Complaints and Claim Appeals
Any dissatisfaction, expressed orally or in writing to Aetna Better Health, about any matter other than an Adverse benefit determination.
Provider Appeal of MCO Claims Determination
A claim appeal is a written request by a provider to give further consideration to a claim reimbursement decision based on the original and or additionally submitted information. The document submitted by the provider must include verbiage including the word “appeal”.
Aetna Better Health will process appeals and adjudicate the claim within thirty (30) days from the date of receipt.
A claim appeal must meet the following requirements:
- It is a request to Appeal a claim determination
- You're now requesting further consideration based on the original and or additionally submitted information
- The document submitted must include verbiage including the word “appeal”. The claim may be appealed in writing by completing an appeal form and/or providing the following:
- Submit a copy of the Remit/EOB page on which the claim is paid or denied.
- Submit one copy of the Remit/EOB for each claim appealed.
- Circle all appealed claims per Remit/EOB page.
- Identify the reason for the appeal.
- If applicable, indicate the incorrect information and provide the corrected information that should be used to appeal the claim.
- Attach a copy of any supporting documentation that is required or has been requested by Aetna Better Health. Supporting documentation to prove timely filing should be the acceptance report from Aetna Better Health to the provider’s claims clearinghouse. Supporting documentation must be on a separate page and not copied on the opposite side of the Remit/EOB.
Note: It is strongly recommended that providers submitting appeals retain a copy of the documentation being sent.
You can submit Claim Reconsiderations along with the dispute form in writing to:
Aetna Better Health of Texas
Complaints and Appeals Team
P.O. Box 60938
Phoenix, AZ 85082
Verbally by calling:
Medicaid STAR 1-800-248-7767 (Bexar), 1-800-306-8612 (Tarrant)
Medicaid STAR Kids 1-844-STRKIDS (1-844-787-5437)
CHIP or CHIP Perinate 1-866-818-0959 (Bexar), 1-800-245-5380 (Tarrant)
By Email: TXComplaintsandAppeals@AETNA.com
Provider Complaint to HHSC
You can also file a complaint with HHSC by email:
- Information regarding provider complaints and appeals, please refer to the Provider Manual.