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Filing a grievance
Both in-network and out-of-network providers may file verbal grievances with us. We can resolve them outside the formal grievances and appeals process. Your 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 process. In these cases, we transfer them. These include grievances that you may file on behalf of a member.
Filing an appeal
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.
You can file an appeal if:
- We denied reimbursement for a medical procedure or item you provided for a member due to lack of medical necessity or no prior authorization (PA) when it was required
- You have a claim that has been denied or paid differently than you expected and wasn’t resolved to your satisfaction through the dispute process
Are you filing an appeal on a member’s behalf?
You or the member’s designated representative can file on their behalf with their written consent. Just complete the authorization release for standard appeal form (PDF). Then, fax the form with the appeal to: 1-866-669-2459.
File a grievance or appeal now
You can file a grievance or appeal:
You can fax your grievance or appeal to 1-866-669-2459.
You can send your grievance or appeal to:
Aetna Better Health® of Virginia
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 someone who reports to that person