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Grievances and appeals

Member grievance system overview

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.

 

Member grievance and appeal processes

Providers filing a grievance

Both in-network and out-of-network providers may file a formal grievance with us for things like:

 

  • Policies
  • Procedures
  • Administrative functions 
  • Billing and payment disputes
  • Lost or incomplete claim forms or electronic submissions
  • Inappropriate or unapproved referrals initiated by the provider

 

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.

Filing an appeal

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:

 

  • Revise the appeal within the time frame specified in the acknowledgment letter
  • Withdraw an appeal at any time up to the Appeal Committee review

 

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.

File a grievance or appeal now

You can file a grievance or an appeal:

Online

You can file a grievance or an appeal online after logging in to our Provider Portal:

By phone

Providers can file a grievance or ask about the appeal process by calling the Provider Services department at 1-855-772-9076 (TTY: 711).

By mail

You can file a grievance or an appeal by filling out a dispute form (PDF) and sending it to:

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

By fax

You can file a grievance or an appeal by filling out a dispute form (PDF) and faxing it to us at 1-844-886-8349.