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Grievances and appeals

Filing a grievance

Both in-network and out-of-network providers may file verbal grievances with us. We can resolve them outside the formal appeal and grievance process. Provider grievances could be based on things like:


  • Policies and procedures

  • One of our decisions

  • A disagreement about whether a service, supply or procedure is a covered benefit, is medically necessary or is done in the appropriate setting

  • Any other issue of concern


Some provider grievances are subject to the member grievance process. In these cases, we transfer them. These include grievances:


  • From a provider on behalf of a member with written consent (except for an expedited request)

  • That don’t require written consent from the member

Filing an appeal

Provider appeal process 


Both in-network and out-of-network providers have the right to appeal our claims determinations within 60 calendar days of receipt of the claim denial. To appeal, just use the Health Care Provider Application to Appeal a Claims Determination (PDF).


You can submit this appeal form if our determination:


  • Resulted in the claim not being paid at all for reasons other than a utilization management (UM) determination or a determination of ineligibility, coordination of benefits or fraud investigation
  • Resulted in the claim being paid at a rate you didn’t expect based on a contact with us or the terms of the member’s NJ FamilyCare (Medicaid) coverage
  • Resulted in the claim being paid at a rate you didn’t expect because of differences in our treatment of the codes in the claim compared to what you believe is appropriate
  • Indicated that we need more substantiating documentation to support the claim and you believe the required info is inconsistent with our claims-handling policies and procedures or isn’t relevant to the claim


You can also submit this appeal form if you believe:


  • We’ve failed to adjudicate the claim, or an uncontested part of a claim, in a timely manner consistent with the law and the terms of the provider’s contract (if any)
  • You received appropriate authorization from us or another carrier for the services, but our determination notes we won’t pay because appropriate authorization is lacking
  • We’ve failed to appropriately pay interest on the claim
  • Our statement that we overpaid one or more claims is wrong, or that the amount we calculated as overpaid is wrong 

File a grievance or appeal now

We have processes designed to let you tell us when you’re dissatisfied with a decision we make. You can file a grievance or appeal:

By phone

You can file a grievance or appeal by phone. Just call 1-855-232-3596 (TTY: 711). We’re here for you 24 hours a day, 7 days a week.

By mail

You can file a grievance or appeal by mail. Send your grievance or appeal to:


Aetna Better Health of New Jersey

PO Box 81040

5801 Postal Road

Cleveland, OH  44181

Reviews of grievances and appeals


Clinical grievances and appeals reviews are completed by health professionals who:


  • Hold an active, unrestricted license to practice medicine or in a health profession
  • Are board certified (if applicable)
  • Are in the same profession or in a similar specialty as normally manages the condition, procedure or treatment concerned in the case
  • Are neither the same reviewer that made the original decision nor the subordinate of the person that made the first decision

State fair hearings

Members or their designated representative, including a provider acting on their behalf with their written consent, can ask for a state fair hearing. This request goes through the State of New Jersey Division of Medical Assistance and Health Services (DMAHS). They can ask for a state fair hearing only after they’ve received the Internal Appeal Decision Letter. The member or their representative must complete the request within 120 calendar days of the initial adverse action.

Member grievance system overview

Members can file a grievance when they’re unhappy with the quality of care or service they received from us or one of their providers, or when they don’t agree with a decision we made about coverage. And they can file an appeal if they want us to review or change our coverage decision.


The New Jersey Department of Banking and Insurance has developed a consent form (PDF) that provides:


  • Patient agreement to representation by a health care provider in a UM appeal
  • Authorization from the patient for release of medical records for the appeals process
  • A way for patients to subsequently revoke consent to representation and release of medical records

When requested, we help our members complete grievance and appeal forms and take other steps. You can learn more about the member grievance and appeal processes.


Just check your provider manual (PDF) for answers about grievances and appeals.

Also of interest: