Grievances & Appeals

Members or their designated representative can file a request for an appeal or grievance with Aetna Better Health of Kansas orally or in writing.

A representative is someone who acts on the member’s behalf, including but not limited to a family member, friend, guardian, provider, or an attorney. Representatives must be designated in writing. A provider, acting on behalf of a member, and with the member’s written consent, may file a grievance or appeal with Aetna Better Health of Kansas. Members and their representatives including providers with written consent may also file a State Fair Hearing as appropriate. When a provider acts on behalf of a member the request follows the member appeal and grievance processes and timeframes. 

Aetna Better Health of Kansas informs members and providers of the appeal and grievance processes for grievances, appeals and State Fair Hearings. This information is also contained in the Member Handbook. When requested, we give members reasonable assistance in completing forms and taking other procedural steps. Our assistance includes, but is not limited to, providing interpreter services and toll-free numbers that have adequate TTY/TTD and interpreter capability at no cost to the member.

Both network and out-of-network providers may file a grievance verbally or in writing directly with Aetna Better Health of Kansas in regard to our policies, procedures or any aspect of our administrative functions that is not requesting review of an action within 180 calendar days from the incident. Providers can also file a verbal grievance with Aetna Better Health of Kansas by calling 1-855-221-5656. To file a grievance in writing, providers should write to:

Aetna Better Health of Kansas
PO Box 81040
Cleveland, OH 44181

An acknowledgement letter will be sent within 10 calendar days summarizing the grievance and will include instruction on how to:

  • Revise the grievance within the timeframe specified in the acknowledgement letter
  • Withdraw a grievance at any time until Grievance Committee review

If the grievance requires research or input by another department, the Appeals and Grievance Manager will forward the information to the affected department and coordinate with the affected department to thoroughly research each grievance using applicable statutory, regulatory, and contractual provisions and our written policies and procedures, collecting pertinent facts from all parties. The grievance with all research will be presented to the Grievance Committee for decision. The Grievance Committee will include a provider with same or similar specialty if the grievance is related to a clinical issue. The Grievance Committee will consider the additional information and will resolve the grievance. 

Aetna Better Health of Kansas will resolve all provider grievances within 30 calendar days of receipt of the grievance and will notify the provider of the resolution within 5 calendar days of the decision.

A provider may request a reconsideration if they would like us to review the adverse payment decision. A reconsideration, which is optional, is available to providers prior to submitting an appeal. Reconsideration requests must be submitted within 120 calendar days (an additional 3 calendar days is allowed for mailing time) from the date of the notice of the adverse action.

Providers may submit reconsideration requests orally by contacting the Provider Experience department at 1-855-221-5656, (TTY: 711). Providers can submit a written reconsideration to:

Aetna Better Health of Kansas
PO Box 81040
Cleveland, OH 44181

Fax: 1-833-857-7050

We acknowledge provider reconsiderations in writing within 10 calendar days of receipt. Aetna Better Health will review your reconsideration request and provide a written response within 30 calendar days of receipt.

A provider may file an appeal in writing about an adverse payment decision, if they are not satisfied with the outcome of the reconsideration determination or if they wish to bypass the reconsideration process. A provider may file an appeal within 60 calendar days (an additional 3 calendar days is allowed for mailing time) from the date of the notice of adverse action if no reconsideration was requested. If reconsideration was requested, providers have 60 calendar days (an additional 3 calendar days for mailing time) from the date of the reconsideration resolution letter. Post service items or services are standard appeal and are not eligible for expedited processing.

All written appeals should be sent to the following: 

Aetna Better Health of Kansas
PO Box 81040
Cleveland, OH 44181
Fax: 1-833-857-7050

An acknowledgement letter will be sent within 10 calendar days of receipt summarizing the appeal and will include instruction on how to:

  • Revise the appeal within the timeframe specified in the acknowledgement letter
  • Withdraw an appeal at any time until Appeal Committee reviews.  The appeal along with all research will be presented to the Appeal Committee for decision. The Appeal Committee will include a provider with same or similar specialty. The Appeal Committee will consider the additional information and will issue a written appeal decision within 30 calendar days of receipt.

Providers may request a State Fair Hearing through the Office of Administrative Hearings after the appeal with Aetna Better Health. This request must be completed within 120 calendar days (with an additional 3 calendar days for mailing time), following the date of the appeal resolution letter. Information on how to submit a State Fair Hearing request is included in Appeal Resolution Letter.

Providers may request a State Fair Hearing for a denial of payment for covered and non-covered services.  Providers may also request a State Fair Hearing regarding an incorrect payment by Aetna Better Health or a notice from Aetna Better Health regarding an overpayment.

The request for a State Fair Hearing must be submitted in writing to the following:

State of Kansas
Office of Administrative Hearings
1020 S. Kansas Ave.
Topeka, KS 66612-1327

External Independent Third-Party Review (EITPR) Providers may request an EITPR for denials of a new healthcare services or a claim for reimbursement following a provider appeal through Aetna Better Health after the appeal with Aetna Better Health. This request must be completed within 60 calendar days (an additional 3 calendar days for mailing time), file following the date of the appeal resolution letter. Information on how to submit an EITPR request is included in Appeal Resolution Letter. It is not required to request an EITPR before requesting a State Fair Hearing. The provider may go direct to State Fair Hearing.

 

  • The request must identify the specific issue or dispute in question and why Aetna Better Health’s decision is incorrect.
  • The request must also include the provider’s designated contact’s information such as name, mailing address, phone, fax and email.
  • The request should be in writing and sent to:

Aetna Better Health of Kansas Appeal and Grievance Department
PO Box 81040
5801 Postal Road Cleveland, OH 44181
Fax: 1-833-857-7050
Email: KSAppealandGrievance@AETNA.com

We acknowledge the EITPR in writing within 5 business days to the provider’s designated contact, notify Kansas Department of Health & Environment, Division of Health Care Finance (KDHE-DHCF) of the provider’s request, and notify the affected member of the provider’s request for review. In the event Aetna appeals the review we acknowledge we will within 15 business days of receipt of the approved review request, the MCO will provide all documentation submitted by the provider for the

MCO’s appeal process to KDHE-DHCF or notify KDHE-DHCF that the provider has not completed the appeal process. The provider can have someone they know; a friend, relative, spokesperson, or attorney represent them or act on their behalf. A provider must tell Aetna Better Health in writing, the name of that person and how they can reach him or her. The external reviewer will render a decision within 30 calendar days of receiving the information and will notify provider, Aetna and KDHE within 10 business days of receiving the reviewer’s decision. If the EITPR decision reverses the decision to deny Aetna Better Health will authorize or provide the disputed payment promptly. If the final result of the EITPR is to uphold the Aetna Better Health decision, the provider can request a State Fair Hearing within 30 calendar days plus 3 calendar days from the date of the MCOs EITPR decision letter.

All requests must be sent using the Request for External Independent Third-Party Review form.

By signing this form, you acknowledge that you will be held responsible for the costs associated with the External Independent Third-Party Review in the event the reviewer upholds the Aetna Better of Kansas decision. Forms that are not signed will not be processed.