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Complaints and appeals

We want you to be happy with the care you get. So if you’re ever unhappy with your health plan or a provider, you can file a complaint (also called a grievance). And if you’re unhappy with a decision we made, you can file an appeal. This process helps us make our services better.

 

To learn more, just visit our materials and forms page to check your member handbook.

Help us better serve you

Help us better serve you

A complaint

 

You’re unhappy with the quality of care or services you received from:

 

  • One of your providers (for example, vision or dental services providers) 

  • A pharmacy or hospital

  • Your health plan 

 

Here are some things you can file a complaint 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.

Do you have a complaint? Filing a complaint or appeal won’t affect your health care 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. 

 

An appeal

 

This means you disagree with a decision we made. You’ll get a letter from us if we deny, stop, hold or reduce an ongoing service or treatment you’ve been receiving. We call this a Notice of Action. 

 

Then, if you like, you can file an appeal. You’d 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 primary care provider (PCP) or other provider requested
  • Not giving you the service in a timely manner
  • Not approving a service for you because it was not in our network

Note: You can file an appeal about any decision we made. It does not have to be about a denied or reduced service or treatment.

File here

I want to file a complaint or appeal

 

You have options for filing a complaint or appeal. And we’re here to help you through the process. If you don’t speak English, we can provide an interpreter at no cost.

What happens next?

What happens next?

Complaints

 

There's no time limit for filing a complaint. If you filed a written complaint by mail, we’ll send you a letter saying that we received it. We’ll try to resolve your complaint right away. We may call you for more info.

 

Some timelines to note with your complaint

 

  • Within 3 calendar days (for complaints filed by mail): We’ll send you a letter saying that we received your complaint.
  • Within 30 calendar days: We’ll tell you our decision. 
  • Up to 14 calendar days: We may extend the decision time about your complaint if we need more info and the delay is in your interest. If we extend the time, we’ll send you a letter to explain the delay. 

Appeals

 

A provider with the same or like specialty as your treating provider will review your appeal (except for administrative appeals).
 

Some timelines to note with your appeal 

 

  • Within 60 calendar days from the date on our decision letter: You or your representative need to file the appeal.
  • Within 13 calendar days from the date on our Notice of Action letter: You need to file your appeal if you want your benefits and services to continue while we review your appeal.
  • Within 30 calendar days (standard appeal): We’ll tell you our decision. 
  • Up to 14 calendar days: We may extend the decision time about your appeal if we need more info and the delay is in your interest. If we extend the time, we’ll send you a letter to explain the delay.  

Expedited or quick appeal

 

  • Within 72 hours: We’ll tell you our decision if your appeal is for urgent, emergency or hospital care. Or if waiting up to 14 days for a decision could be harmful to your health.

More help with complaints and appeals

If you need more help or don’t agree with our appeal decision, here are some options.

You can have someone else file a complaint or appeal for you. They can also act for you in a state fair 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 us written permission to allow the person to act for you. You’ll need to write a letter for:

 

  • Complaints 
  • Appeals
  • State fair hearings: Send the letter to the Bureau for Medical Services (BMS) and include it with your state fair hearing request.
  •  

When you write a letter, tell us that you want someone else to act for you to file a complaint or appeal. Be sure to include:

 

  • Your name
  • Your member ID number from your ID card
  • The name of the person you want to represent you 
  • What your grievance or appeal is about
  •  

Then, sign the letter and send it to:

Aetna Better Health of West Virginia 

PO Box 81139 

5801 Postal Road 

Cleveland, OH 44181

Is your provider filing on your behalf? If yes, be sure they use this address, not the provider address.

When we get the letter, the person you chose can act for you. If someone else files a complaint or appeal for you, you can’t file one yourself about the same item. 

Are you appealing our decision to deny, stop, hold or reduce an ongoing service or treatment you’ve been receiving? If yes, and you’d like those services to continue during your appeal, you must request for them to continue within 13 days of our decision letter. Additionally, these services will continue as long as:

 

  • You file your appeal on or before the last day of the original authorized period, or within 13 days of our decision letter, whichever is later
  • The appeal involves stopping, holding or reducing a treatment that was approved before
  • The authorization hasn’t expired
  • An authorized provider ordered the services in question 

Your services will continue until one of these things happens:

 

  • You withdraw the appeal.
  • The original authorization period for your services has been met.
  • 13 days have passed since we mailed you our appeal decision.

This applies unless you have asked for a state fair hearing with continuation of services. Read more about this topic under the “State fair hearing” tab.

 

The appeal decision

 

  • If the appeal decision isn’t in your favor: You may need to pay for the disputed services that you continued to receive during your appeal.
  • If the appeal decision is in your favor: We’ll provide the disputed services within 72 hours from the date of the appeal decision if you didn’t continue to get these services during the appeal. And we’ll pay for these services if you did continue to get them during the appeal.

You can speed up your appeal if waiting up to 14 calendar days is 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 we need more info 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
  • Health care 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 72 hours. Then, we’ll process your appeal normally, in the usual timeframe (30 days). 

You can ask for a state fair hearing from the Bureau for Medical Services (BMS) 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 also ask for a state fair hearing within 120 days of the date of the appeal decision letter. We’ll mail you the state fair hearing request form to complete. To get the form, just call us at 1-888-348-2922 (TTY: 711).

 

You can send your completed state fair hearing request form to:

WV Bureau for Medical Services/Office of Medicaid Managed Care 

350 Capitol Street, Room 251 

Charleston, WV 25301-3708

 

The state will hear your case and decide within 90 days of your request for a state fair hearing.

 

Questions about requesting a state fair hearing? Just call us at 1-888-348-2922 (TTY: 711). You can also call the Department of Health and Human Resources at 1-304-558-0684.

You can ask for a state fair hearing from the Bureau for Medical Services (BMS) 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 also ask for a state fair hearing within 120 days of the date of the appeal decision letter. We’ll mail you the state fair hearing request form to complete. To get the form, just call us at 1-888-348-2922 (TTY: 711).

 

You can send your completed state fair hearing request form to:

WV Children's Health Insurance Program

350 Capitol Street, Room 251

Charleston, WV 25301

 

The state will hear your case and decide within 90 days of your request for a state fair hearing.

 

Questions about requesting a state fair hearing? Just call us at 1-888-348-2922 (TTY: 711). You can also call the Department of Health and Human Resources at 1-304-558-0684.

Was your appeal based on a decision to deny, stop, hold or reduce an ongoing service or treatment? If so, and you file for a state fair hearing, you have the right to ask that your services continue while your appeal is pending. Check the box on the state fair hearing form that you want to continue services. 

 

You must ask for your services to continue in writing within 13 days of the date of our appeal decision letter. Your services will continue until one of these things happens:

 

  • You withdraw the appeal
  • The original authorization period for your services has ended
  • The State Fair Hearing Officer denies your request 

If you miss the 13-day deadline, we’ll reduce, hold or stop your services by the effective date.

 

The state fair hearing decision

 

  • If the state fair hearing decision isn’t in your favor (agrees with our decision): You may need to pay for the disputed services if you continued to get them while your hearing was pending.
  • If the state fair hearing decision is in your favor (reverses our decision): We’ll make sure you get the disputed services right away — as soon as your health condition requires. If you continued to get the disputed services while your hearing was pending, we’ll pay for the covered services.
 

Your language, your format



You need to understand your rights when it comes to complaints and appeals. Do you need info in another language? Just call us at 1-888-348-2922 (TTY: 711). We’re here for you 24 hours a day, 7 days week. We’ll share this info in your primary language. You can also get info other formats, like large print or braille.