We want you to be happy with services you get from Aetna Better Health and our providers. If you are not happy, you can make a complaint to us.

Grievances

A grievance is a complaint about any matter other than a denied, reduced or terminated service.

Aetna Better Health takes member grievances very seriously. We want to know what is wrong so we can make our services better. If you have a grievance about a provider or about the quality of care or services you have received, you should let us know right away. Aetna Better Health has special procedures in place to help members who file grievances. We will do our best to answer your questions or help to resolve your concern.

Filing a grievance will not affect your health care services or your benefits coverage.

These are examples of when you might want to file a grievance:

• > Your provider or an Aetna Better Health staff member did not respect your rights.
  
• > You had trouble getting an appointment with your provider in an appropriate amount of time.
  
• > You were unhappy with the quality of care or treatment you received.
  
• > Your provider or an Aetna Better Health staff member was rude to you.
  
• > Your provider or an Aetna Better Health staff member was insensitive to your cultural needs or other special needs you may have.

You can make your grievance on the phone or in writing. You can call Member Services for help at 1-866-212-2851. You can also send or fax a letter telling us about your grievance to:

Aetna Better Health
Attn: Grievance and Appeals Dept.
One South Wacker Drive, Mail Stop F646
Chicago, IL 60606
Fax: 1-855-545-5196

Appeals

An appeal is a way for you to ask for someone to review our actions. The list below includes examples of when you might want to file an appeal.

• > Not approving a service your provider asks for
  
• > Stopping a service that was approved before
  
• > Not paying for a service your PCP or other provider asked for
  
• > Not giving you the service in a timely manner
  
• > Not answering your appeal in a timely manner
  
• > Not approving a service for you because it was not in our network

If we decide that the requested service cannot be approved, or if a service is reduced, stopped or ended, you will get a "Notice of Action" letter from us. This letter will tell you the following:

• > What action was taken and the reason for it
  
• > Your right to file an appeal and how to do it
  
• > Your right to ask for a State Fair Hearing from the Department of Human Services and how to do it
  
• > Your right to ask for an expedited resolution and how to do it
  
• > Your right to ask to have benefits continue during your appeal, how to do it and when you may have to pay for the services

You must file your appeal within 30 calendar days from the date on the Notice of Action letter.

Here are two ways to file an appeal:

• > Call Member Services at 1-866-212-2851. If you do not speak English, we can provide an interpreter at no cost to you. If you are hearing impaired, call the Illinois Relay at 711.
  
• > Write to us at:
  
  Aetna Better Health
  Attn: Grievance and Appeals Dept
  One South Wacker Drive, Mail Stop F646
  Chicago, IL 60606
  Fax: 1-855-545-5196

Someone can represent you when you file your appeal, such as a family member, friend or provider. You must agree to this in writing. Send us a letter telling us that you want someone else to represent you and file an appeal for you. Include your name, member ID number from your ID card, the name of the person you want to represent you and what action you are appealing. When we get the letter from you, the person you picked can represent you. If someone else files an appeal for you, you cannot file one yourself for that action.

You or your representative, including a provider acting with your written permission, may start an appeal within 30 calendar days from the date on our Notice of Action letter. But if you want your services to continue while your appeal is reviewed, you must file your appeal no later than 10 business days from the date on our Notice of Action letter. We can help you write your appeal, if needed.

What Happens Next

• We will send you a letter within three business days saying we got your appeal. We will tell you if we need more information.
  
• > We will tell you how to give us more information in person or in writing, if needed.
  
• > You provide more information about your appeal, if needed.
  
• > You can see your appeal file.
  
• > You can be there when the Appeals Committee reviews your appeal.
  
• > The Appeals Committee will review your appeal. They will let you know if they need more information and will make a decision within 15 business days of receiving that information but no more than 30 calendar days. We will call you to tell you the decision. We will also send the results to you in writing. The decision letter will tell you what we will do and why.
  
• > A provider with the same or similar specialty as your treating provider will review your appeal. It will not be the same provider who made the original decision to deny, reduce or stop the medical service.
  
• > The provider who reviews your appeal will not report to the provider who made the original decision about your case.
  
• > We can extend the time for making a decision about your grievance by up to 14 days. We may extend the time to get more information. If we do this, we will send you a letter explaining the delay.
  
• > You can also ask for an extension, if you need more time.

If the Appeals Committee's decision agrees with the Notice of Action, you may have to pay for the cost of the services you got during the review. If the Appeals Committee's decision does not agree with the Notice of Action, we will let the services start right away.

Learn more, including how to expedite your appeal, in your Member Handbook.

Q&As