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Filing a grievance
The provider grievance process is for providers to voice grievances about us, our contracted vendors or other issues that:
Don’t request review of an action
Require a written decision
Both in-network and out-of-network providers may file a verbal grievance with us. We can resolve these outside the formal appeal and grievance process. Provider grievances 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
Some provider grievances are subject to the member grievance process. In these cases, we transfer them. These include grievances:
From a provider on behalf of a member with written consent (except for an expedited request)
That don’t require written consent from the member
Filing an appeal
Provider appeal process
The provider appeal process is for provider grievances that:
Require review because they can’t be resolved through the informal grievance process
Request review of an action
Require a written decision
You can file an appeal within 90 days of receiving a Notice of Action. We’ll send an acknowledgment letter within 5 business days. The letter summarizes the appeal and tells how to:
Revise the appeal within the time frame specified in the acknowledgment letter
Withdraw an appeal at any time up to the Appeal Committee review
The Appeals and Grievance Manager presents the appeal, along with all research, to the Appeal Committee for decision. The Appeal Committee includes a provider with the same or a similar specialty. They’ll consider the additional information and make an appeal decision.
For standard appeals, we’ll always send you a letter within five business days to let you know we received your info. If you’re concerned that we didn’t receive your fax, letter or call notes, just call us at 1-855-300-5528 (TTY: 711).
File a grievance or appeal now
Clinical grievances 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 the subordinate of the person that made the first decision
We have processes designed to let you tell us when you’re dissatisfied with a decision we make. You can file a grievance or appeal:
You can file a grievance or appeal online. Just log in to your Provider Portal.
Some key timelines
Within 5 business days of receiving your appeal: We’ll send you a letter to tell you we received it.
Within 30 calendar days of receiving your appeal: We’ll send you a decision letter with an explanation. This letter will have the credentials of the person or people involved in the appeal review. If you ask, we can respond by faxed letter if we have your fax number.
A 14-day calendar-day extension: We may extend the appeal response time if we need extra time to investigate the appeal. We’ll only do so if it benefits you. If this isn’t acceptable, you have the right to file a grievance to dispute the extra time.
Provider external review
If you don’t agree with our appeal decision, the state allows you to have a third-party review of your case, pursuant to 907 KAR 17:035.
An external review is your right to have an outside reviewer review our decision. The state of Kentucky chooses the reviewer. You can ask for an external review when we make an adverse decision on an appeal you submit about:
A medical necessity determination
Coverage of a given service by Medicaid
Provider fulfillment of MCO requirements for the covered service
We must receive your request for an external review within 60 calendar days of the postmark date on the envelope containing our decision or of the electronic receipt date, if we sent your decision by fax or email.
When you ask for an external review, include a letter that:
Clearly states each specific issue and dispute you have with our decision
Clearly states the reason you believe our decision is wrong
Includes the name, mailing address, email address, fax and telephone number of the designated contact person we may contact about your request
You can send your request for an external review:
You can mail your request and the required documentation to:
Aetna Better Health of Kentucky
Attn: Complaint and Appeal Department
PO Box 81040
5801 Postal Rd
Cleveland, OH 44181
You can fax your request and the required documentation to
Member grievance system overview
Members can file a grievance when they’re unhappy with the quality of care or service they received from us or one of their providers, or when they don’t agree with a decision we made about coverage. And they can file an appeal if they want us to review or change our coverage decision.
When requested, we help our members complete grievance and appeal forms and take other steps. You can learn more about the member grievance and appeal process: