Grievances & Appeals

Members or their designated representative can file a request for reconsideration or express dissatisfaction with Aetna Better Health of California orally or in writing. Requests for reconsideration are classified as an appeal. All other expressions of dissatisfaction are classified as a grievance. When the grievance is received by phone and can be resolved by the next business day and it is not related to reconsideration or an appeal it is classified as an exempt grievance.

A representative is someone who acts on the member’s behalf, including but not limited to a family member, friend, guardian, provider, or an attorney. Representatives must be designated in writing. A network provider, acting on behalf of a member, and with the member’s written consent, may file a grievance or appeal with Aetna Better Health of California. Members and their representatives, including providers with written consent, may also file an Independent Medical Review (IMR) or Medi-Cal State Fair Hearing as appropriate. When a provider acts on behalf of a member, the request follows the member appeal and grievance processes and timeframes.

Aetna Better Health of California informs members and providers of the grievance system processes for exempt grievances, grievances, appeals, IMRs and Medi-Cal State Fair Hearings. This information is also contained in the Member Evidence of Coverage/Handbook. When requested, we give members reasonable assistance in completing forms and taking other procedural steps. Our assistance includes, but is not limited to, providing interpreter services and toll-free numbers that have adequate TTY/TTD and interpreter capability at no cost to the member.

Network providers may file a payment dispute verbally or in writing direct to Aetna Better Health of California to resolve billing, payment and other administrative disputes for any reason including but not limited to: lost or incomplete claim forms or electronic submissions; requests for additional explanation as to services or treatment rendered by a health care provider; inappropriate or unapproved referrals initiated by the provider; or any other reason for billing disputes. Provider Payment Disputes do not include disputes related to medical necessity. Providers can file a verbal dispute with Aetna Better Health of California by calling Provider Services Department at 1-855-772-9076. To file a dispute in writing, providers should write to:

Aetna Better Health of California
Provider Services
10260 Meanley Dr.
San Diego, CA 92131

The Provider may also be asked to complete and submit the Dispute Form with any appropriate supporting documentation.

If the dispute is regarding claim resubmission or reconsideration, the dispute may be referred to the Claims Inquiry Claims Research (CICR) Department. For all disputes, Aetna Better Health of California will notify the Provider of the dispute resolution by phone, email, fax or in writing.

Both network and out-of-network providers may file a formal grievance in writing directly with Aetna Better Health of California in regard to our policies, procedures or any aspect of our administrative functions including dissatisfaction with the resolution of a payment dispute or provider complaint that is not requesting review of an action within one hundred eighty (180) calendar days from when they became aware of the issue. Providers can also file a verbal grievance with Aetna Better Health of California when it is related to Aetna Better Health of California staff or contracted vendor behavior by calling 1-855-772-9076. To file a grievance in writing, providers should write to:

Aetna Better Health of California
Appeal and Grievance Manager
10260 Meanley Dr.
San Diego, CA 92131

The Appeals and Grievance Manager assumes primary responsibility for coordinating and managing provider grievances, and for disseminating information to the Provider about the status of the grievance.

An acknowledgement letter will be sent within five (5) business days summarizing the grievance and will include instruction on how to:

  • Revise the grievance within the timeframe specified in the acknowledgement letter
  • Withdraw a grievance at any time until Grievance Committee review

If the grievance requires research or input by another department, the Appeals and Grievance Manager will forward the information to the affected department and coordinate with the affected department to thoroughly research each grievance using applicable statutory, regulatory, and contractual provisions and Aetna Better Health of California’s written policies and procedures, collecting pertinent facts from all parties. The grievance with all research will be presented to the Grievance Committee for decision. The Grievance Committee will include a provider with same or similar specialty if the grievance is related to a clinical issue. The Grievance Committee will consider the additional information and will resolve the grievance.

Aetna Better Health of California will resolve all provider grievances within thirty (30) calendar days of receipt of the grievance and will notify the provider of the resolution within ten (10) calendar days of the decision.

A provider may file a formal appeal in writing, a formal request to reconsider a decision (e.g., utilization review recommendation, administrative action), with Aetna Better Health of California within one hundred eighty (180) calendar days from the Aetna Better Health of California Notice of Action. The expiration date to file an appeal is included in the Notice of Action. All written appeals should be sent to the following:

Aetna Better Health of California
Appeal and Grievance Manager
10260 Meanley Dr.
San Diego, CA 92131

The Appeals and Grievance Manager assumes primary responsibility for coordinating and managing Provider appeals, and for disseminating information to the Provider about the status of the appeal.

An acknowledgement letter will be sent within five (5) business days summarizing the appeal and will include instruction on how to:

  • Revise the appeal within the timeframe specified in the acknowledgement letter
  • Withdraw an appeal at any time until Appeal Committee review

The appeal with all research will be presented to the Appeal Committee for decision. The Appeal Committee will include a provider with same or similar specialty. The Appeal Committee will consider the additional information and will issue an appeal decision. Aetna Better Health of California will inform providers through the Provider Manual and other methods, including periodic provider newsletters, training, provider orientation, the website and by the provider calling their Provider Services Representative about the provider appeal process.