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Grievances and appeals

Member grievance system overview

Members can file a grievance when they are unhappy with the quality of care or service they received from us or one of their providers. They can file a complaint when they do not agree with a decision we made about coverage. And they can file an appeal if they want us to review or change our coverage decision.

 

A member or their designated representative can file a grievance, complaint or appeal in writing or over the phone. The member must designate their representative in writing before or within 10 business days after filing. A representative can be a family member, friend, guardian, attorney or provider. Members and their representatives may also file for an Independent Medical Review (IMR) or a Maryland state fair hearing. If a provider is representing a member, the request follows the member grievance and appeal processes and time frames.

 

Members must file appeals with us no later than 60 calendar days from the date on the Adverse Benefit Determination letter. The expiration date to file an appeal is in the Notice of Action. If the member’s provider is filing an appeal on their behalf, they must also file it within 60 calendar days from the date of the Adverse Benefit Determination letter.

 

When requested, we help our members complete grievance and appeal forms and take other steps. 

 

Member grievance and appeal processes

Providers filing a grievance or complaint

The provider grievance process is for provider complaints about us or our contracted vendors or other issues that:

 

  • Do not request review of an action
  • Require a written decision

 

Both in-network and out-of-network providers may file a verbal grievance or complaint with us. We can resolve these outside the formal appeal and grievance process. Some examples of provider grievances and complaints include:

 

  • Policies and procedures
  • A decision made by Aetna Better Health® of Maryland
  • A disagreement about whether a service, supply or procedure is a covered benefit, is medically necessary or is being done in the appropriate setting

 

Some provider complaints are subject to the member complaint process, where we transfer them. These include complaints that:

 

  • Come from a provider on behalf of a member with written consent (except for an expedited request)
  • Do not require written consent from the member

Filing an appeal

Provider appeal process

 

The provider appeal process is for provider complaints that:

 

  • Require review because they cannot be resolved through the informal complaint process
  • Request review of an action
  • Require a written decision

You can file an appeal within 90 days of receiving a Notice of Action. We will send an acknowledgment letter within five business days. The letter summarizes the appeal and tells 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 presents the appeal, along with all research, to the Appeal Committee for decision. The Appeal Committee includes a provider with the same or a similar specialty. They will consider the additional information and make an appeal decision.

File a grievance, complaint or appeal now

You can file a grievance, complaint or appeal:

Online

You can file a grievance, complaint or appeal online. Just log in to our Provider Portal.

By phone

You can file a grievance or complaint by phone. Or ask about the appeal process. Just call 1-866-827-2710 (TTY: 711)

By mail

You can file an appeal by filling out a Provider Appeal Form (PDF). Then, send it to:

Aetna Better Health of Maryland
Attn: Appeal and Grievance Department
PO Box 81040
5801 Postal Road
Cleveland, OH 44181

By fax

You can file a grievance or an appeal by filling out a Grievance and Appeal Form (PDF). Then, fax it to us at 1-844-886-8349

Provider payment disputes

Network providers may file a payment dispute verbally or in writing. We can help resolve billing, payment and other administrative disputes for any reason. Please see our claims page for more information about filing a dispute.