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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 or complaint. 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’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 

 

A complaint: You don’t agree with a decision we made about coverage. 

 

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 service. We call this an Adverse Benefit Determination. Then, you can file an appeal. Your doctor or someone else can file an appeal for you. 

File your grievance or appeal

I want to file a grievance, complaint or appeal

 

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

 

What happens next?

What happens next?

Grievances

 

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

 

Complaints

 

When you don’t agree with a benefit decision we made about coverage, we transfer your complaint to Appeals.

 

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 

 

We’ll send you a letter after we get your appeal. Here are some timelines to note:

 

  • Within 5 days: We’ll send you a letter to let you know we received your appeal and we’re working on it.

  • Within 30 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.

  • Within 72 hours (expedited): Sometimes, we’ll review an appeal in this time frame. This happens when your doctor feels your condition is serious. 

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

More help with grievances, complaints and appeals

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

If we haven’t solved the issue, you can ask the state for help. Just call 1-800-284-4510. You can call from 8 AM to 5 PM, Monday to Friday. You’ll be able to ask questions or explain your problem. They can:

 

  • Answer your questions

  • Work with us to help solve your problem

  • Help with community services you may need 

  • Send your appeal to a nurse in the Complaint Resolution Unit with the goal of resolving the issue in up to 10 days or providing other options

Did you appeal our decision and receive a written denial? If yes, you can ask the state to review our decision. Just call the HealthChoice Help Line 1-800-284-4510

 

Tell them you’d like to appeal the Aetna Better Health® decision. They’ll try to resolve your issue in 10 business days. If they can’t, you’ll receive info about your options.

You may be able to keep getting a service while the state reviews your appeal. This can happen if:

 

  • The service was already approved

  • You were already receiving the service 

  • The time period for the approval hasn’t expired 

 

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? Call the HealthChoice Help Line at 1-800-284-4510.  

To appeal the state’s decision, ask the state to file a notice of appeal with the Office of Administrative Hearings. Make your request within 120 days of getting your appeal decision letter (notice of resolution). This office will set a hearing date within 30 days of the day you file your appeal with them.

 

You can also ask for an expedited appeal. If you have a serious condition, the state may decide your hearing should happen sooner. In that case, they’ll hold your hearing and decide within 72 hours.  

 

Questions about state fair hearings? You can call the HealthChoice Help Line at 1-800-284-4510. You can also check your member handbook to learn more about appeals and state fair hearings.

 

Do you believe you haven’t been treated fairly? If so, you can file a complaint with this office: 

 

Office for Civil Rights Region III  

Department of Health and Human Services 

150 S. Independence Mall West, Suite 372  

Public Ledger Building 

Philadelphia, PA 19106  

Phone: 1-800-368-1019 (TDD: 1-800-537-7697)

Fax: 215-861-4431 

 

You can also visit the Office for Civil Rights website to learn more.

Do you have a complaint about long-term care services? This office helps older people and those with disabilities, as well as their families:

 

Maryland Department of Aging 

301 West Preston Street  

Suite 1007 

Baltimore, Maryland 21201  

Phone: 1-800-243-3425 (TDD: 711)

Fax: 410-333-7943