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Grievances and appeals

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:

By fax

Our secure fax is here for you 24 hours a day, 7 days a week. This is the fastest and best way to file a grievance or appeal. Our grievance form (PDF) or appeal form (PDF) can make the process easier, but they’re not required. Just fax your grievance or appeal to 1-855-454-5585.

By phone

You can file a grievance or appeal by phone. Just call 1-855-300-5528 (TTY: 711). We’re here for you Monday through Friday, 7 AM to 7 PM ET.

By mail

You can file a grievance or appeal by mail. Our grievance form (PDF) or appeal form (PDF) can make the process easier, but they’re not required. Send your grievance or appeal to:


Aetna Better Health of Kentucky 

Attn: Complaint and Appeal Department 

PO Box 81040 

5801 Postal Rd 

Cleveland, OH 44181 

By email

You can file a grievance or an appeal by email. Our grievance form (PDF) or appeal form (PDF) can make the process easier, but they’re not required. Email your grievance or appeal


You can file a grievance or appeal online. Just log in to your Provider Portal.

Appeal resolution

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:

By mail

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 

By fax

You can fax your request and the required documentation to 

By email

You can email us your request and the required documentation. 

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:


Just check your provider manual (PDF) for answers about grievances and appeals.

Also of interest: