Appeals and grievances online form

I want to file an appeal or grievance

1. Appeal or grievance details

Tell us about the appeal or grievance in the fields below. You’ll want to fill in all fields with an asterisk (*).

*Check one:

I’m filing an appeal.

I’m filing a grievance.

*Date For appeals, give the date on the Notice of Action letter you received. For grievances, give the date of the issue or event.

*Description

Tell us about the appeal or grievance. You can send us medical records or other information to support your appeal. Since there are risks of sharing information via email, we remind you to send your email securely. To send in your requests securely, you can also use the OhioRISE member portal.

2. Member information

Share your information in the fields below. You’ll want to fill in all fields with an asterisk (*).

*Name

*Date of birth

*Address 1

Address 2

*City

*State

*Zip Code Example: 12345

*Phone Number Example: 1234567890

*MEMBER ID/BILLING NUMBER

*Are you filing this appeal or grievance for someone else?

Yes, I’m a representative.

No, I’m the member.

Representatives are family members, friends, caregivers or providers. This is someone the member approved in writing to act for them, or others legally able to act for the member. It can be the member’s legal guardian or someone who holds power of attorney. You’ll need to send us this proof of representation if you haven’t already. You can send it using one of the methods listed at the bottom of this form.

3. Representative information

Share the representative’s information in the fields below. You’ll want to fill in all fields with an asterisk (*).

*Name

*Relationship Your relationship to member

*Date of birth

*Address 1

Address 2

*City

*State

*Zip Code Example: 12345

*Phone Number Example: 1234567890

Expedited appeals

You can ask for an expedited appeal if you or your provider believes our standard time frame of 15 days to make an appeal decision will risk your life or health.

Check this box if you believe you need a decision within 72 hours. If you have a supporting statement from your provider, you can send it using one of the methods at the bottom of this form.

*Sign

*Date Today's date

*Who are you?

Contact us

You can send us more information by:

Phone: 1-833-711-0773 (TTY: 711) from 7 a.m. to 8 p.m., Monday through Friday.
Fax: 1-833-928-1259 (toll-free)
Email: OHRiseAppealandGrievance@AETNA.com
Mail: Aetna Better Health® of Ohio
Grievance System Manager
 PO Box 81139
5801 Postal Road
Cleveland, OH 44181

Non-discrimination notice

Aetna Better Health® of Ohio follows state and federal civil rights laws that protect you from discrimination or unfair treatment.

Read our full non-discrimination notice

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Appeals and grievances online form

I want to file an appeal or grievance

Expedited appeals

Contact us

Non-discrimination notice

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