Skip to main content

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. This process helps us make our services better.

 

To learn more, just visit our Materials and forms page to check your member handbook.

Help us better serve you

Help us better serve you

A grievance

 

You’re unhappy with the quality of care or services you received from:

 

  • One of your providers (for example, vision or dental services providers) 

  • A pharmacy or hospital

  • Your health plan 

 

Here are some things you may file a grievance about:

 

  • You were unhappy with the quality of care or treatment you received.
  • Your provider or a plan staff member was rude to you or didn’t respect your rights.
  • You had trouble getting an appointment with your provider in a reasonable amount of time.
  • Your provider or a plan staff member wasn’t sensitive to your cultural needs or other special needs you may have.

Do you have a grievance? Filing a grievance or appeal won’t affect your health care services or benefits coverage. Just let us know right away. We have special processes to help you. And we’ll do our best to answer your questions and resolve your issue. We’ll also keep all your info private.

 

An appeal

 

This means you disagree with a decision we made about your coverage for services your provider believes are medically necessary. You’ll get a letter from us if we deny, stop, hold or reduce an ongoing service or treatment you’ve been receiving. We call this a Notice of Adverse Benefit Determination.

 

Then, if you like, you can file an appeal. You’d like us to review the decision to be sure we were correct about things like:

 

  • Not approving a service your provider asked for
  • Stopping a service that was approved before
  • Not paying for a service your PCP or other provider requested
  • Not giving you the service in a timely manner
  • Not approving a service for you because it was not in our network

File your grievance or appeal here

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. If you don’t speak English, we can provide an interpreter at no cost.

 

What happens next?

What happens next?

Grievances

 

There's no time limit for filing a grievance. We’ll send you a letter saying that we received it. We’ll try to resolve your grievance right away. We may call you for more info. 

  • Within 72 hours after receipt of your grievance: We’ll respond in this timeframe if your grievance is due to our denial of your request for a fast decision. 
  • Within 72 hours after receipt of your grievance: We’ll respond in this timeframe if your grievance is due to an extension of our appeal decision time.
  • Within 90 days after the receipt of your grievance: We’ll respond in this timeframe for all other types of grievances.

Our letter will include our decision and the reasons for it. We’ll also provide our contact info in case you have questions about the decision. 

 

Appeals

 

The person who receives your appeal will record it. A provider with the same or like specialty as your treating provider will review your appeal. This provider won’t:

 

  • Be the same provider who made the original decision to deny, stop, hold or reduce your service
  • Report to the provider who made the original decision about your case

We’ll send a letter telling you that we received your appeal. It will tell you about next steps. There is no cost to see your:

 

  • Appeal file
  • Medical records
  • Any info about your appeal 

You’ll be able to present your case to the Appeals Committee in writing or in person. During the COVID-19 pandemic, you may need to do so in writing versus being present physically.

  • Within 5 business days: We’ll send you a letter saying we received your appeal. We’ll let you know if we need more info and how to provide it.
  • Within 60 calendar days from the date on our Adverse Benefit Determination letter: You or your representative need to file your appeal.
  • Before or within 10 days from the date on our Adverse Benefit Determination letter: You need to file your appeal if you want your services to continue while we review your appeal.
  • Within 30 calendar days (standard): We’ll let you know our decision on your appeal in writing. The decision letter will tell you what we’ll do and why. 
  • Up to 14 days: We may extend the decision time about your appeal if we need more info and the delay is in your interest. If we extend the time, we’ll send you a letter to explain the delay. You can also ask for more time if you need it.
  • Within 72 hours: We’ll let you know our decision in this amount of time if your appeal was for urgent or emergency care, you’re in the hospital or your provider says that waiting up to 30 days for a decision could be harmful to your health.

We’ll send the results of your appeal in writing. The decision letter will tell you about:

 

  • Our decision and the reasons behind it
  • Your other appeal rights
  • Your right to ask for a state fair hearing from the Louisiana Department of Health and how to do so if you’re eligible
  • Who can appear at a state fair hearing on your behalf
  • If you can keep receiving services during the state fair hearing

More help with grievances and appeals

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

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 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. 

 

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 Louisiana

Grievance and Appeals Dept.
ATTN: Grievance System Manager

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:

 

  • 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 happen:

 

  • 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

 

  • 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.

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 14 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). 

You can ask for a state fair hearing from the Louisiana Department of Health 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 120 days of the date of the appeal decision letter from your internal appeal.

 

You have many options to ask for a state fair hearing. Just contact the Louisiana Division of Administrative Law:

 

Online

 

Complete the online recipient appeal request form

 

By mail

 

You can also mail the online recipient appeal request form. Print the form, complete it and mail it to:

 

Division of Administrative Law – HH Section

P.O. Box 4189
Baton Rouge, LA 70821-4189

 

By fax

 

You can also fax the online recipient appeal request form. Print the form, complete it and fax it to 225-219-9823.

 

By phone

 

Just call 225-342-5800.

 

Who decides the outcome in a state fair hearing?

 

The Louisiana Division of Administrative Law makes a recommendation about your hearing to the Secretary of the Louisiana Department of Health. The Secretary makes the final decision about your state fair hearing appeal.

Was your appeal was 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. Check the box on the online recipient appeal request form that you want to continue services.

 

You must ask for your services to continue in writing within 10 days of the date of our appeal decision letter. 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.

 

If you miss the 10-day deadline, we’ll reduce, hold or stop your services by the effective date.

 

The state fair hearing decision

 

  • 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.

 

 

Your language, your format


It’s important to understand your rights when it comes to grievances and appeals. Do you need info in another language? Just call us at 1-855-242-0802 (TTY: 711). We’re here for you 24 hours a day, 7 days a week. We’ll share this info in your primary language. You can also get info other formats, like large print or braille.