Grievances and appeals

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 and appeals, you can write a letter or fill out the authorization release form (PDF). If you need us to send you the form, just call 1-855-221-5656 (TTY: 711).
• For state fair hearings, you can write a letter to the Office of Administrative Hearings 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 Kansas

Attn: Appeal and Grievance Department

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. 

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:
 

For general (non-waiver) services
 

• You file your appeal on or before the last day of the original authorized period, or within 10 days of our decision letter, whichever is later
• The appeal involves stopping, holding or reducing a treatment that was approved before
• The authorization hasn’t expired
• An authorized provider ordered the services in question 

Your services will continue until one of these things happens:

• You withdraw the appeal.
• The original authorization period for your services has been met.
• 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 for general (non-waiver) services

• 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.
   

For Home- and Community-Based Services (HCBS) waiver services
 

Your services will continue during your appeal, as long as:
 

• You file your appeal within 63 days of the date of our Notice of Adverse Benefit Determination

• The appeal involves stopping, holding or reducing a treatment that was approved before 

• The authorization hasn’t expired

• An authorized provider ordered the services in question

Your HCBS waiver services will continue until one of these things happens:
 

• You withdraw the appeal.

• You do not file your appeal within 63 calendar days of the date of our Notice of Adverse Benefit Determination.

• You or your authorized representative requests previously authorized HCBS services or benefits to end and be replaced with another HCBS service or benefit.

The appeal decision for HCBS waiver services
 

• If the appeal decision isn’t in your favor: Your benefits will not continue past 123 calendar days of the date of our appeal decision letter unless you request a state fair hearing. You will not have to pay for the services that you continued to receive during the appeal, unless fraud has occurred.

• 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.

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 30 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
• Availability of care
• 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 2 days. Then, we’ll process your appeal normally, in the usual timeframe (30 days). 

Was your appeal based on a decision to deny authorization for a new service? Or to deny a claim for reimbursement? If so, and our decision on your appeal isn’t in your favor, your provider can request an EITPR in writing within 63 days of our appeal decision letter. 

Your provider’s request must include the EITPR form, details of the specific issue you’d like to be reviewed and an explanation of why you disagree with our decision. 

Your provider can send the request by email, fax or mail.

Email: KSAppealandGrievance@Aetna.com

Fax: 1-833-857-7050

Mailing address:

Aetna Better Health of Kansas 

Attn: Grievances and Appeals Department 

PO Box 81139

5801 Postal Rd 

Cleveland, OH 44181 

If the result of the EITPR isn't in your favor (agrees with our decision about your appeal), you or your provider can request a state fair hearing within 30 days of receiving our decision letter.

You can ask for a state fair hearing from the Office of Administrative Hearings 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 123 days of the date of the appeal decision letter from your appeal. 

You have many options to ask for a state fair hearing. You can contact us or the Office of Administrative Hearings:

By mail

You can also mail the request for Medicaid hearing form (PDF). Print the form, complete it and mail it to:

Office of Administrative Hearings

1020 South Kansas Avenue

Topeka, Kansas 66612

Online

Log in to your Member Portal to complete the online form. 

By email

You can email us to ask for a state fair hearing.

By phone

Just call us at 1-855-221-5656 (TTY: 711). 

Was your appeal based on a decision to deny, stop, hold or reduce an ongoing service or treatment? If so, and you file for a state fair hearing, you have the right to ask that your services continue while your appeal is pending. Just call us at 1-855-221-5656 (TTY: 711).

You must ask for your services to continue within 10 days of the date of our appeal decision letter. If you miss the 10-day deadline, we’ll reduce, hold or stop your services by the effective date.
 

For general (non-waiver) services
 

Your services will continue until one of these things happens:
 

• You withdraw the appeal.

• The original authorization period for your services has ended.

• The State Fair Hearing Officer denies your request.

The state fair hearing decision for general (non-waiver) services
 

• If the state fair hearing decision isn’t in your favor (agrees with our decision): You may need to pay for the disputed services if you continued to get them while your hearing was pending.

• If the state fair hearing decision is in your favor (reverses our decision): We’ll make sure you get the disputed services right away — as soon as your health condition requires. If you continued to get the disputed services while your hearing was pending, we’ll pay for the covered services.

For HCBS waiver benefits

Your services will continue until one of these things happens:
 

• You do not request a state fair hearing within 123 calendar days of the date of the appeal decision letter.

• You withdraw the state fair hearing request.

• The original authorization period for your services has ended.

• The State Fair Hearing Officer denies your request.

• You or your authorized representative requests previously authorized HCBS services or benefits to end and be replaced with another HCBS service or benefit.

The state fair hearing decision for HCBS waiver services

• If the state fair hearing decision isn’t in your favor (agrees with our decision): Your benefits will not continue past 123 calendar days of the date of the appeal decision letter. You will not have to pay for the services that you continued to receive during the state fair hearing, unless fraud has occurred.

• If the state fair hearing decision is in your favor: We’ll make sure you get the disputed services right away — as soon as your health condition requires. If you continued to get the disputed services while your hearing was pending, we’ll pay for the covered services.