A grievance is when you’re unhappy with the quality of care or service you received from:
You file an appeal when you want to review and change a decision we made about your coverage.
We take your concerns seriously. Let us know how we can improve our service. There’s no time limit for filing a grievance. An appeal can be filed after you receive a Notice of Action telling you that we are denying, delaying, changing or ending a service. An appeal must be filed within 60 days from the date you received your notice. You must file an appeal within 10 calendar days of getting your notice if you want to continue your current treatment.
After your grievance or appeal is filed, we will:
After your expedited grievance or appeal is filed, we will:
For more information about filing a grievance or requesting an appeal, see your member handbook.
If you don’t agree with the appeal decision or you never received your letter in the mail, you can ask for a state fair hearing or an IMR.
You can request a state fair hearing within 120 days of getting your appeal decision letter. You can make your request:
Fill out the form provided with resolution of your appeal notice.
Send the letter to:
California Department of Social Services
State Hearings Division
PO Box 944243, Mail Station 9-17-37
Sacramento, CA 94244-2430
Your PCP can file for a state fair hearing on your behalf, after you give them your written permission.
Call the Department of Social Services Public Inquiry and Response Unit at 1-800-952-5253
or 1-800-952-8349 if you have impaired hearing or speech.
You can request an IMR within 180 days of getting your appeal decision letter. An IMR is done by a third-party reviewer who is not a part of Aetna Better Health of California. You can request an IMR if:
You can’t ask for an IMR if you have already asked for a state fair hearing for the item or service you are appealing.
How do I request an IMR?
You can expedite your appeal if waiting 30 calendar days would harm your health. A decision will be made within 72 hours of receiving your appeal.
Just call
Member Services at
1-855-772-9076 (TTY: 711).
You can expedite your appeal if waiting 30 calendar days would harm your health. A decision will be made within 72 hours of receiving your appeal.
Just call
Member Services at
1-855-772-9076 (TTY: 711).
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