Grievances & Appeals

The California Department of Managed Health Care (DMHC) is responsible for regulating health care service plans. If you have a grievance against Aetna Better Health, you should first call Member Services at 1-855-772-9076, TTY 711, and use our grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you.

If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call DMHC for assistance.

You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services.

DMHC has a toll-free telephone number, 1-888-HMO-2219, TDD 1-877-688-9891 for the hearing and speech impaired. DMHC's website has complaint forms, IMR application forms and instructions online.

A grievance is any communication by you to us of dissatisfaction about the care and treatment you receive from our staff or providers of covered services including vision, transportation and dental services. For example, if someone was rude to you or you do not like the quality of care or services you have received from us, you can file a grievance.

Aetna Better Health takes member grievances very seriously. We want to know what is wrong so we can make our services better. If you have a grievance about a provider or about the quality of care or services you have received, you should let us know right away. Aetna Better Health has special procedures in place to help members file grievances. We will do our best to answer your questions or help to resolve your concern. Filing a grievance will not affect your health care services or your benefits coverage.

These are examples of when you might want to file a grievance:

  • Your provider or an Aetna Better Health staff member did not respect your rights.
  • You had trouble getting an appointment with your provider in an appropriate amount of time.
  • You were unhappy with the quality of care or treatment you received.
  • Your provider or an Aetna Better Health staff member was rude to you.
  • Your provider or an Aetna Better Health staff member was insensitive to your cultural needs or other special needs you may have.

For more information about grievances, see your evidence of coverage (handbook).

There is no time limit to file a grievance. You can file a grievance with us at any time by phone, in writing or online.

Call us: 1-855-772-9076

Write to us:
Aetna Better Health of California
Appeal and Grievance Department
10260 Meanley Drive
San Diego, CA 92131

Online: You may file a grievance online using the Grievance Form.

File at your provider’s office: You can fill out a grievance form available at your provider’s office.

Grievances will be resolved within thirty (30) calendar days from receipt of the request. For more information about filing a grievance, see your evidence of coverage (handbook).

An appeal is different from a complaint. An appeal is a request for Aetna Better Health of California to review and change a decision we made about coverage for a requested service. If we sent you a Notice of Action (NOA) letter telling you that we are denying, delaying, changing or ending a service, and you do not agree with our decision, you can file an appeal. Your PCP can also file an appeal for you with your written permission.

You must file an appeal within 60 calendar days from the date on the NOA you received. If you are currently getting treatment and you want to continue getting treatment, then you must ask for an appeal within 10 calendar days from the date the NOA was delivered to you, or before the date Aetna Better Health of California says services will stop. When you request the appeal, please tell us that you want to continue receiving services.

You must file an appeal within 60 calendar days from the date on the NOA you received. You can file an appeal with us at by phone, in writing or online.

Call us: 1-855-772-9076

Write to us:
Aetna Better Health of California
Appeal and Grievance Department
10260 Meanley Drive
San Diego, CA 92131

Online: You may file an appeal online using the Appeals Form.

File at your provider’s office: You can fill out a appeals form available at your provider’s office.

Expect for expedited cases, appeals will be resolved within thirty (30) calendar days from receipt of the request. For more information about filing an appeal, see your evidence of coverage (handbook). 

If you or your doctor wants us to make a fast decision because the time it takes to resolve your grievance or appeal would put your life, health, or ability to function in danger, you can ask for an expedited (fast) review. To ask for an expedited review, call 1-855-772-9076 (TTY 711). We will make a decision within 72 hours of receiving your grievance or appeal. For more information about expedited review, see your evidence of coverage (handbook).

You can use the secure online Grievance Form to submit a grievance or appeal. To use this form, give us as much information as you can. Describe the situation in detail include the date the incident happened, the names of the people involved and details about what happened. After a review of your request we may contact you to get additional information about your case.

You can also:

Call us: 1-855-772-9076

Write to us:
Aetna Better Health of California
Appeal and Grievance Department
10260 Meanley Drive
San Diego, CA 92131

Or file at your provider’s office: You can fill out a grievance form available at your provider’s office.

 

An IMR is when an outside reviewer who is not related to the health plan reviews your case. If you want an IMR, you must first file an appeal with Aetna Better Health of California. If you do not hear from your health plan within 30 calendar days, or if you are unhappy with your health plan’s decision, then you may then request an IMR. You must ask for an IMR within 6 months from the date on the notice telling you of the appeal decision.

You may be able to get an IMR right away without filing an appeal first. This is in cases where your health is in immediate danger or the request was denied because treatment was considered experimental or investigational.

The California Department of Managed Health Care is responsible for regulating health care service plans. If you have a grievance against your health plan, you should first telephone your health plan at 1-855-772-9076 (TTY 711) and use your health plan’s grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of a proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature and payment disputes for emergency or urgent medical services. The department also has a toll-free telephone number (1-888-HMO-2219) and a TDD line (1-877-688-9891) for the hearing and speech impaired. The department’s website has complaint forms, IMR application forms and instructions online.

A State Hearing is an appeal if you disagree with a decision we have made regarding your health care services. This includes termination or reductions in service. It is not a court hearing. This is a hearing that includes you, an Administrative Law Judge from the California Department of Social Services and a Plan representative. You can also have an authorized representative represent you at the hearing. You can notify the State Hearings Division if you need language assistance. If you ask for an interpreter, a state approved interpreter will be there to help you. You can request a State Hearing at any time in the appeal process.

If you want a State Hearing, you must ask for one within 120 days from the date of the “Notice of Appeal Resolution” letter. You can ask for a State Hearing over the phone or in writing:

  • If you decide to ask for a State Hearing by phone, please call 1-800-952-5253. This number can be very busy, so you may get a message to call back later. If you have trouble speaking or hearing, please call TTY/TDD 1-800-952-8349.
  • If you decide to ask for a State Hearing in writing, you will need to fill out a State Hearing form or send a letter to:

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

Be sure to include your name, address, telephone number, Social Security Number, and the reason you want a State Hearing. If someone is helping you ask for a State Hearing, add their name, address, and telephone number to the form or letter. If you need an interpreter, tell us what language you speak, and we will provide one for free.

For more information about State Hearings, see your evidence of coverage (handbook).