Fillable Instructions Provider Reconsideration, Appeal and Complaint/Grievance (Aetna Better Health)

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Instructions Provider Reconsideration, Appeal and Complaint/Grievance (Aetna Better Health)

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Aetna Better Health
®
of Illinois
3200 Highland Avenue, F648
Downers Grove, IL 60515
1
Proprietary
Provider Reconsideration, Appeal and Complaint/Grievance
Instructions
Provider submissions will be reviewed and processed according to the definitions in this
document, including but not limited to Resubmissions (Corrected Claims and Reconsiderations),
Retroactive Authorization Requests, Appeals, Complaints and Grievances. Provider Claim
reconsiderations and retrospective authorization reviews do not include pre-service disputes
that were denied due to not meeting medical necessity. Pre-service denials are processed as
member appeals and are subject to member policies and timeframes.
Timeframe to request each option
Options – Defined on the following pages Provider Submission Timeframe
Resubmission – Corrected Claim, see page 1-
2
Within 180 days of the date of service
Resubmission – Reconsideration, see page 2-
3
Within 90 days of original denial
Retroactive Authorization Request (Post
Service), see page 3-4
Must be received within 30 days of the date of service.
A response will be issued within 30 business days from
the date of receipt.
Member Appeal (Provider submitting on
Member’s behalf), see page 4
Within 60 days of the original denial
Provider Complaint/Grievance, see page 4-5 At any time
State Complaint Portal, see page 6 Over 30 calendar days from and under 60 calendar
days post receipt of MCO tracking number Untimely
response to appeal or complaint beginning day 31
Within 30 calendar days after appeal decision or
complaint resolution
Not to exceed 60 calendar days from submission of the
appeal or complaint
Directions for each option
A RESUBMISSION/CORRECTED CLAIM is a request for review of a claim denial or payment
amount on a claim originally denied because of incorrect coding or missing information that
prevents Aetna Better Health from processing the claim. The claim with the missing
Aetna Better Health
®
of Illinois
3200 Highland Avenue, F648
Downers Grove, IL 60515
2
Proprietary
information may be resubmitted electronically or in hard copy. Please see the following
examples and instructions for various forms resubmission:
Corrected Claim
Examples of a corrected claim: (Step 1 if applicable)
Newly added modifier
Code changes
Any change to the original claim
a) Electronic - Clearinghouse: Resubmit your claim via your Clearinghouse to payer ID
68024. When submitting claims to our plan, use the payer ID number “68024”. For
CMS-1500 claims you’ll need to identify your resubmission with a "7” indicator field
and TOB XX7 for UB-04 claims.
b) Electronic - Portal: Claims can also be resubmitted electronically via the WebConnect
portal. When submitting claims to our plan, use the payer ID number “68024”. For
CMS-1500 claims you’ll need to identify your resubmission with a "7” indicator field
and TOB XX7 for UB-04 claims.
c) Paper: Submit a corrected claim marked at the top of the claim “CORRECTED CLAIM
FOR RESUBMISSION” along with the completed Provider Dispute and Resubmission
form, found on the last page and mail it with all the following:
• An updated copy of the claim — all lines must be rebilled
• A copy of the original claim (a reprint or a copy is acceptable)
• A copy of the remittance advice on which the claim was denied or incorrectly
paid
• A brief note describing the requested correction
• Any additional appropriate documentation
• Corrected Claim Resubmissions should be submitted to:
Aetna Better Health of Illinois
P.O. Box 66545
Phoenix, AZ 85082-6545
A RECONSIDERATION can be submitted if a claim does not require any changes, but a provider
is not satisfied with the claim disposition and wishes to dispute the original outcome.
Reconsideration
Examples of Reconsiderations: (Step 1 if applicable)
Itemized Bill
•
All claims associated with an Itemized Bill must be broken out per Rev Code to
verify charges billed on the UB match the charges billed on the Itemized Bill.
(Please attach I-Bill that is broken out by rev code with sub-totals.)
Duplicate Claim
Aetna Better Health
®
of Illinois
3200 Highland Avenue, F648
Downers Grove, IL 60515
3
Proprietary
• Review request for a claim whose original reason for denial was “duplicate”
• Provide documentation as to why the claim or service is not a duplicate such
as medical records showing two services were performed
Untimely Filing of the Claim
• A review of a claim that was submitted outside the timeframe
• Provide good cause justification documentation for late filing; OR
• For electronically submitted claims provide the second level of acceptance
report as proof of timely filing
• Refer to Proof of Timely Filing Requirements in the Aetna Provider Manual
Untimely Decision Making
• A review of a decision where Aetna did not render the decision on a prior
authorization timely
• Provide a copy of the denial showing the received date and the decision date
Coordination of Benefits
• Attach EOB or letter from primary carrier
Claim/Coding Edit
• We use two (2) claims edit applications: Claim Check and Cotiviti. Please refer
to the Aetna Provider Manual for details.
•
Submit a claim form marked at the top “RECONSIDERATION” along with the
completed Provider Dispute and Resubmission form, found on the last page.
• Submit additional information required to reconsider the claim
• Information should be submitted single sided
• Please refer to the provider manual for provider filing timeframes.
• Reconsiderations should be submitted to:
Aetna Better Health of Illinois
P.O. Box 66545
Phoenix, AZ 85082-6545
A RETROSPECTIVE AUTHORIZATION DISPUTE is a request for review of post-service,
authorization related claim denials for potential reprocessing when they are: 1) attributed to
authorizations not kept current due to extenuating circumstances or 2) medical necessity
disputes requiring review of medical records.
Examples of Retrospective Authorization Disputes: (Step 2 if applicable)
Requests by Provider for review of claims for medical necessity
Dispute of denied days during concurrent review
Aetna Better Health
®
of Illinois
3200 Highland Avenue, F648
Downers Grove, IL 60515
4
Proprietary
Request for review of additional services not authorized
Retro Authorization Request
Claims that were denied due to no authorization on file. Medical records must be included with
the resubmission.
Submit your request by fax or mail with all supporting documentation clearly marked as
“FILING A RETROSPECTIVE AUTH DISPUTE” to:
Aetna Better Health of Illinois
Attn Appeal and Grievance Department
PO Box 81040
5801 Postal Road
Cleveland, OH 44181
Fax: 844-951-2143
Retro Authorization Requests can also be submitted electronically, again marked as “FILING
A RETROSPECTIVE AUTH DISPUTE” to:
Email: ILAppealandGrievance@AETNA.com
Via Provider Portal: Use Provider Appeal option with the heading bolded above
An APPEAL can be submitted on behalf of the member for review of the following items. Please
refer to the Aetna Better Health of Illinois Provider Manual, located on our website at
AetnaBetterHealth.com/Illinois-Medicaid for details.
Examples of Appeals: (Step 2 if applicable)
On Behalf of a Member:
• Continued stay concurrent review
• Urgent or Emergent review
• Pre-Service (Prior Authorization) requests
• Must have written consent to act on behalf of the member
• When filing on behalf of a member the request is processed as a Member Appeal and is
subject to the member appeal policies and timeframes
A PROVIDER COMPLAINT/GRIEVANCE is an expression of dissatisfaction unrelated to a request
for Aetna to reconsider our decision on the denial of a claim or the payment on a claim. This is
also referred to as a grievance. Please refer to the Aetna Better Health Provider Manual,
located on our website at AetnaBetterHealth.com/Illinois-Medicaid for details.
Examples of Complaints/Grievances: (Step 1 if applicable)
Aetna Better Health
®
of Illinois
3200 Highland Avenue, F648
Downers Grove, IL 60515
5
Proprietary
Dissatisfaction with administrative functions or policies
Vendor staff service or behavior
Aetna Staff behavior
On Behalf of a Member
• When filing on behalf of a member the request is processed as a Member Grievance and
is subject to the member grievance policies and timeframes
If any of the above member appeal or provider complaints/grievance examples apply, please
DO NOT use the Resubmission & Reconsideration form. You may submit your request to file
a member appeal or a provider complaint/grievance to the below address. Please submit your
request by fax or mail with all supporting documentation clearly marked as “FILING AN
APPEAL PROVIDER COMPLAINT” or “FILING A GRIEVANCE” to:
Aetna Better Health of Illinois
Attn Appeal and Grievance Department
PO Box 81040
5801 Postal Road
Cleveland, OH 44181
Fax: 844-951-2143
Email: ILAppealandGrievance@AETNA.com
You may also submit a provider complaint/grievance through the portal. For all appeals and
grievances submitted you can log into the portal within 5 business days to check the status of your
request and obtain a unique identifier for the item submitted.
Aetna Better Health
®
of Illinois
3200 Highland Avenue, F648
Downers Grove, IL 60515
6
Proprietary
State Portal Complaints:
Following the resubmission process, you may make a complaint through the Illinois Department
of Healthcare and Family Services (HFS) through the state portal.
When attempting to resolve issues with Aetna Better Health of Illinois you will receive a unique
reference number. The reference number will vary based on how you attempted to resolve the
issue.
1. When contacting our Customer Service at 1-866-329-4701, providers will receive a
tracking/reference number from the agent handling your inquiry (i.e. #PDXGR1234567).
2. When contacting Network Relations Consultants, the Network Relations Consultant will
provide a reference number (i.e. #1234).
3. When mailing in or resubmitting a claim dispute/reconsideration through our Provider
Portal, the provider must complete the requested information and attach or upload any
appropriate supporting documentation. The decision will be sent in the form of a
provider remittance and the tracking/reference number will be the adjusted claims
number from that remittance (i.e. the claim number ending in A1, A2, A3, etc.).
4. When filing a provider complaint or grievance you will receive an provider complaint or
grievance number in the acknowledgment and resolution letters. (APXXXX, or GRXXXX)
To submit through the portal; follow the directions at this link:
https://medicaid.aetna.com/MWP/login
Aetna Better Health
®
of Illinois
3200 Highland Avenue, F648
Downers Grove, IL 60515
7
Provider Resubmission & Reconsideration Form
Please complete the information below in its entirety and mail with supporting
documentation to the designated address. Incomplete or missing information may result in
your Dispute being returned or decision upheld.
Select the appropriate reason
□ Incorrect Denial of Claim or Claim
Line(s)
□
Incorrect Rate Payment
□ Coordination of Benefits □ Consent form Denial
□ Code or Modifier Issue □ Other ________________________
Your Dispute Must Include:
• This completed form
• Copy of the original claim
• Any additional information (proof from
primary payer, required documentation,
CMS or Medicaid references as needed,
etc.)
Provider Name:
Provider NPI:
Submitter’s name:
Provider Phone Number:
Date(s) of Service:
Claim Number(s):
Member Name:
Member ID #:
Please indicate the specific reason for your request and any pertinent details below:
______________________________________________________________________________
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Instructions Provider Reconsideration, Appeal and ComplaintGrievance (Aetna Better Health)

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Completed 30 November 2021

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