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Filing a complaint
Both in-network and out-of-network providers may file verbal complaints with us within 60 days from the Notice of Action. We can resolve them outside the formal complaints and appeals process. Your complaints 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 complaints are subject to the member process. In these cases, we transfer them. These include complaints that you may file on behalf of a member.
Filing an appeal
In-network providers have the right to appeal the result of a decision. You’ll want to file your appeal in writing within 90 calendar days of the Notice of Action.
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
Claim dispute vs. claim appeal
We have two separate and distinct processes for resolving claim disputes and appeals. Check your provider manual for more details.
Before filing an appeal:
You should contact Claims Inquiry/Claims Research (CICR) as the first step to clarify any denials or other actions relevant to the claim. In many cases, claim denials are the result of inaccurate filing practices, so be sure to call beforehand to check on claim information. Just call 1-888-348-2922 (TTY: 711). Or check your provider manual for more information.
File a complaint or appeal now
You can file a [grievance/complaint] or appeal:
You can fax your complaint or appeal:
You can send your complaint or appeal to:
Aetna Better Health® of West Virginia
PO Box 81040
5801 Postal Rd
Cleveland, OH 44181
Reviews of complaints and appeals
Clinical complaints 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