Free fillable Instructions Provider Reconsideration, Appeal and Complaint/Grievance (Aetna Better Health) PDF form (2024)

Aetna Better Health

of Illinois

3200 Highland Avenue, F648

Downers Grove, IL 60515

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-

Within 180 days of the date of service

Resubmission – Reconsideration, see page 2-

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

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

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• 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 circ*mstances 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

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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

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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

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

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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