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Grievances and appeals

We want you to be happy with the care you get. So if you’re ever unhappy with your health plan or a provider, you can file a grievance. And if you’re unhappy with a decision we made, you can file an appeal.

 

To learn more, just check your member handbook.

Help us better serve you

Help us better serve you

A grievance: You don’t agree with a decision we made about your coverage. Or you’re unhappy with the quality of care or services you received from:

 

  • One of your doctors, like your primary care physician (PCP)

  • One of your providers, like a pharmacy or hospital

  • Your health plan 

 

An appeal: You want us to review and change a decision we made about your coverage. You’ll get a letter from us if we reduce, stop or can’t approve a service. We call this an Adverse Benefit Determination. Then, you can file an appeal. 

File your grievance or appeal

I want to file a grievance or appeal

 

You have options for filing a grievance or appeal. And we’re here to help you through the process. 

 

Choosing someone to act for you

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 authorized representative. They may be:

 

  • Your provider
  • Your friend
  • Your legal guardian
  • Your attorney
  • Your family member
  • Another person 

 

You have to give written permission to the person, allowing them to act for you. You can write a letter or fill out a consent form. If you need the form, call us at 1-855-300-5528 (TTY: 711). If you write a letter, sign it and send it to:

 

Aetna Better Health of Kentucky
Attn: Complaint and Appeal Department
PO Box 81139
5801 Postal Road
Cleveland, OH 44181

What happens next?

What happens next?

Grievances

 

There's no time limit for filing a grievance. We’ll send you a letter within 5 working days after we get your grievance. Then, we’ll send our decision in another letter within 30 days. 

 

Appeals


You can file an appeal after you receive an Adverse Benefit Determination letter (denial). This letter says we won’t cover the service you want. You’ll want to send your appeal:

 

  • Within 60 days of getting your denial letter

  • Within 10 calendar days of getting your denial letter — if your appeal is for ongoing benefits that we had already approved, that you were already getting and that haven’t expired 

 

You can call us to appeal a decision, but you’ll also want to put it in writing. Just ask us for a form or write a letter. If we send you a form with a letter, check the date on the letter. You’ll want to send us your letter or form back within 10 calendar days from that date. Also, tell us why you think we should change our decision. Your letter must include:

 

  • Your name, phone number, member ID number and mailing address
  • Your doctor’s name
  • The date of the service you want covered
  • Any info that may help change our decision

 

Here are some timelines to note for your appeal:

 

  • Within 5 working days: We’ll send you a letter to let you know we received your appeal and we’re working on it. The letter includes info about your appeal meeting and how you can take part.
  • Within 30 calendar days (standard): We’ll review your appeal in this time frame if we have all the info we need.
  • Up to 44 days: The appeal may take this much time if you need more time to share info or if we need more time to gather info. We’ll only take extra time if this will help you. You can file a grievance if you don’t agree with taking the extra time.
  • Within 72 hours (expedited): Sometimes, we’ll review an appeal in this time frame. This happens when your doctor feels your condition is serious and your request meets the guidelines. Need an expedited appeal? Just call us at 1-855-300-5528 (TTY: 711). You don’t need to make this request in writing.
  • Within 24 hours: After you make an expedited appeal, you’ll have this much time to send us any more info to consider in your appeal review. If we can’t approve an expedited appeal, we’ll call to let you know. Then, we’ll process your appeal normally.

 

Once we review your appeal, you’ll receive a letter with our decision.

 

Worried about the outcome? We’ll never take any negative action against you or your provider if you file a grievance or appeal. We’re here to help you through the process.

More help with grievances and appeals

If you need more help or don’t agree with our appeal decision, here are some options.

If you don’t agree with our appeal decision, you can ask the state to look at your case. This is a state fair hearing. The state’s rules say you must wait for your appeal to be complete first. To qualify for a state fair hearing:

 

  • Write a letter explaining why you need a state fair hearing
  • Give the date of service and kind of service we denied
  • Include a copy of the last appeal decision letter we sent you
  • Mail the letter within 120 days from the date on the most recent decision letter we sent you

 

To ask for a state fair hearing, send your letter to:

 

Kentucky Department for Medicaid Services
Division of Program Quality and Outcomes
Attention: State Fair Hearings
275 East Main Street, 6C-C
Frankfort, KY 40621-0001

 

The state hearings officer will send you a letter with your hearing date and time. The letter also explains the hearing process.

 

Questions? You can call us at 1-855-300-5528 (TTY: 711). Or check your member handbook to learn more about appeals and state fair hearings.

You may be able to keep getting a service when you ask for an appeal or during a state fair hearing. This can happen if:

 

  • Your appeal is about a service we stopped or a service we authorized before but have now reduced in amount
  • An authorized provider ordered the service
  •  The time period for the approval hasn’t expired
  • You write or call us to ask for continued services

 

Just call us at 1-855-300-5528 (TTY: 711). You can also write to us at:

 

Aetna Better Health of Kentucky
Attn: Complaint and Appeal Department
PO Box 81139
5801 Postal Road
Cleveland, OH 44181

 

We need to get your letter within 10 days of the date on the decision letter we sent you before your appeal.

 

Note: If you don’t win your appeal, you may have to pay for the services you received during the appeal review. Need to learn more? Just call us at 1-855-300-5528 (TTY: 711)

This office answers questions, looks into complaints and helps settle them. Need help or more info? Just call the office at 1-800-372-2973 (TTY: 1-800-627-4702). You can also write the office at:

 

Office of the Ombudsman and Administrative Review

Attn: Medicaid Appeals and Reconsiderations

275 East Main Street, 2E-O

Frankfort, KY 40621

An advance directive is a legal document. It tells your doctors what medical care you do and don’t want. And it’s only for when you can’t speak for yourself due to an accident or illness. It’s called an “advance directive” because you make these decisions before you need care.

 

You or your authorized representative can file a grievance if your provider doesn’t follow your advance directive. Just send it to:

 

Director, Division of Health Care

Cabinet for Health and Family Services

275 East Main Street, 5E-A

Frankfort, KY 40621-0001

or

Inspector General

Cabinet for Health and Family Services

275 East Main Street, 5E-A

Frankfort, KY 40621-0001