Frequently Asked Questions

How do I change my PCP?

To change your PCP, call Member Services. We can help. You need to do this before you visit your new doctor. Your change will happen the first day of the month. If you make your change by the 20th day of the month, you can use your new PCP or OB/GYN by the 1st of the next month.

Who do I call if I have a complaint?

Complaints/grievances are when you call or send a letter to Aetna Better Health to tell us you are not happy with any part of your benefits, services or Aetna Better Health.
 
If you:

• Do not agree with a decision made by Aetna Better Health
• Are not happy with any services received
• Are not happy about any other part of Aetna Better Health or your provider, you can file a complaint/grievance.

You may do this by calling Member Services or writing it down and sending it to:
 
Aetna Better Health of Virginia
Attn: Grievances and Appeals Department
9881 Mayland Drive
Richmond, Virginia 23233
 
By doing this, you are filing a complaint to tell us why you do not like a decision. You can file a complaint/grievance at any time after the event you are unhappy about. It can be filed to any Aetna Better Health staff person, either orally or in writing.  If you need help in completing any forms or help with any other procedural steps to file a complaint/grievance, including interpreter services, please call Member Services.
 
If you call Member Services, we will take all of the information you give us and investigate the problem.
 
We may ask for the following information:

• Your name
• Your Aetna Better Health member ID number
• Your date of birth
• Your provider’s name
• The date of service
• Your mailing address

A complaint/grievance should be resolved within 30 calendar days from the date we receive it. You will not be punished in any way for filing a complaint/grievance.

Contact information for Aetna Better Health of Virginia Member Services

Medallion/FAMIS – Member Services

1-800-279-1878 (TTY 711)
24 hours a day, 7 days a week

CCC Plus – Member Services

1-855-652-8249 (TTY 711)
24 hours a day, 7 days a week

How do I file an appeal?

If you are not happy with our answer to your complaint/grievance or we have denied any part of your request for a health care service, you or someone with your okay can file something called an appeal. To file an appeal, or to request assistance with filing an appeal, call Member Services. You or your representative acting on your behalf have 60 calendar days after you receive our decision on your complaint/ grievance or you receive denial for any part of your request for a health care service to file an appeal.

To file an appeal you will need to send us a written request that has:

• Your name
• Your provider’s name
• The date of service
• Your mailing address
• An explanation of why we should reverse our decision
• A copy of any information that will support your request, such as additional documents, records or information that are relevant to your appeal

A written appeal needs to be mailed to:

Aetna Better Health of Virginia
Attn: Appeals Coordinator
9881 Mayland Drive
Richmond, Virginia 23233

If you are not able to file a written appeal, you or your representative can call us and we will ask for the information listed above and document the appeal for you. We will let you know we’ve received your appeal and you can get copies of documents, records and information about the appeal. We’ll give these documents to you for free.
 
A committee comprised of persons not involved with the original decision will look at your appeal. If your appeal involves a medical (clinical) issue, the committee will include a health care professional whose training and experience qualifies him or her to make a decision on this medical issue. If your appeal is administrative (not based on a medical issue), the committee will consist of members of our senior management staff. If desired, you can participate in the meeting and speak to members of the committee. You may also ask a doctor, health care provider or member representative to meet with the committee in your place. If you decide to meet with the committee, you will be provided a toll free number to call.
 
An appeal should be resolved within 30 calendar days from the date we receive it. If we need more time or more information for the appeal, or if you want to provide more information, you or we can ask for 14 additional calendar days to finish the appeal. If we need more time or information for the appeal, you will be sent a written notice of the delay and the reasons for it before the day 14. You will have the right to file a grievance if you disagree with the reason for the delay in the appeal decision. If you want to provide more information to us regarding the appeal, you must request the extension before the day 14. The time to make a decision on an appeal can be extended up to 14 more days if you or we need the extra time.
 
Fast (Expedited) Appeals

There is a fast appeal process to respond to cases where death or serious injury could result or in cancer patients when a delay in a decision could result in severe pain to the patient. This is also called an expedited appeal. You or your representative may call us for this type of appeal. If we allow the fast (expedited) appeal, we will make a decision as quickly as your condition requires, within 72 hours from the initial receipt of the appeal for Medallion and CCC Plus Members and 48 hours for FAMIS members.

For appeals relating to pain prescriptions for cancer patients, the decision will be made in 24 hours or less. If you want to provide more information or if it’s your interest, you or we can ask for 14 additional calendar days to finish the appeal. If we need more time or information for the appeal, you’ll be sent a written notice of the delay and the reasons for it.
 
We do not punish your doctor in any way for requesting a fast appeal or for supporting your request for a fast appeal.
 
If we decide your appeal is not a fast appeal, we will handle your appeal like a regular appeal. You and your doctor will receive a phone call or a letter letting you know that we will be following the normal appeal process. We will let you know what the normal appeal process time frames are when we call or send you and your doctor the letter.
 
State Fair Hearings Process (Medallion/CCC Plus)

If you are not happy with our appeal and your appeal is about our decision to deny, reduce, change or terminate payment for your health care services and you have exhausted our appeal process you or your representative can request a State Fair Hearing if it is within 120 days of the notice of the appeal decision from us.. You can only request a State Fair Hearing if it relates to a denial of a service, a reduction in service, termination of a previously preauthorized service, or failure to provide service timely. Your request for a State Fair Hearing should be in writing and sent to:
 
Division of Appeals
Department of Medical Assistance Services (DMAS)
600 E. Broad Street, Suite 1300
Richmond, Virginia 23219
1-804-371-8488

External Review (FAMIS)

If you are not happy with our appeal and your appeal is about our decision to deny, reduce, change or terminate payment for your health care services and you have exhausted our appeal process, you or your representative can request an External Review within 30 calendar days of the notice of the appeal decision from us. You can only request an External Review if it relates to a denial of a service, a reduction in service, termination of a previously preauthorized service, or failure to provide service timely. Your request for an External Review should be in writing and sent to:

FAMIS External Review
c/o KePro
2810 N. Parham Rd.
Suite #305
Henrico, VA 23294
804-622-8900

Contact information for Aetna Better Health of Virginia Member Services

Medallion/FAMIS – Member Services

1-800-279-1878 (TTY 711)
24 hours a day, 7 days a week

CCC Plus – Member Services

1-855-652-8249 (TTY 711)
24 hours a day, 7 days a week

Who should I call to enroll my new baby?

When your family size changes, you move, or get health insurance other than Medicaid, call Aetna Better Health Member Services and your local DSS. Aetna Better Health Member Services can be reached at:

Medallion/FAMIS – Member Services

1-800-279-1878 (TTY 711)
24 hours a day, 7 days a week

CCC Plus – Member Services

1-855-652-8249 (TTY 711)
24 hours a day, 7 days a week

Call Member Services if:

• You have a new person in your family.
• Someone leaves your family home.
• You move. If you move from your current address, we may not be able to cover you under the Aetna Better Health program but we will help you continue to get services until you are disenrolled. Aetna Better Health Member Services will be able to tell you if your new address is in our service area. Contact your local DSS if you move. You may be disenrolled from the Medicaid program if your mail is returned to DSS.

Babies born to mothers enrolled in Aetna Better Health will be automatically enrolled in Aetna Better Health for the birth month plus two more months. CALL YOUR LOCAL DSS TO GET A MEDICAID/FAMIS PLUS ID NUMBER FOR YOUR BABY. This is important to make sure your baby does not have a problem receiving care. If your baby does not have a Medicaid number by the end of the third month, your baby will no longer be covered by Aetna Better Health or Medicaid.

FAMIS MOMS

Babies born to FAMIS MOMS will be enrolled automatically in Aetna Better Health for the birth month plus 2 additional months. Please call your local DSS to get a Medicaid/FAMIS Plus ID number for your baby. This is important to make sure your baby does not have a problem receiving care. If the baby does not have a Medicaid/FAMIS Plus ID number by the end of the third month following birth, the baby will lose coverage.

What if my address changes?

Please call Member Services to let us know.

Medallion/FAMIS – Member Services

1-800-279-1878 (TTY 711)
24 hours a day, 7 days a week

CCC Plus – Member Services

1-855-652-8249 (TTY 711)
24 hours a day, 7 days a week

What do I do if I lose my Aetna Better Health ID card?

If your card is lost or stolen, please call Member Services immediately.

Medallion/FAMIS – Member Services

1-800-279-1878 (TTY 711)
24 hours a day, 7 days a week

CCC Plus – Member Services

1-855-652-8249 (TTY 711)
24 hours a day, 7 days a week