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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. 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, like your primary care provider (PCP)

  • A pharmacy or hospital

  • Your health plan 

 

Here are some things you may file a grievance about:

 

  • You haven’t gotten services that we approved.
  • 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 won’t affect your health care services or benefits coverage. Providers and plan staff can’t take any action against you for filing a grievance. 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.

 

An appeal

 

This means you disagree with a decision we made about your coverage for services your provider believes are medically necessary. You’d like us to review the decision.

 

You’ll get a letter from us if we:

 

  • Deny a service, a treatment, medical equipment or medication
  • Stop, suspend or reduce an ongoing service or treatment you’ve been receiving

We call this letter a Notice of Adverse Benefit Determination. Then, if you like, you can file an appeal.

 

All appeals go through our Utilization Management Appeal process. You can ask for an appeal verbally or in writing. You have 60 calendar days from the date on your Notice of Adverse Benefit Determination to ask for an appeal.

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. 

 

What happens next?

What happens next?

Grievances

 

There's no time limit for filing a grievance. We’ll send you a letter within 3 business days after we get your grievance. We’ll try to resolve your grievance right away. We may call you for more information.

 

  • Within 30 calendar days (standard grievance): We’ll send a letter with the grievance committee’s decision and any action we’ll take to resolve your grievance.
  • Within 72 hours (expedited or quick grievance): We’ll send a letter with the grievance committee’s decision and any action we’ll take to resolve your grievance. We may also call you with the decision.

Your letter will include all these things:

 

  • Our decision and the reasons for it
  • Any action we’ll take to resolve your grievance
  • Our contact information in case you have questions about the decision 

You have other grievance rights. You can also:

 

  • Send us any information you think is important to your grievance
  • Ask to see your file anytime in the process
  • Attend the grievance committee review

Just call us if you’d like to attend the grievance committee review. Be sure to do so within the timeframe noted in our response to your grievance. We’ll send that response within 3 business days of receipt.

 

Internal appeal

 

The internal appeal is the first stage of the appeal process. 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, suspend or reduce your service
  • Be someone who reports to or is supervised by the provider who made the original decision about your case
  • Within 60 calendar days: You or your representative need to file an internal appeal in this amount of time from the date on our Notice of Adverse Benefit Determination letter.
  • Within 30 calendar days: We’ll let you know our decision on your internal appeal in this amount of time.
  • 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 to you in writing. The decision letter will:

 

  •  Explain our decision and the reasons behind it
  • Tell you about your right to ask for an External Independent Utilization Review Organization (IURO) Appeal and how to do so
  • Tell you about your right to request a State Fair Hearing and how to do so if you’re eligible

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 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 1-855-232-3596 (TTY: 711).

 

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 is about

 

Then, sign the letter and send it to:

Aetna Better Health

Attn: Grievance and Appeals 

PO Box 81139

5801 Postal Road 

Cleveland, OH 44181

 

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 issue. 

Are you appealing our decision to deny, stop, suspend 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 the letter notifying you of the plan’s decision, whichever is later
  • The appeal involves stopping, suspending or reducing a treatment that was approved before
  • An authorized provider ordered the services in question 

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’ll also send you a letter.

 

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 conditions 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 calendar days. Then, we’ll process your appeal normally, in the usual timeframe. 

If our decision on your internal appeal isn’t in your favor, you can request another appeal. This is an external appeal with an Independent Utilization Review Organization (IURO). This group isn’t connected with our plan.

 

Are you a NJ FamilyCare A or ABP member? If yes, you can also request a State Fair Hearing. Check the “Options for NJ FamilyCare A and ABP members” section on this page to learn more.

 

How to ask for an external appeal

 

We’ll send you a letter to explain the outcome of your internal appeal. The letter will include an external appeal application. Just fill out this form completely to ask for an external review.  Then, you can send it by:

 

Mail

 

NJ Department of Banking and Insurance Consumer Protection Services Office of Managed Care
P.O. Box 329
Trenton, New Jersey 08625-0329

 

Fax

 

609-633-0807

 

Email

 

ihcap@dobi.nj.gov

 

Was the application missing from your letter? If yes, contact us for another copy. Call 1-855-232-3596 (TTY:711). We’re here for you 24 hours a day, 7 days a week.

 

Questions about filing an external appeal? Call the New Jersey Department of Banking and Insurance at 1-888-393-1062. Then, choose option 3.

 

Here are some timelines to note:

  • Within 60 days from the date on your internal appeal decision letter: You or your representative have this much time to file an external appeal. The IURO will review your request. Then, they’ll send you a letter. It will explain whether they have accepted your case for review.
  • Within 45 calendar days: If the IURO accepts your case, they’ll make a decision as soon as possible, but won’t take longer than this much time after receiving your request.
  • Within 48 hours: The IURO will make a decision within this much time if you’ve asked for an expedited decision. You can do so if the usual time (45 days) for an independent utilization review will harm your health.
  • Within 48 hours: The IURO will call you with their expedited decision. If they can’t reach you, they’ll send you a letter with their decision within this much time.

Are you a NJ FamilyCare A or ABP member? If so, you can ask for a State Fair Hearing if you don’t agree with our internal appeal decision. You must wait for your internal appeal to be complete first. If you decide to also request an External (IURO) Appeal, you can choose one of these options:

 

  • Ask for the external appeal before you ask for a State Fair Hearing
  • Ask for them at the same time

Check the “Options for NJ FamilyCare A and ABP members” section on this page to learn more.

 

You must also ask for a State Fair Hearing in writing within 120 days of the date on the outcome letter from your internal appeal. Write to this address with your request:

 

State of New Jersey Division of Medical Assistance and Health Services Fair Hearing Unit
P.O. Box 712
Trenton, NJ 08625-0712

 

Questions? Just call NJ FamilyCare at 1-800-701-0710 for help.

 

At the State Fair Hearing, you may act for yourself, or authorize someone else to act for you. 

Was your appeal based on a decision to deny, stop, suspend 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. You must ask in writing for your services to continue:

 

  • Within 10 calendar days of the date on the Notice of Action letter following an adverse determination on an internal appeal (if you ask for a State Fair Hearing right after your internal appeal), or
  • Within 10 calendar days of the date of the Notice of Action letter following an adverse determination on an external appeal (if you ask for an external appeal before asking for a State Fair Hearing), or
  • On or before the final day of the previous approval for the services in question, whichever is later

 

If the State Fair Hearing decision isn’t in your favor, you may have to pay for the services you asked to continue when you asked for a State Fair Hearing.

Are you a NJ FamilyCare A or ABP member? If yes, you can ask for both the external appeal and the State Fair Hearing. You can do this after you complete your internal appeal. You can:

 

  • Ask for an external appeal and, if the outcome wasn’t in your favor, pursue a State Fair Hearing, or
  • Ask for an external appeal and a State Fair Hearing at the same time, or
  • Ask for a State Fair Hearing without asking for an external appeal
 

Your language, your format

 

It’s important to understand your rights when it comes to grievances and appeals. Do you need information in another language? Just call us at 1-855-232-3596 (TTY:711). We’re here for you 24 hours a day, 7 days a week. We’ll share this information in your primary language. You can also get information in other formats, like large print or braille.