Grievances and Appeals
If a member is not satisfied with service they have received from Aetna Better Health or a provider, or if they are unhappy with a decision Aetna Better Health has made, they can file a grievance or appeal. As a network provider, with the member’s written consent, you may act on behalf of a member and file a grievance or appeal, or request a State Fair Hearing.
The following summarizes various aspects of the complaint process. For more information and specific instructions, please see the Provider Handbook.
A grievance may be filed with Aetna Better Health verbally or in writing by the member or the member’s authorized representative (which may be a provider). In most cases, a decision on the grievance is reached within 30 days of the grievance’s filing. If we are unable to resolve a grievance within 30 days, we may request a 14-day extension.
When the member is advised in writing of the outcome of the investigation of the grievance, the Notice of Resolution also tells a member how to obtain information on filing a State Fair Hearing.
To file a grievance verbally, members should call Member Services toll free at 1-866-212-2851. To file a grievance in writing, members should write to:
Aetna Better Health
Attn: Grievance and Appeals Dept.
One South Wacker Drive, Mail Stop F646
Chicago, IL 60606
Members can request that their provider or a caregiver, friend or family member file a grievance on their behalf. They must request this in writing. To request that someone else files a grievance on their behalf, the member must send Aetna Better Health a letter, telling us that they want someone else to represent them and file a grievance for them. The letter must include the member’s name, member ID number, the name of the person they want to represent them and the nature of their grievance they are filing. When we receive the member’s letter, the person they have chosen can represent them. If someone else files a grievance for a member, the member cannot file one for that action.
A member may file an appeal, a formal request to reconsider a decision (e.g., benefit payment, administrative action, quality-of-care or quality-of-service issue) with Aetna Better Health. Authorized member representatives, including providers, may also file an appeal on the member’s behalf with the written consent of the member. All appeals must be filed no later than 30 calendar days from the postmark on the Aetna Better Health Notice of Action. The expiration date to file an appeal is included in the Notice of Action.
Appeals may be filed either verbally by contacting the Member Services Department or by submitting a request in writing. Unless the member is requesting an expedited appeal resolution, a verbal appeal request must be followed by a written, signed appeal.
Members can request that their provider or a caregiver, friend or family member file an appeal on their behalf. They must request this in writing. To request that someone else files an appeal on their behalf, the member must send Aetna Better Health a letter, telling us that they want someone else to represent them and file an appeal for them. The letter must include the member’s name, member ID number, the name of the person they want to represent them and which action they are appealing. When we receive the member’s letter, the person they have chosen can represent them. If someone else files an appeal for a member, the member cannot file one for that action.
Aetna Better Health resolves all appeals effectively and efficiently as the members health requires. On occasion, certain issues may require a quick decision. These issues, known as expedited appeals, occur in situations where a member’s life, health, or ability to attain, maintain, or regain maximum function may be at risk, or in the opinion of the treating provider, the member’s condition can not be adequately managed without urgent care or services. If the member’s ability to attain, maintain or regain maximum function is not a risk, the request to have the appeal decided in an expedited time frame may be denied and the appeal processed in the normal 30 calendar days.
DHS State Fair Hearing
At any time during the appeals process, the member and/or the member’s representative may request a State Fair Hearing through the Illinois Department of Human Services Bureau of Assistance Hearings if it is within 30 calendar days from Aetna Better Health’s Notice of Action letter.
The Illinois Department of Human Services Bureau of Assistance Hearings renders the final decision about services.
A member may ask for a State Fair Hearing at any time during the appeals process. They do not have to wait until Aetna Better Health gives an answer. However, the member must ask for a State Fair Hearing within 30 calendar days of receiving the Notice of Action letter.
At the State Fair Hearing, the member may represent himself or herself, use a lawyer or have a relative or friend speak for them. They can ask for a State Fair Hearing in one of the following ways.
Their local Family Community Resource Center can give them an appeal form to request a State Fair Hearing and will help them fill it out, if they wish.
They can make their request by writing to:
HFS Bureau of Administrative Hearings
Bureau of Administrative Hearings
401 S Clinton Street
Chicago, IL 60607
Or they may call 1-800-435-0774 (TTY: 1-877-734-7429). The call is free. Representatives are available Monday through Friday from 8:30 a.m. to 4:45 p.m.
Aetna Better Health and our contracted providers are responsible for timely resolution of any disputes between both parties. Disputes will be settled according to the terms of our contractual agreement and there will be no disruption or interference with the provision of services to members as a result of disputes.
Aetna Better Health will inform providers through the Provider Handbook and other methods, such as newsletters, training, provider orientation and our website, about the provider dispute process.
Aetna Better Health’s Provider Services Representatives are available to discuss a provider’s dissatisfaction of an issue covered by this policy, and if unable to satisfy the provider’s inquiry, the Provider Complaint Process will be offered.
Both network and out-of-network providers may file a complaint verbally or in writing directly with Aetna Better Health in regard to our policies, procedures or any aspect of our administrative functions.
The Appeals and Grievance Manager assumes primary responsibility for coordinating and managing provider complaints, and for disseminating information to the provider about the status of the complaint.