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Help us better serve you
Help us better serve you
A grievance
You’re unhappy with the quality of care or services you received from:
One of your providers (for example, vision or dental services providers)
A pharmacy or hospital
Your health plan
Here are some things you can file a grievance about:
- You were unhappy with the quality of care or treatment you received.
- Your provider or a plan staff member was rude to you or didn’t respect your rights.
- You had trouble getting an appointment with your provider in a reasonable amount of time.
- Your provider or a plan staff member wasn’t sensitive to your cultural needs or other special needs you may have.
Do you have a grievance? Filing a grievance or appeal won’t affect your health care services or benefits coverage. Just let us know right away. We have special processes to help you. And we’ll do our best to answer your questions and resolve your issue.
An appeal
This means you disagree with a decision we made about your coverage for services your provider believes are medically necessary. You’ll get a letter from us if we deny, stop, hold or reduce an ongoing service or treatment you’ve been receiving. We call this a Notice of Adverse Benefit Determination.
Then, if you like, you can file an appeal. You’d like us to review the decision to be sure we were correct about things like:
- Not approving a service your provider asked for
- Stopping a service that was approved before
- Not paying for a service your primary care physician (PCP) or other provider requested
- Not giving you the service in a timely manner
- Not approving a service for you because it was not in our network
What happens next?
What happens next?
Grievances
There's no time limit for filing a grievance. We’ll send you a letter saying that we received it. We’ll try to resolve your grievance right away. We may call you for more info.
Some timelines to note with your grievance
- Within 3 calendar days: We’ll send you a letter saying that we received your grievance.
- Within 90 calendar days: We’ll tell you our decision.
- Up to 14 calendar days: We may extend the decision time about your grievance if we need more info and the delay is in your interest. If we extend the time, we’ll send you a letter to explain the delay.
Appeals
A provider with the same or like specialty as your treating provider will review your appeal.
Some timelines to note with your appeal
- Within 60 calendar days from the date on our decision letter: You or your representative need to file the appeal.
- Within 10 calendar days from the date on our decision letter: You need to file your appeal if you want your benefits and services to continue while we review your appeal.
- Within 30 calendar days (standard appeal): We’ll tell you our decision.
- Up to 14 calendar days: We may extend the decision time about your appeal if we need more info and the delay is in your interest. If we extend the time, we’ll send you a letter to explain the delay.
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More help with grievances and appeals
If you need more help or don’t agree with our appeal decision, here are some options.
You can have someone else file a grievance or appeal for you. They can also act for you in a state fair hearing. This person is your member representative. They may be:
- Your provider
- Your family member
- Your friend
- Your legal guardian
- Your attorney
- Another person
You have to give written permission to the person, allowing them to act for you.
- For grievances, you can write a letter.
- For appeals, you can write a letter or fill out the authorized representative appeals form (PDF). If you need the form, you can also call us at 1-866-316-3784 (TTY: 711).
- For state fair hearings, you can write a letter and include it with your state fair hearing request.
If you write a letter, tell us that you want someone else to act for you to file a grievance or appeal. Be sure to include:
- Your name
- Your member ID number from your ID card
- The name of the person you want to represent you
- What your grievance or appeal is about
Then, sign the letter and send it to:
Aetna Better Health of Michigan
Attn: Appeals Coordinator
PO Box 81139
5801 Postal Road
Cleveland, OH 44181
Is your provider filing on your behalf? If yes, be sure they use this address, not the provider address.
When we get the letter, the person you chose can act for you. If someone else files a grievance or appeal for you, you can’t file one yourself about the same item.
What is a coverage decision?
A coverage decision is the initial decision we make about a member’s benefits and coverage. It also determines the amount we will pay for the member’s medical services or drugs. We make a coverage decision whenever we decide what is covered for an enrollee and how much we’ll pay. If you’re not sure if a service is covered by Medicaid, you can ask for a coverage decision before the service is provided.
Who can I call with questions about coverage decisions?
- Member Services: To request a coverage decision or an appeal on a member’s behalf, you can call Member Services at 1-866-316-3784 (TTY: 711). You can get help 24 hours a day, 7 days a week. You can also ask for a coverage decision or appeal in writing.
- The Beneficiary Help Line: This help line helps solve problems for Medicaid enrollees. Just call 1-800-642-3195.
Are you appealing our decision to deny, stop, hold or reduce an ongoing service or treatment you’ve been receiving? If yes, those services will continue automatically during your appeal, as long as you file your appeal on or before 10 days of receiving our decision letter.
Your services will continue until one of these things happens:
- You withdraw the appeal.
- 10 days have passed since we mailed you our appeal decision.
This applies unless you have asked for a state fair hearing with continuation of services. Read more about this topic under the “state fair hearing” tab.
The appeal decision
- If the appeal decision isn’t in your favor: You may need to pay for the disputed services that you continued to receive during your appeal.
- If the appeal decision is in your favor: We’ll provide the disputed services within 72 hours from the date of the appeal decision if you didn’t continue to get these services during the appeal. And we’ll pay for these services if you did continue to get them during the appeal.
You can speed up your appeal if waiting up to 30 calendar days is harmful to your health. This is an expedited or quick decision. Just call us — either you or your provider can call. We’ll call you with the decision within 72 hours. We can increase the review period up to 14 days if you ask for an extension or we need more info and the delay is in your interest.
You can also ask for a quick decision in situations that involve:
- Urgent or emergency care
- A new or continued hospital stay
- Health care services for which you have received emergency services but haven’t yet been discharged from a hospital or other facility
If we can’t approve an expedited appeal, we’ll call to let you know. We’ll also send you a letter within 3 days. Then, we’ll process your appeal normally, in the usual time frame (30 days).
You can ask for a state fair hearing from the Michigan Office of Administrative Hearings and Rules (MOAHR) if you don’t agree with our appeal decision. The state’s rules say you must wait for your internal appeal to be complete first.
You must also ask for a state fair hearing in writing within 120 days of the date of the appeal decision letter from your internal appeal.
To learn more about how to ask for a state fair hearing and the process, check your member handbook. You can also find info about continuing services during the hearing.
Your language, your format
You need to understand your rights when it comes to grievances and appeals. Do you need info in another language? Just call us at 1-866-316-3784 (TTY: 711). We’re here for you Monday through Friday, 8 AM to 5 PM. We’ll share this info in your primary language. You can also get info other formats, like large print or braille.