MAHS) at the same as or instead of ALJ. Aetna Better Health Premier Plan 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 Medicare Appeals Council (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.

Fast appeal process

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 Michigan Department of Community Health, the enrollee can request a reconsideration by the State Office of Administrative Hearings and Rules for the Department of Community Health within 90 calendar days of the denial and/or they may also request a reconsideration through a Patient’s Right to Independent Review (PRIRA) Organization within 60 calendar days of the appeal denial letter.

The Michigan Administrative Hearing System (MAHS) will review the appeal and notify all parties of their decision within 72 hours from receipt of the State Fair Hearing request.

The Patient’s Right to Independent Review (PRIRA) Organization will review the appeal and notify all parties of their decision within 72 hours from receipt of the PRIRA review request.