Grievance and appeals
We want you to be happy with services you get from Aetna Better Health and our providers. If you are not happy, we want you to let us know. We take member grievances very seriously. We want to know what is wrong so we can make our services better.
You or your representative will be able to file a grievance with us in writing, verbally through the toll-free Member Services number at 1-866-827-2710, TTY 711, to any member of our health plan staff or through the website, CONTACT US.
All member information will be handled confidentially. We will not discriminate against any member who has filed a grievance.
Through our Member Services Representatives (MSRs), you will have access to language line interpreters, translation services and alternate formats such as large print, braille and TTY/TDD as needed at no cost to you. Our staff will help explain the process and the forms needed.
A complaint is when you tell us you are unhappy with us or your provider or you do not agree with a decision by us.
Some things you may complain about:
- You are unhappy with the care you are getting.
- You cannot get the service or item you want because it is not a covered service or item.
- You have not gotten services that the Plan has approved.
- Your provider or a plan staff member did not respect your rights
- You had trouble getting an appointment with your provider in the appropriate amount of time
- Your provider or a plan staff member was rude to you
- Your provider or a plan staff member was not sensitive to your cultural needs or other special needs you may have
If a complaint is about a denial of coverage for a service or item that you or your provider asked for, we will automatically transfer it to the Appeal process. The received date will be the same.
If your complaint is about something other an adverse benefit determination, we will automatically transfer it to the grievance process. The received date will be the same.
If your complaint is about something other an adverse benefit determination, this is called a grievance. Examples of grievances include quality of care, not being allowed to exercise your rights, not being able to find a doctor, trouble getting an appointment, or not being treated fairly by someone who works at Aetna Better Health or at your doctor’s office.
If your complaint is about a service you or a provider feels you need but Aetna Better Health will not cover, you can ask Aetna Better Health to review your request again. This request for a review is called an appeal.
If you want to file an appeal you have to file it within 60 days from the date that you receive the letter saying Aetna Better Health would not cover the service you wanted.
Your doctor can also file an appeal for you if you sign a form giving him or her permission. Other people can also help you file an appeal, like a family member or a lawyer.
How to file a Complaint, Grievance or Appeal
To submit a complaint or grievance, you can contact Member Services at 1-866-827-2710, TTY 711. If you need auxiliary aids or interpreter services, let the member services representative know (hearing impaired members can use the Maryland Relay Service, 711). Our member service representatives can assist you with filing a complaint, grievance, or appeal.
You can request to file an appeal verbally but will need to confirm the appeal request in writing, unless it is an expedited resolution request. To file the appeal in writing we can send you a simple form that you can complete, sign, and mail back. We can also assist you in completing the form if you need help. You will also be given the opportunity to give us your testimony and factual arguments prior to the appeal resolution.
Getting help from the HealthChoice Help Line
If you have a question or complaint about your health care and Aetna Better Health has not solved the issue to your satisfaction, you can ask the State for help. The HealthChoice Help Line, 1-800-284-4510, is open Monday through Friday between 8 a.m. and 5 p.m. When you call the Help Line, you can ask your question or explain your problem to one of the Help Line staff, who will:
- Answer your questions
- Work with Aetna Better Health to resolve your problem, or send your complaint to a Complaint Resolution Unit nurse who may:
- Ask Aetna Better Health to provide information about your case within five days;
- Work with your provider and MCO to assist you in getting what you need;
- Help you to get more community services, if needed; or
- Provide guidance on the Aetna Better Health’s appeal process and when you can request a State Fair Hearing.
Asking the State to Review Aetna Better Health’s Decision
If you appealed Aetna Better Health’s initial decision and you received a written denial, you have the opportunity for the State to review your decision. This is called an appeal.
You can contact the HealthChoice Help Line at 1-800-284-4510 and tell the representative that you would like to appeal Aetna Better Health ‘s decision. Your appeal will be sent to a nurse in the Complaint Resolution Unit. The Complaint Resolution Unit will attempt to resolve your issue with us in 10 business days. If it cannot be resolved in 10 business days, you will be sent a notice that gives you your options.
Continuing services during the appeal
There are times when you may be able to keep getting a service while the State reviews your appeal. This can happen if your appeal is about a service that was already authorized, the time period for the authorization has not expired, and you were already receiving the service. Call the HealthChoice Help Line 1-800-284-4510 for more information. If you do not win your appeal, you may have to pay for the services that you received while the appeal was being reviewed.
State Fair Hearings
To appeal one of the State’s decisions, you must request that the State file a notice of appeal with the Office of Administrative Hearings on your behalf. The request for a State Fair Hearing must be submitted no later than 120 days from the date of the Aetna Better Health’s notice of resolution. The Office of Administrative Hearings will set a date for the hearing based on the type of decision being appealed.
- If the appeal is about Aetna Better Health reducing or not giving you a service because both the State and Aetna Better Health thinks you do not have a medical need for the service, the Office of Administrative Hearings will set a hearing date within 20 days of the day you file your appeal with the Office of Administrative Hearings. The Office of Administrative Hearings will make its decision on the case within 30 days of the date of the hearing.
- You can ask for an expedited appeal. If the State thinks your hearing should be held more quickly due to the seriousness of your health condition, a hearing will be held and a decision will be made within 72 hours.
For all other appeals, the Office of Administrative Hearings will set a hearing date within 30 days of the day you file your appeal with the Office of Administrative Hearings. The Office of Administrative Hearings will make its decision on the case within 30 days of the date of the hearing.