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Help us better serve you
Help us better serve you
An appeal
An appeal is an action you can take when you disagree with a decision we made about coverage for services. You may consider taking this action if you get a letter from us, officially called a Notice of Action, that says we’ve denied, stopped, held, or reduced an ongoing service or treatment (otherwise referred to as an "adverse benefit determination”).
If you disagree with a decision we made that negatively affects your benefits, you can also ask for an appeal. An appeal is a review and reconsideration of both coverage and non-coverage decisions. If your services were previously authorized and the appeal involves termination, suspension, or reduction of services prior to you receiving the previously authorized services, your services may continue while your appeal is pending.
You can file an appeal if you would like us to review the decision to be sure we were correct about things like:
- Not approving a service your provider asked for
- Stopping a service that was approved before
- Not paying for a service your provider asked for
- Not giving you the service in a timely manner
- Not approving a service for you because it was not in our network
Your appeal will be reviewed by a provider with the same or like specialty as your treating provider. The reviewer won’t:
- Be the same provider who made the original decision to deny, reduce or stop the service
- Report to the provider who made the original decision about your case
A grievance
A grievance is an action you can take when you are dissatisfied with any matter other than an adverse benefit determination.
Here are some things you may file a grievance about:
- You were unhappy with the quality of care or treatment you received.
- 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.
- You can’t get the service or item you want because it’s not covered.
- You haven’t gotten services that we approved.
Do you have an appeal or grievance? Filing an appeal or grievance won’t affect your healthcare services or benefits coverage. 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.
What happens next?
What happens next?
Appeals
A provider with the same or like specialty as your treating provider will review your appeal.
- Within 60 calendar days from the date on our Notice of Action letter: You or your representative need to file the appeal.
- Within 15 calendar days (standard appeal): We’ll tell you our decision.
- Within 72 hours (expedited or quick appeal): We’ll tell you our decision if your appeal is for urgent, emergency or hospital care. Or if waiting up to 15 days for a decision could be harmful to your health.
Your decision letter
With either time frame, you’ll receive a letter that includes:
- Our decision and the reasons for it.
- Your right to request a state hearing and how to do it.
Grievances
There's no time limit for filing a grievance. We’ll send you a letter saying that we received it. We’ll try to resolve your grievance right away. We may call you for more information.
We’ll decide on your grievance within these time frames:
- Within two business days of receipt if the grievance is regarding access to services.
- Within thirty calendar days of receipt for non-claims-related grievances.
- Within sixty calendar days of receipt for claims-related grievances.
We’ll send a letter with:
- The decision
- Supporting reasons
- Any action we’ll take to resolve your grievance
- Our contact info, so you can ask questions
For grievances that require an expedited or quick decision, you may also get a phone call from us with the decision.
More help with appeals and grievances
Here are some options if you need more help.
You can have someone else file an appeal or grievance for you. They can also act for you in a state hearing. This person is your member representative. They may be:
- Your provider
- Your family member
- Your friend
- Your legal guardian
- Your attorney
- Another person
You have to give written permission allowing the person to act for you. Use this form (PDF) or send us a letter with this information:
- Your name
- Your ID number
- The name of the person you want to represent you
- Information about the grievance or action you want to appeal
Then, sign the letter and send it to:
Aetna Better Health of Ohio
Grievance System Manager
P.O. Box 81139
5801 Postal Road
Cleveland, OH 44481
When we get the letter from you, the person you picked can represent you. If someone else files an appeal or grievance for you, you can’t file your own appeal for that action.
You can speed up your appeal if waiting up to 15 calendar days could be 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 can increase the review period up to 14 days if you ask for an extension or if we need more information and the delay is in your interest.
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.
- Healthcare services 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 1 business day. Then, we’ll process your appeal using the standard time frame of 15 calendar days.
You can ask for a state hearing if you don’t agree with our appeal decision. The state’s rules say you must wait for your appeal to be complete first.
You must ask for a state hearing within 90 days from the mail date of your appeal decision letter.
You have options to ask for a state hearing. Just contact the Bureau of State Hearings at the Ohio Department of Job and Family Services (ODJFS):
By phone
Just call 1-866-635-3748.
By mail
You can also mail your state hearing request letter to:
Ohio Department of Job and Family Services Bureau of State Hearings
P.O. Box 182825
Columbus, Ohio 43218-2825
Your language, your format
You need to understand your rights when it comes to appeals and grievances. Do you need information in another language? Just call us at 1-833-711-0773 (TTY: 711) from 7 a.m. to 8 p.m. Monday through Friday. We’ll share this information in your primary language. You can also get information other formats, like large print or braille.