Provider Appeal and Complaint Form for Aetna Better Health of Maryland
This form is used by providers to file an appeal or grievance with Aetna Better Health of Maryland. Appeals must be filed within 90 business days from the date of retro-authorization denial or adverse determination in the provider claims dispute process. Complaints can be about various subjects including administrative issues, payment, and staff behavior.
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How do I fill this out?
To fill out the Provider Appeal and Complaint Form, you will need to provide detailed information about the provider, member, and the specific claim or issue. Make sure to include all relevant supporting documents. Follow the instructions on the form to ensure your appeal or complaint is processed correctly.
How to fill out the Provider Appeal and Complaint Form for Aetna Better Health of Maryland?
1
Provide the provider's name, TIN, NPI, and Medicaid Provider Number.
2
Enter the member's name and ID number.
3
List the denied claim number(s), dates of service, remittance advice date, billed amount, and paid amount.
4
Select the appropriate reason for your complaint and provide relevant claims information.
5
Mail the completed form and supporting documents to the address provided or fax it to the specified number.
Who needs the Provider Appeal and Complaint Form for Aetna Better Health of Maryland?
1
Providers who have had a request for retro-authorization of service delivery denied or not acknowledged promptly.
2
Providers who have had claims denied or paid differently than expected and were not satisfied with the resolution through the provider dispute process.
3
Providers who wish to file a grievance against Aetna Better Health policies, procedures, or staff behavior.
4
Providers facing administrative issues or payment and reimbursement issues.
5
Providers dissatisfied with the resolution of a dispute.
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What are the instructions for submitting this form?
To submit the Provider Appeal and Complaint Form, ensure all fields are accurately completed and include any supporting documents. Mail the form to Aetna Better Health of Maryland, Attention: Appeals Department, P.O. Box 81040, 5801 Postal Rd, Cleveland, OH 44181. You can also fax the completed form to 1-844-312-4257. For any questions or additional assistance, contact Aetna Better Health at 1-866-827-2710. Our advice is to double-check all entered information and documents to avoid any delays in processing.
What are the important dates for this form in 2024 and 2025?
The important dates for this form in 2024 and 2025 involve timely submission of appeals. Appeals must be filed within 90 business days from the date of retro-authorization denial or the date of an adverse determination in the provider claim dispute process.
What is the purpose of this form?
The purpose of the Provider Appeal and Complaint Form is to give healthcare providers a formal process to address issues related to denied claims, administrative concerns, and staff behavior within Aetna Better Health of Maryland. This form ensures that providers have a structured way to express dissatisfaction and seek resolution in a timely manner. It's vital for maintaining clear communication and resolving disputes between providers and Aetna Better Health.
Tell me about this form and its components and fields line-by-line.
- 1. Provider Name: Enter the full name of the healthcare provider filing the appeal or complaint.
- 2. Provider Tax Identification Number (TIN): Provide the TIN assigned to the healthcare provider.
- 3. Provider Billing National Provider Identifier (NPI): Enter the NPI used for billing purposes.
- 4. Medicaid Provider Number: Provide the Medicaid Provider Number if applicable.
- 5. Member's Name: Enter the full name of the member involved in the appeal or complaint.
- 6. Member's ID Number: Provide the ID number assigned to the member.
- 7. Denied Claim Number(s): List the claim numbers that were denied.
- 8. Date(s) of Service: Enter the dates of the services provided.
- 9. Remittance Advice Date: Provide the date of the remittance advice.
- 10. Billed Amount: Enter the total billed amount for the services.
- 11. Paid Amount: Provide the amount that was paid for the services.
- 12. Contact Name: Enter the name of the contact person for this appeal or complaint.
- 13. Contact Phone Number: Provide the phone number for the contact person.
- 14. Contact Address: Enter the address for the contact person.
- 15. Reason for Complaint: Select the appropriate reason for the complaint from the provided list.
What happens if I fail to submit this form?
Failure to submit the Provider Appeal and Complaint Form can result in unresolved disputes and dissatisfaction. It is critical to submit the form to ensure proper handling and resolution of issues.
- Unresolved Disputes: Pending issues regarding claims and administrative matters will remain unresolved.
- Missed Deadlines: Failure to meet the 90-day filing deadline will forfeit the provider's right to appeal or file a grievance.
How do I know when to use this form?
- 1. Denied Claims: File an appeal for claims that have been denied or paid differently than expected.
- 2. Administrative Issues: Submit a grievance regarding administrative policies and procedures.
- 3. Staff Behavior: File a complaint about the behavior of Aetna Better Health or vendor staff.
- 4. Payment Disputes: Address issues regarding payment and reimbursement.
- 5. Resolution Dissatisfaction: Express dissatisfaction with the resolution of a previous dispute.
Frequently Asked Questions
How do I fill out the Provider Appeal and Complaint Form?
To fill out the form, provide details about the provider, member, and the denied claim or grievance, and submit the form along with any supporting documents.
How do I submit the completed form?
You can mail the completed form and documents to Aetna Better Health of Maryland or fax them to the specified number.
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Yes, you can add your electronic signature to the form using PrintFriendly's signing tools.
Can I share the completed form with others?
Yes, PrintFriendly allows you to share the completed form via email or direct link.
What information do I need to provide on the form?
You will need to provide details about the provider, member, denied claim number, dates of service, and other relevant information.
How long do I have to file an appeal?
Appeals must be filed within 90 business days from the date of the denial or adverse determination.
What should I do if I have a grievance?
Select the appropriate reason for your complaint on the form and include relevant claims information and supporting documents.
Where do I send the completed form?
Mail the completed form and supporting documents to the address provided or fax them to the specified number.
Can I download my edited form?
Yes, you can download the edited form after making changes on PrintFriendly.
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