Grievance & Appeals
We want you to be happy with services you get from us and our providers. We want you to let us know if you are unhappy. We take member grievances and appeals very seriously. We want to know what is wrong so we can make our services better.
We want to make sure you understand your rights related to grievances and appeals. If you need information in another language let us know. We will notify you in your primary language of these rights.
We can also provide information in alternate formats, such as Large Print, or braille.
A grievance is when you tell us you are unhappy with us or your provider or you do not agree with a decision we have made.
Some things you may file a grievance about:
- You are unhappy with the care you are getting.
- You have not gotten services that the Plan has approved.
- Your provider or a plan staff member did not 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 was rude to you.
- Your provider or a plan staff member was not sensitive to your cultural needs or other special needs you may have.
If you disagree with our decision to deny coverage for a service or item that you or your provider asked for, this is an appeal, and it will be automatically transferred to the Utilization Management Appeal process. The received date will be the same.
If you have a grievance about a provider or about the quality of care or services you have received, you should let us know right away. We have special procedures in place to help members who file grievances. We will do our best to answer your questions and to help resolve your issue. Filing a grievance will not affect your health care services or your benefits coverage.
How to file a grievance
You can submit a grievance by phone or in writing.
Call us: 1-855-232-3596, TTY 711
Fax us: 1-855-321-9566
Write to us:
Aetna Better Health of New Jersey
Attn: Grievance System and Appeals
PO Box 81139
5801 Postal Road
Cleveland, OH 44181
Tell us what happened You can write to us with your grievance. Tell us in detail what happened. Include the date the incident happened and the names of the people involved. Be sure to include your name and your member ID number. We may call you to get more information about your grievance.
Have someone represent you in a grievance You can have someone represent you, such as a family member, friend or provider. You must agree to this in writing. Send us a letter telling us that you want someone else to represent you and file a grievance for you. Include your name, member ID number from your ID card, the name of the person you want to represent you and what your grievance is about.
When we get the letter from you, the person you picked can represent you. If someone else files a grievance for you, you cannot file one yourself about the same item.
Other grievance rights You can send us any information that you feel is important to your grievance. You can also ask to see your file at any time throughout the process. You have the right to attend the grievance committee review. If you want to attend, call us and tell us you want to attend. The timeframes to tell us you want to attend are in the letter we will send you within three (3) business days after receiving your grievance.
Timeframes for resolving your grievance We will try to resolve your grievance right away. We may call you for more information. The grievance committee will make a decision within the following timeframes:
- Thirty (30) calendar days of receipt for a standard grievance
- Three (3) business days of receipt for an expedited grievance
For grievances that require an expedited (quick) decision, you may get a phone call from us with the decision. You will get a letter from us within three (3) business days of receipt. The letter will include the decision reached and the reasons for the decision, along with our contact information if you have questions about the decision.
Appeals (Utilization Management Appeals)
A Utilization Management (UM) appeal is a way for you to ask us to reconsider our decisions with regard to medically necessary services. If we deny your request for a service (or request for us to pay for a service), or if we decide to reduce, suspend, or stop an ongoing service or a course of treatment you have been receiving, you can request an appeal. You can request an appeal verbally or in writing. You have sixty (60) calendar days from your Notice of Adverse Benefit Determination to request an appeal.
Continuation of Benefits During an Appeal
If you are appealing our decision to reduce, suspend, or stop an ongoing service or a course of treatment you have been receiving, those services will continue automatically during your appeal as long as the following conditions are met:
- You file your appeal in a timely fashion;
- The appeal involves the termination, suspension, or reduction of a previously authorized course of treatment;
- The services in question were ordered by an authorized provider;
- You file your appeal on or before the last day of the original authorized period, or within ten days of the letter notifying you of the plan’s decision, whichever is later.
Have someone represent you in an appeal You can have someone represent you when you file your appeal. This could be a family member, friend or provider. You must agree to this in writing. Send us a letter telling us that you want someone else to represent you and file an appeal for you. Include your name, member ID number from your ID card, the name of the person you want to represent you and what action you are appealing.
When we get the letter from you, the person you picked can represent you.
Internal Appeal The Internal Appeal is the first stage of the appeal process. Your appeal will be reviewed by a provider with the same or like specialty as your treating provider. It will not be the same provider who made the original decision to deny, reduce, or stop the medical service. The provider who reviews your appeal will not report to the provider who made the original decision about your case.
We will let you know our decision on your Internal Appeal within thirty (30) calendar days (unless your appeal was for urgent or emergency care, you are in the hospital, or your provider states that waiting up to 30 days for a decision could be harmful to your health, in which case we will make our decision within seventy-two (72) hours). We will send the results to you in writing. The decision letter will:
- Explain our decision, and the reasoning behind it;
- Tell you about your right to request an External Independent Utilization Review Organization (IURO) Appeal, and how to do so; and
- Tell you about your right to request a State Fair Hearing and how to do so (if you are eligible).
How to file You can call or write us with your Internal Appeal. If you ask, we can help you with your appeal.
Call us: 1‑855‑232‑3596, TTY 711
Fax us: 1‑844‑321‑9566
Write to us:
Aetna Better Health of New Jersey
Attn: Grievance System and Appeals
PO Box 81139
5801 Postal Road
Cleveland, OH 44181
Tell us what happened If you write to us, include your name, member ID number, the date of your Notice of Adverse Benefit Determination letter, information about your case and why you are asking for the appeal.
Your timeframes for filing You or your representative need to file an Internal Appeal within sixty (60) calendar days from the date on our Notice of Adverse Benefit Determination letter.
How to ask for an expedited (quick) decision If you or your provider feel the usual timeframe for an appeal to be decided (up to 30 calendar days) will harm your health, you can ask us to make an expedited (quick) decision. You or your provider can ask for an expedited decision by calling us. Aetna Better Health of New Jersey will call you with the decision within 72 hours and send you a letter with the decision.
You may also request an expedited decision for the following reasons: situations involving urgent or emergency care, an admission to a hospital, availability of care, continued hospital stay, and health care services for which you have received emergency services but have not yet been discharged from a hospital or other facility.
If it is determined that processing your Internal Appeal in the usual thirty (30) calendar day
timeframe will not harm your health, your appeal will be decided within the usual timeframe. We will call you to let you know that your appeal will be processed in the usual timeframe, and we will send you a written letter within two (2) calendar days.
Next Steps: External (IURO) Appeal If our decision on your Internal Appeal is not in your favor, you can request an appeal with an Independent Utilization Review Organization (IURO); this independent organization is not connected with our plan.
How to File The letter we send you explaining the outcome of your Internal Appeal will include a form called the External Appeal Application. To request an External (IURO) Appeal, you must fill out this form completely, and send it to the address below:
NJ Department of Banking and Insurance Consumer Protection Services Office of Managed Care
P.O. Box 329
Trenton, New Jersey 08625-0329
If the External Appeal Application is missing from the appeal adverse outcome letter, you should call the New Jersey Department of Banking and Insurance’s toll-free telephone number (1-888-393-1062) to request a copy. You can also call that toll-free number with any questions about how to file an external appeal (please keep in mind, however, that you cannot request an External/IURO Appeal by phone).
Your timeframes for filing You, or your representative, need to file an External Appeal within sixty (60) days from the date on our Internal Appeal Decision Letter.
What happens next? The Independent Utilization Review Organization (IURO) will review your request. The IURO will send a letter telling you whether or not they have accepted your case for review.
If so, the IURO will make a decision as soon as possible, but not later than forty-five (45) calendar days after receipt of your request for IURO review. If the usual time for an Independent Utilization Review will harm your health, you can ask the IURO to make an expedited decision. The IURO will then make a decision within forty-eight (48) hours. The IURO will call you with their decision; if they cannot reach you, they will send you a letter with their decision within forty-eight (48) hours.
You can find more information at www.nj.gov/dobi/divisioninsurance/managedcare/umappeal.htm
State Fair Hearing
If you are a NJ FamilyCare A member or a NJ FamilyCare ABP member, you may also ask for a State Fair Hearing. You may ask for a State Fair Hearing only after you have received a decision on your Internal Appeal. You must request a State Fair Hearing in writing within one-hundred-twenty (120) days of the date of the outcome letter from your Internal Appeal.
At the State Fair Hearing, you may represent yourself, or you may legally authorize someone else to represent you. You must ask for a State Fair Hearing in writing by contacting DMAHS at the following address:
State of New Jersey Division of Medical Assistance and Health Services Fair Hearing Unit
P.O. Box 712
Trenton, NJ 08625-0712
You can call the following number if you have questions: 1‑800‑356‑1561
If your appeal was based on a decision to reduce, suspend, or stop an ongoing service or a course of treatment, and you file for a Medicaid State Fair Hearing, you have the right to request to have your services continue while your appeal is pending. You must ask, in writing, for your services to continue:
- Within ten (10) calendar days of the date of the notice of action letter following an adverse determination resulting from an internal appeal (if you choose to request a State Fair Hearing immediately following your Internal Appeal);
- Within ten (10) calendar days of the date of the notice of action letter following an adverse determination resulting from an external (IURO) appeal (if you chose to request an External/IURO Appeal before requesting a State Fair Hearing); or
- On or before the final day of the previously approved authorization for the services in question, whichever is later.
If the denial decision is upheld, you may have to pay for the cost of the services you requested to continue when you requested a State Fair Hearing.
OPTIONS: External (IURO) Appeal and State Fair Hearing (if you are a NJ FamilyCare A or ABP member)
Please note that once you have completed the Internal Appeal, you have access to both the External (IURO) Appeal and the State Fair Hearing. You can:
- Request an External (IURO) Appeal, wait until it is completed, and choose to pursue a State Fair Hearing if the outcome was not in your favor;
- Request and External (IURO) Appeal and a State Fair Hearing at the same time; or
- Request a State Fair Hearing without requesting an External (IURO) Appeal.