A member can file a grievance when they are unhappy with the quality of care or service they received from one of their providers or from Aetna Better Health® of California. They can make an appeal if they want to change or review a decision made about coverage.
A member or their designated representative can file a grievance or an appeal in writing or over the phone. The member must designate their representative in writing. A representative can be a family member, friend, guardian, attorney or another provider. Members and their representatives may also file for an independent medical review (IMR) or a Medi-Cal state fair hearing. If a provider is representing a member, the request follows the member grievance and appeal processes and time frames.
When requested, we help our members complete grievance and appeal forms and take other procedural steps.
Both in-network and out-of-network providers may file a formal grievance with us for things like:
Provider payment disputes do not include disputes related to medical necessity.
You may also be asked to submit a dispute form (PDF) with any appropriate supporting documentation.
If the grievance is about claim resubmission or reconsideration, we may refer the dispute to the Claims Inquiry Claims Research (CICR) department. Then, we’ll notify you about the dispute resolution by phone, by email, by fax or in writing.
If the grievance needs research by or input from another department, the Appeals and Grievance Manager will send the information to the affected department. They will coordinate with that department to research each grievance using applicable statutory, regulatory and contractual provisions.
You can file an appeal within 180 days of receiving a Notice of Action. The Appeals and Grievance Manager will send an acknowledgment letter within five business days. The letter will summarize the appeal and include instructions on how to:
The Appeals and Grievance Manager will present the appeal, along with all research, to the Appeal Committee for decision. The Appeal Committee will include a provider with the same or a similar specialty. They will consider the additional information and will issue an appeal decision.
You can file a grievance or an appeal:
You can file a grievance or an appeal online after logging in to our Provider Portal:
Providers can file a grievance or ask about the appeal process by calling the Provider Services department at 1-855-772-9076 (TTY: 711).
You can file a grievance or an appeal by filling out a dispute form (PDF) and sending it to:
Aetna Better Health of California
10260 Meanley Dr.
San Diego, CA 92131
Links to various Aetna Better Health and non-Aetna Better Health sites are provided for your convenience. Aetna Better Health of California is not responsible or liable for non-Aetna Better Health content, accuracy or privacy practices of linked sites or for products or services described on these sites.
This link will take you to the Aetna Better Health® of California provider website. It contains information for health care professionals. If you don't want to leave the member site, click or tap the "x" in the upper right-hand corner.
This link will take you to the main Aetna Better Health website. Aetna Better Health of California is not responsible or liable for this specific content.