Quejas y apelaciones
Members can file complaints or appeals with their health plan.
Enrollee complaint system: complaints, coverage decisions & appeals
We take complaints and appeals very seriously. We want to know what's wrong so we can improve our services. Enrollees can file a grievance or make an appeal if they are not satisfied. A network provider may act on behalf of an enrollee with the enrollee's written consent. With that authorization, the provider may file a grievance, or request an appeal, and a State Fair Hearing.
We inform enrollees and providers of the complaints, appeals, and State Fair Hear 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.
Enrollees have the right to file a grievance if they have a problem or concern about the care or services they have received. The grievance process is used for certain types of problems. This includes problems related to quality of care, waiting times and the customer service they received. A grievance may be made with us orally or in writing by the enrollee or the enrollee's authorized representative. That includes providers.
In most cases, a decision about the grievance is reached within 90 calendar days of the date the grievance was made. If we are unable to resolve a grievance within 90 calendar days, we may ask for 14 more calendar days to make a decision. In these cases, we will give a reason for the delay in writing to the member and, if asked, to the State Agency.
Enrollees are advised in writing of the outcome of the investigation of the grievance within three 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 a State Fair Hearing if applicable.
Fast complaint resolution
Aetna Better Health resolves grievances 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.
In most cases, a decision on the outcome of an expedited grievance is reached within 72 hours of the date the grievance was made. Enrollees are advised orally of the resolution within the 72 hours, followed by a written notification of resolution within 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 a State Fair Hearing if applicable
What is a coverage decision?
A coverage decision is the initial decision we make about a member's benefits and coverage. It also determines the amount we will pay for the member's medical services or drugs. We make a coverage decision whenever we decide what is covered for an enrollee and how much we will pay. If you are not sure if a service is covered Medicaid, you or your patient can ask for a coverage decision before the service is provided.
Who can I call with questions about coverage decisions?
Any of the below can help you.
To request a coverage decision or an appeal on a member’s behalf, just call Member Services at 1-866-316-3784 (TTY 711). The line is open 24 hours a day, 7 days a week. You can ask for coverage decision or appeal in writing.
You can also get free help by calling the Beneficiary Help Line at 1-800-642-3195. The Help Line helps solve problems for Medicaid enrollees.
You can also ask another provider, friend or family member to act on your behalf. This person will act as your representative to ask for a coverage decision or make an appeal.
If you receive a denial notice for a prescription drug, you have the right to file an appeal, also called a “redetermination” request.
Please see the Aetna Better Health℠ of Michigan Member Handbook for more information about prescription drug coverage decisions and appeals.
Audiencia imparcial estatal
Within 120 days of an Adverse Action Notice, you can request a State Fair Hearing through the Michigan Department of Health and Human Services. Members Services can assist members with completing the Request for State Fair Hearing form by calling 1-866-316-3784(TTY 711). This request can be submitted during the appeals process. Send request to:
Michigan Administrative Hearing System For the Michigan Department of Health and Human Services
P.O. Box 30763
Lansing, MI 48909