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Grievances and appeals

For detailed information about state hearings, independent medical reviews (IMRs), or grievances and appeals, see your member handbook.

Help us better serve you

Help us better serve you

A grievance is when you’re unhappy with the quality of care or service you received from:

 

  • One of your doctors
  • One of your providers
  • Aetna Better Health® of California

You file an appeal when you want to review and change a decision we made about your coverage.

I want to file a grievance or an appeal

We take your concerns seriously. Let us know how we can improve our service. There’s no time limit for filing a grievance. An appeal can be filed after you receive a Notice of Action telling you that we are denying, delaying, changing or ending a service. An appeal must be filed within 60 days from the date you received your notice. You must file an appeal within 10 calendar days of getting your notice if you want to continue your current treatment.

File your grievance or appeal here

Next steps

Next steps

After your grievance or appeal is filed, we will:

 

  • Send you a letter telling you we received your standard grievance or appeal within 5 calendar days
  • Send another letter telling you how we resolved your problem within 30 calendar days

After your expedited grievance or appeal is filed, we will:

 

  • Confirm the content of your expedited appeal at the time of receipt
  • Confirm the content of your request and send you a resolution letter within 72 hours

For more information about filing a grievance or requesting an appeal, see your member handbook.

 

If you don’t agree with the appeal decision or you never received your letter in the mail, you can ask for a state fair hearing or an IMR.

State fair hearings

You can request a state fair hearing within 120 days of getting your appeal decision letter. You can make your request:

By mail

Fill out the form provided with resolution of your appeal notice.
Send the letter to:

California Department of Social Services
State Hearings Division
PO Box 944243, Mail Station 9-17-37
Sacramento, CA 94244-2430

Through your primary care physician (PCP)

Your PCP can file for a state fair hearing on your behalf, after you give them your written permission.

By phone

Call the Department of Social Services Public Inquiry and Response Unit at 1-800-952-5253 

or 1-800-952-8349 if you have impaired hearing or speech.

IMRs

IMRs

You can request an IMR within 180 days of getting your appeal decision letter. An IMR is done by a third-party reviewer who is not a part of Aetna Better Health of California. You can request an IMR if:

 

  • Your appeal was denied, was delayed or is changing 
  • A service is ending due to not meeting medical necessity
  • Your health is in immediate danger
  • Your request was denied because treatment was considered experimental

You can’t ask for an IMR if you have already asked for a state fair hearing for the item or service you are appealing.

 

How do I request an IMR?

  • Call the California Department of Managed Health Care at 1-888-HMO-2219. The department also has a toll-free telephone number (1-888-466-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired.
  • Fill out an IMR application online.

Expedited reviews

You can expedite your appeal if waiting 30 calendar days would harm your health. A decision will be made within 72 hours of receiving your appeal.

 

Just call
Member Services at
1-855-772-9076 (TTY: 711).