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Complaints and appeals

Questions?

Just check your provider manual for answers about complaints and appeals. Or contact us.

Filing a complaint

Both in-network and out-of-network providers may file verbal complaints with us. You must file within 90 days of the dispute resolution or when you became aware of the issue. We can resolve complaints outside the formal complaints and appeals process. Your complaints could be based on things like:

 

  • Policies and procedures 

  • One of our decisions

  • A disagreement about whether a service, supply or procedure is a covered benefit, is medically necessary or is done in the appropriate setting 

  • Any other issue of concern

Some provider complaints are subject to the member process. In these cases, we transfer them. These include complaints and grievances that you may file on behalf of a member.

Filing an appeal

Both in-network and out-of-network providers have the right to appeal our claims determinations within  60 calendar days of receipt of the claim denial.  

 

You can file an appeal if:

 

  • We denied reimbursement for a medical procedure or item you provided for a member due to lack of medical necessity or no prior authorization (PA) when it was required
  • You have a claim that has been denied or paid differently than you expected and wasn’t resolved to your satisfaction through the dispute process

To learn more about claims adjustment or reconsideration, just visit our claims page

File a complaint or appeal now

You can file a complaint or appeal:

Online

You can file a complaint or appeal in your Provider Portal. Need help with registration? Just contact Availity at 1-800-282-4548. You can get help from 8 AM to 8 PM ET, Monday through Friday.

By email

You can email us your complaint or appeal.

By fax

You can fax your complaint or appeal to 860-607-7894.

By phone

You can call us with your complaint or appeal:

Medicaid Managed Medical Assistance: 1-800-441-5501 (TTY: 711)

Long-Term Care: 1-844-645-7371 (TTY: 711)

Florida Healthy Kids: 1-844-528-5815 (TTY: 711)

By mail

You can send your complaint or appeal to:

Aetna Better Health of Florida

PO Box 81040

5801 Postal Road

Cleveland, OH 44181

Reviews of complaints and appeals

Clinical complaints and appeals reviews are completed by health professionals who: 

 

  • Hold an active, unrestricted license to practice medicine or in a health profession
  • Are board certified (if applicable)
  • Are in the same profession or in a similar specialty as normally manages the condition, procedure or treatment concerned in the case
  • Are neither the same reviewer that made the original decision nor someone who reports to that person 

Member complaints, grievances and appeals overview

 

When members ask, we help them complete complaint, grievance and appeal forms and take other steps.

 

Member complaints, grievances and appeals

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