Non-Part D Complaints, Coverage Decisions & 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 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.

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^® Member Services?
• Do you feel you are being encouraged to leave our plan (disenroll)?

Complaints about physical accessibility

• You cannot physically access the health care services and facilities in a doctor or provider’s office.

Complaints about language access

• Your doctor or provider does not provide you with an interpreter during your appointment.

Cleanliness

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

Waiting times

• Did you have trouble getting an appointment, or wait too long to get it?
• Have you been kept waiting too long (examples: 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? You can make a complaint:

Timeliness of actions related to coverage decisions and appeals

• If you have asked us for a "fast response" for a coverage decision or appeal within 72 hours, and we said we will not provide a fast response.
• If you believe we are not meeting deadlines for a standard coverage decision or an answer to an appeal within 14 calendar days.
• When we do not give you a decision within the timeframes above, we are required to forward your case to the Independent Review Organization. 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 Organization 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 file a complaint

Follow this process for making a complaint. If you have questions, please give us a call at Member Services, 1-855-463-0933 (TTY: 711), 8 AM to 8 PM, seven days a week.

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.

Start by calling Member Services, 1-855-463-0933 (TTY: 711), 8 AM to 8 PM, seven days a week. 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:

Aetna

PO Box 818070
Cleveland, OH 44181
Fax: 1-855-883-9555

 

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 can make your complaint at any time unless you are requesting remedial action then it must be made within 60 days after you have the problem you want to report.
• 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 will not, 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 will give you an answer within 24 hours.
• If you ask for a written response, file a written grievance, or your complaint is related to quality of care, we will respond to you 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 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 days (44 days total) to answer your complaint.
• If we do not agree with some or all of your complaint or don't take responsibility for the problem you are complaining about, we will let you know. Our response will include our reasons for this 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:

1. You can make your complaint directly to the Quality Improvement Organization. You don’t have to make the complaint with Aetna. If you make a complaint to the Quality Improvement Organization, Aetna will work with them to resolve your complaint.
   
   
2. You can make your complaint about quality of care to Aetna and to the Quality Improvement Organization.
   
   Livanta is Virginia’s Quality Improvement Organization. You may contact Livanta at 1-888-396-4646 or by writing:
   
   Livanta
   10820 Guilford Road, Suite 202
   Annapolis Junction, MD 20701

Complaints to Medicare

You are now able to submit feedback about your Medicare health plan or prescription drug plan directly to Medicare.

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), 24 hours a day, 7 days a week. TTY 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.

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 1-855-463-0933 (TTY: 711), 8 AM to 8 PM, seven 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. 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. 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 Medicare Advantage Dual Eligible Special Needs Plan members have the right to make an appeal, also called a “reconsideration,”  if they receive notice of any of the following:

• Aetna denied payment for renal dialysis services a member received while temporarily outside of the Aetna service area
• Aetna denied payment for emergency services, post-stabilization care or urgently needed services a member received while temporarily outside of the Aetna service area
• Aetna denied payment for any other health services furnished by a provider that a member believes should be covered
• Aetna refused to authorize, provide or reimburse a member for services, in whole or in part, that the member believes should be covered
• Aetna 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 60 days from the date of the notification letter. The member can call or write a letter to Aetna 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 1-855-463-0933 (TTY: 711), 8 AM to 8 PM, seven days a week to make an appeal or send it to:

Aetna
Appeals Department

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-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 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. The member’s doctor may need to provide oral support to request an expedited appeal but does not need written support.
2. Aetna 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^® appeals process for denied services and payment. Appeal options are determined by how the item or service being appealed is standardly covered by Medicare, Virginia 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
2. Reconsideration by the Independent Review Entity (IRE) and/or, State Fair Hearing by the Virginia Department of Medical Assistance Services' (DMAS)
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 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 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 agrees with the original denial, in whole or in part, for a service that is standardly covered only by Virginia Department of Medicaid, the enrollee can request a State Fair Hearing by the Virginia Department of Medical Assistance Services' (DMAS).

The Virginia Department of Medical Assistance Services' (DMAS) will review the appeal and notify all parties of their decision.

If Aetna's 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's 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 Virginia Department of Medical Assistance Services' (DMAS) 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 Virginia Department of Medical Assistance Services' (DMAS), the member may also request a State Fair Hearing by the Virginia Department of Medical Assistance Services' (DMAS). Aetna 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.

Fast appeal process

Fast review

This is only available for reconsiderations for services not yet received. Upon receipt of the appeal, Aetna 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 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. For fast appeals, Aetna 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 agrees with the original denial, in whole or in part, for a service that is standardly covered only by Virginia Department of Medicaid, the enrollee can request a State Fair Hearing by the Virginia Department of Medical Assistance Services' (DMAS).

The Virginia Department of Medical Assistance Services' (DMAS) will review the appeal and notify all parties of their decision.

If Aetna's 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's 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 Virginia Department of Medical Assistance Services' (DMAS) the case is automatically forwarded for reconsideration to the IRE.

The IRE will review the appeal and notify all parties of their decision within 72 hours for expedited requests and 30 days for standard requests, from the day it is received by the IRE (plus 14 days if an extension is taken).  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 by Virginia Department of Medicaid, the enrollee can request a State Fair Hearing by the Virginia Department of Medical Assistance Services' (DMAS). Aetna will remind the member of this right, and how to request a State 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.