Complaints and appeals

You can have someone else file a complaint or appeal for you. They can also act for you in a state fair hearing. This person is your member representative. They may be:

• Your provider
• Your family member 
• Your friend
• Your legal guardian
• Your attorney
• Another person

You have to give us written permission to allow the person to act for you. You’ll need to write a letter for:

• Complaints 
• Appeals
• State fair hearings: Send the letter to the Bureau for Medical Services (BMS) and include it with your state fair hearing request.

 

When you write a letter, tell us that you want someone else to act for you to file a complaint or appeal. Be sure to include:

• Your name
• Your member ID number from your ID card
• The name of the person you want to represent you 
• What your grievance or appeal is about

 

Then, sign the letter and send it to:

Aetna Better Health of West Virginia 

PO Box 81139 

5801 Postal Road 

Cleveland, OH 44181

Is your provider filing on your behalf? If yes, be sure they use this address, not the provider address.

When we get the letter, the person you chose can act for you. If someone else files a complaint or appeal for you, you can’t file one yourself about the same item. 

Are you appealing our decision to deny, stop, hold or reduce an ongoing service or treatment you’ve been receiving? If yes, and you’d like those services to continue during your appeal, you must request for them to continue within 13 days of our decision letter. Additionally, these services will continue as long as:

• You file your appeal on or before the last day of the original authorized period, or within 13 days of our decision letter, whichever is later
• The appeal involves stopping, holding or reducing a treatment that was approved before
• The authorization hasn’t expired
• An authorized provider ordered the services in question 

Your services will continue until one of these things happens:

• You withdraw the appeal.
• The original authorization period for your services has been met.
• 13 days have passed since we mailed you our appeal decision.
  

This applies unless you have asked for a state fair hearing with continuation of services. Read more about this topic under the “State fair hearing” tab.

The appeal decision

• If the appeal decision isn’t in your favor: You may need to pay for the disputed services that you continued to receive during your appeal.
• If the appeal decision is in your favor: We’ll provide the disputed services within 72 hours from the date of the appeal decision if you didn’t continue to get these services during the appeal. And we’ll pay for these services if you did continue to get them during the appeal.

You can speed up your appeal if waiting up to 14 calendar days is harmful to your health. This is an expedited or quick decision. Just call us — either you or your provider can call. We’ll call you with the decision within 72 hours. We can increase the review period up to 14 days if you ask for an extension or we need more info and the delay is in your interest.

You can also ask for a quick decision in situations that involve:

• Urgent or emergency care
• A new or continued hospital stay
• Availability of care
• Health care services for which you have received emergency services but haven’t yet been discharged from a hospital or other facility

If we can’t approve an expedited appeal, we’ll call to let you know. We’ll also send you a letter within 72 hours. Then, we’ll process your appeal normally, in the usual timeframe (30 days). 

You can ask for a state fair hearing from the Bureau for Medical Services (BMS) if you don’t agree with our appeal decision. The state’s rules say you must wait for your appeal to be complete first. 

You must also ask for a state fair hearing within 120 days of the date of the appeal decision letter. We’ll mail you the state fair hearing request form to complete. To get the form, just call us at 1-888-348-2922 (TTY: 711).

You can send your completed state fair hearing request form to:

WV Children's Health Insurance Program

350 Capitol Street, Room 251

Charleston, WV 25301

The state will hear your case and decide within 90 days of your request for a state fair hearing.

Questions about requesting a state fair hearing? Just call us at 1-888-348-2922 (TTY: 711). You can also call the Department of Health and Human Resources at 1-304-558-0684.

Was your appeal based on a decision to deny, stop, hold or reduce an ongoing service or treatment? If so, and you file for a state fair hearing, you have the right to ask that your services continue while your appeal is pending. Check the box on the state fair hearing form that you want to continue services. 

You must ask for your services to continue in writing within 13 days of the date of our appeal decision letter. Your services will continue until one of these things happens:

• You withdraw the appeal
• The original authorization period for your services has ended
• The State Fair Hearing Officer denies your request 

If you miss the 13-day deadline, we’ll reduce, hold or stop your services by the effective date.

The state fair hearing decision

• If the state fair hearing decision isn’t in your favor (agrees with our decision): You may need to pay for the disputed services if you continued to get them while your hearing was pending.
• If the state fair hearing decision is in your favor (reverses our decision): We’ll make sure you get the disputed services right away — as soon as your health condition requires. If you continued to get the disputed services while your hearing was pending, we’ll pay for the covered services.