Compliants & Appeals

Grievances and Appeals

Grievances

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

Aetna Better Health of Illinois Family Health Plan 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 of Illinois Family Health Plan 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 a member might want to file a grievance.

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

The member can file your grievance on the phone by calling Member Services at 866-212-2851.  They also can file their grievance in writing via mail or fax at:

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

Appeals

The member may not agree with a decision or an action made by Aetna Better Health of Illinois Family Health Plan about their services or an item they requested.  An appeal is a way for the member to ask for a review of our actions. They may appeal within sixty (60) calendar days of the date on our Notice of Action form. If they want their services to stay the same while they appeal, the member must say so when they appeal, and they must file their appeal no later than ten (10) calendar days from the date on our Notice of Action form.  The list below includes examples of when the member might want to file an appeal.

• Not approving or paying for a service or item a provider asks for
• Stopping a service that was approved before
• Not giving the service or items in a timely manner
• Not advising you the right to freedom of choice of providers
• Not approving a service because it was not in our network

If we decide that a requested service or item cannot be approved, or if a service is reduced or stopped , the member 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
• The members right to file an appeal and how to do it
• The members to ask for a State Fair Hearing and how to do it
• The members in some circumstances to ask for an expedited appeal and how to do it
• The members to ask to have benefits continue during your appeal, how to do it and when they may have to pay for the services

Here are two ways to file an appeal.

1)      Call Member Services at 1-866-212-2851. File an appeal over the phone, the member must follow it with a written signed appeal request. 

2)      Mail or fax written appeal request to:

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

If the member does not speak English, we can provide an interpreter at no cost. If they are hearing impaired, call the Illinois Relay at 711.

Can someone help the member with the appeal process?
The member has several options for assistance. The member may:

• Ask someone they know to assist in representing you. This could be their Primary Care Physician or a family member, for example. 
• Choose to be represented by a legal professional.
• If they are in the Disabilities Waiver, Traumatic Brain Injury Waiver, or HIV/AIDS Waiver, they may also contact CAP (Client Assistance Program) to request their assistance at 1-800-641-3929 (Voice) or 1-888-460-5111 (TTY).

For more information, please contact our Provider Services team at 1-866-212-2851.