Non Part D complaints, coverage decisions & appeals

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Provider Grievance System: Complaints, grievances & 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’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 may be asked to complete and submit the Provider Dispute Form and any appropriate supporting documentation to the Provider Services Department. The Provider Dispute Form PDF Opens In New Window is accessible on Aetna Better Health Plan’s website, via fax or by mail.　

Aetna Better Health will inform the provider of its decision via email, fax, telephone, or in writing.

In the event the provider remains dissatisfied with the dispute determination, the Provider is notified that a grievance or appeal as appropriate may be initiated. Aetna Better Health of Ohio’s Grievance and Appeal policies, as well as the Aetna Better Health of Ohio Provider Handbook, includes the process by which the provider can submit a grievance or appeal.

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 PDF Opens In New Window 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 Non-Contracting Provider Payment Dispute decision letter will give information on how to request and IRE review. The IRE will process the request within sixty (60) calendar days of receipt and will notify all parties of their decision concerning the appeal.  If the decision is overturned, Aetna Better Health of Ohio 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 file 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 Department assumes primary responsibility for coordinating and managing Provider grievances.

An acknowledgement letter will be sent within three (3) business days summarizing the grievance and will include instructions 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 department 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, with all research included, will be presented to the Grievance Committee for decision. If the grievance is related to a clinical issue, the Grievance Committee will include a provider who has the same or a similar specialty. The Grievance Committee will consider the additional information and will resolve the grievance within forty-five (45) business days.

Aetna Better Health shall communicate its decision via telephone, email, fax within two (2) business days of the decision and in writing if requested within ten (10) calendar days from the date of the decision.

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 plan 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.

Enrollee Grievance System: Complaints, coverage decisions & appeals

Overview
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 make file a grievance, request an appeal, a State Fair Hearing, an Independent Review Entity (IRE), an Administrative Law Judge (ALJ), a Medicare Appeals Council (MAC) or a Judicial Review, as applicable.

We inform enrollees and providers of the complaints, appeals, State Fair Hearing, 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 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, including providers. In most cases, a decision on the outcome of the grievance is reached within thirty (30) calendar days of the date the grievance was made. If we are unable to resolve a grievance within thirty (30) calendar days, we may ask to extend the grievance 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 the State Agency.

Enrollees are advised in writing of the outcome of the investigation of the grievance 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. The notice also tells an enrollee how to obtain information on filing a State Fair Hearing if applicable.

Fast Complaint Resolution
Aetna Better Health of Ohio 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. These issues 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 authorization or fast appeal decision making does not meet criteria and has transferred the request to a standard request

Enrollees and their representative if designated are informed of their right to request a expedited grievances in the Enrollee Handbook and in the extension and denial of fast processing prior authorization and appeal letters.

In most cases, a decision on the outcome of an expedited grievance is reached within twenty-four (24) hours of the date the grievance 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 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.

Appointment of representative

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 PDF Opens In New Window

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: 711), 24 hours a day, 7 days a week. The call is free.
• 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 Livanta, which is located at:

Livanta
Attn: Beneficiary Complaints
10820 Guilford Rd., Ste# 202
Annapolis Junction, MD 20701

Toll-Free Phone: 1-888-524-9900
Toll-Free TTY: 1-888-985-8775

See chapter 9, section 11 for information about complaints in the Member Handbook Opens In New Window.

Regulatory complaints

For items/services 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 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 Ombudsman’s office at 1-800-282-1206, or to CMS through 1-800-MEDICARE.

Enrollee Appeals in the Member Handbook Opens In New Window

Coverage decisions

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:

• You can call us at Member Services at 1-855-364-0974 (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.
• Call the Ohio Medicaid Hotline for free help. The Ohio Medicaid Hotline helps people enrolled in Medicaid with problems. The phone number is 1-800-324-8680.
• Talk to your doctor or other provider. Your doctor or other provider 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 another person to act for you as your "representative" to ask for a coverage decision or make an appeal.
• 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 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 will need to fill out the Appointment of Representative form.
• However, you do not have to have a lawyer or a representative to ask for any kind of coverage decision or to make an appeal.

Appeals

Aetna Better Health of Ohio members have the right to make an appeal, also called a “reconsideration,”  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 90 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 15 calendar days from the date the appeal was received. For payment decisions, we will notify the member in writing not later than 60 calendar days.

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

Aetna Better Health of Ohio

Appeals Department

PO Box 818070

Cleveland, Ohio 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-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. 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. 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 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 the member’s 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 Medicaid or both.  The coverage decision letter will explain the appeal options for the item or service being denied.

The legal term for “fast Appeal” is “expedited reconsideration.”

Appeal levels

1. Reconsideration by Aetna Better Health of Ohio
2. Reconsideration by the Independent Review Entity (IRE)
   Reconsideration by the Ohio Department of Healthcare and Family Services Bureau of Administrative Hearings
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, and with a clinical expert when necessary. Aetna Better Health of Ohio will notify the member in less than 15 calendar days for service requests (plus 14 days if an extension is taken) or in less than 60 calendar days for payment reconsiderations.

If Aetna Better Health of Ohio agrees with the original denial, in whole or in part, for a service that is standardly covered only by Ohio Department of Medicaid, the enrollee can request a reconsideration by the Ohio Department of Medicaid Bureau of State Hearings.

The Ohio Department of Medicaid Bureau of State Hearings will review the appeal and notify all parties of their decision within 90 calendar days from receipt of the State Fair Hearing request.

If the Aetna Better Health of Ohio 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 IRE.

If Aetna Better Health of Ohio 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 Ohio Department of Medicaid 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 days for service requests and 60 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 ALJ. The member must follow the instructions on the notice from the IRE.  If the service is standardly covered by both Medicare and Ohio Department of Medicaid, the member may also request a reconsideration by the Ohio Department of Medicaid Bureau of State Hearings.  Aetna Better Health of Ohio 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 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.

The fast appeal process

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, along with 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 an appeal (plus 14 days if an extension is taken).

If Aetna Better Health of Ohio agrees with the original denial, in whole or in part, for a service that is standardly covered only by Ohio Department of Medicaid, the enrollee can request a reconsideration by the Ohio Department of Medicaid Bureau of State Hearings.

The Ohio Department of Medicaid Bureau of State Hearings will review the appeal and notify all parties of their decision within 90 calendar days from receipt of the State Fair Hearing request.

If the Aetna Better Health of Ohio 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 IRE.

If Aetna Better Health of Ohio 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 Ohio Department of Medicaid the case is automatically forwarded for reconsideration to the IRE.

The IRE will review the appeal and notify all parties of their decision within 24 hours for service requests and 10 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 ALJ. The member must follow the instructions on the notice from the IRE.  If the service is standardly covered by both Medicare and Ohio Department of Medicaid, the member may also request a reconsideration by the Ohio Department of Medicaid Bureau of State Hearings.  Aetna Better Health of Ohio 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 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.