Appeals & complaints

An appeal is a request to reconsider a decision (e.g., utilization review recommendation, benefit payment, administrative action), with Aetna Better Health of New Jersey.  Authorized member representatives, including providers, may also file an appeal on the member’s behalf with the written consent of the member. 

Members or their designated representatives can file an appeal with Aetna Better Health of New Jersey either orally or in writing. Representatives must be designated in writing. 

Appeals are classified in three stages:

Stage 1

  • Informal Utilization Management Appeals
  • Expedited Informal Utilization Management Appeals

Stage 2

  • Formal Utilization Management Appeals
  • Expedited Formal Utilization Management Appeals

Stage 3

  • Independent Utilization Review
  • Expedited Independent Utilization Review

The member or authorized representative may also appeal directly to DMAHS through the State fair hearing process. State fair hearing appeals may be submitted at the same time as, instead of, or after the completion of the member appeal with Aetna Better Health of New Jersey. 

A complaint is a verbal expression of dissatisfaction with Aetna Better Health of New Jersey filed by the member, or their designated representative, that can be resolved within five (5) business days. Complaints that cannot be resolved within five (5) business days will be automatically transferred to a grievance with the original received date.  Complaints that require a review of an action will be transferred to the informal utilization management appeal. This is called a Stage 1 Appeal.

Members or their designated representative can file a complaint orally. They can file a grievance or appeal with Aetna Better Health of New Jersey orally or in writing. A representative is someone who assists with the appeal on the member’s behalf, including but not limited to a family member, friend, guardian, provider, or an attorney. Representatives must be designated in writing. A network provider, acting on behalf of a member, and with the member’s written consent, may file a grievance or appeal with Aetna Better Health of New Jersey.

A grievance is an expression of dissatisfaction by the member, or their designated representative, received orally or in writing, that could not be resolved within five (5) business days. These pertain to any matter other than review of an action. Grievance subjects may include, but are not limited to, dissatisfaction with access to coverage and drug utilization.  Grievances may be filed with Aetna Better Health of New Jersey orally or in writing by the member or the designated representative, including providers. Aetna Better Health of New Jersey responds to grievances within the following timeframes:

  • Thirty (30) calendar days of receipt for a standard grievance 
  • Three (3) business days of receipt for an expedited grievance

A provider may file a formal appeal in writing, a formal request to reconsider a decision (e.g., utilization review recommendation, administrative action), with Aetna Better Health of New Jersey within ninety (90) calendar days from the Aetna Better Health of New Jersey Notice of Action. The expiration date to file an appeal is included in the Notice of Action. All written appeals should be sent to the following address:

Aetna Better Health of New Jersey
Provider Services
3 Independence Way, Suite 400
Princeton, NJ 08540-6626

Both network and out-of-network providers may file a verbal complaint with Aetna Better Health of New Jersey.  Provider complaints are expressions of dissatisfaction filed with Aetna Better Health of New Jersey that can be resolved outside of the formal appeal and grievance process.  Provider complaints include, but are not limited to, dissatisfaction with:

  • Policies and procedures
  • A decision made by Aetna Better Health of New Jersey
  • A disagreement as to whether a service, supply or procedure is a covered benefit, is medically necessary, or is performed in the appropriate setting

Providers can file a complaint with Aetna Better Health of New Jersey by calling the Provider Services Department at 1-855-232-3596

Both network and out-of-network providers may file a formal grievance in writing directly with Aetna Better Health of New Jersey in regard to our policies, procedures or any aspect of our administrative functions, including dissatisfaction with the resolution of a payment dispute, or a provider complaint that is not requesting review of an action. 

Providers can also file a verbal grievance by calling 1-855-232-3596. To file a grievance in writing, providers should write to:

Aetna Better Health of New Jersey
Provider Services
3 Independence Way, Suite 400
Princeton, NJ 08540-6626

Network providers may file a payment dispute verbally or in writing directly to Aetna Better Health of New Jersey to resolve billing, payment and other administrative disputes for any reason including, but not limited to:

  • Lost or incomplete claim forms or electronic submissions
  • Requests for additional explanation as to services or treatment rendered by a health care provider
  • Inappropriate or unapproved referrals initiated by the provider
  • Any other reason for billing disputes

Note: Provider payment disputes do not include disputes related to medical necessity.

Providers can file a verbal dispute with Aetna Better Health of New Jersey by calling Provider Services Department at 1-855-232-3596. To file a dispute in writing, providers should write to:

Aetna Better Health of New Jersey
Provider Services
3 Independence Way, Suite 400
Princeton, NJ 08540-6626 

Providers need to complete and submit the dispute form with any appropriate supporting documentation.

Members or their designated representative, including a provider acting on their behalf with their written consent, may request a State Fair Hearing through DMHAS:

  • At the same time as filing an Stage 1 or Stage 2 appeal with Aetna Better Health of New Jersey
  • After the Aetna Better Health of New Jersey Stage 1 or Stage 2 appeal decision
  • Instead of filing for an Stage 1 or Stage 2 appeal with Aetna Better Health of New Jersey

This request must be completed within twenty (20) calendar days of the adverse action.