Grievance & Appeals
A Utilization Management (UM) appeal is a way for a member to ask us to reconsider our decisions with regard to medically necessary services. If we deny your request for a service (or request for us to pay for a service), or if we decide to reduce, suspend, or stop an ongoing service or a course of treatment a member has been receiving, a member can request an appeal. Members can request an appeal verbally or in writing. However, if a member calls, he/she must follow up by sending us a written, signed appeal request. Members have sixty (60) calendar days from your Notice of Adverse Benefit Determination to request an appeal.
Members or their designated representatives can file an appeal with Aetna Better Health of New Jersey either orally or in writing. Representatives must be designated in writing. Services will continue automatically while the appeal is pending, as long as the appeal is asked for on or before:
- The last approved day a member is receiving the services, or
- Within 10 days of receiving the notice that the services will be stopping, whichever is later. A member does not need to ask for the services to be continued.
There are two types of appeal
- Utilization Management Appeals
- Expedited Utilization Management Appeals
- Independent Utilization Review
- Expedited Independent Utilization Review
The member or authorized representative may also appeal directly to DMAHS through the State fair hearing process. State fair hearing appeals may be submitted at the same time as, instead of, or after the completion of the member appeal with Aetna Better Health of New Jersey.
Please refer to the Member Grievance & Appeals webpage for additional information.
A grievance is when a member tells us he or she is unhappy with us or their provider or they do not agree with a decision we have made.
Some things you may file a grievance about:
- He/she is unhappy with the care you are getting.
- He/she has not gotten services that the Plan has approved.
- His/her provider or a plan staff member did not respect your rights.
- He/she had trouble getting an appointment with your provider in a reasonable amount of time.
His/her provider or a plan staff member was rude to you.
His/her provider or a plan staff member was not sensitive to your cultural needs or other special needs you may have.
If a member disagrees with our decision to deny coverage for a service or item that he/she or their provider asked for, this is an appeal, and it will be automatically transferred to the Utilization Management Appeal process. The received date will be the same.
We will try to resolve your grievance right away. We may call you for more information. The grievance committee will make a decision within the following timeframes:
- Thirty (30) calendar days of receipt for a standard grievance
- Three (3) business days of receipt for an expedited grievance
For grievances that require an expedited (quick) decision, you may get a phone call from us with the decision. You will get a letter from us within three (3) business days of receipt. The letter will include the decision reached and the reasons for the decision, along with our contact information if you have questions about the decision.
For more information about filing a grievance, please visit our member webpage.
Participating and Non-Participating Providers have the right to appeal ABHNJ claims determination(s) within sixty (60) calendar days of receipt of the claim denial. To appeal ABHNJ claims determination(s), providers must utilize the Health Care Provider Application to Appeal a Claims Determination.
A provider MAY submit a Health Care Provider Application to Appeal a Claims Determination IF our determination:
- Resulted in the claim not being paid at all for reasons other than a UM determination or a determination of ineligibility, coordination of benefits or fraud investigation
- Resulted in the claim being paid at a rate the provider did not expect based upon a contact with us or the terms of the member’s Medicaid/FamilyCare coverage.
- Resulted in the claim being paid at a rate the provider did not expect because of differences in Our treatment of the codes in the claim from what the provider believes is appropriate
- Indicated that we require additional substantiating documentation to support the claim and the provider believes that the required information is inconsistent with Our stated claims handling policies and procedures, or is not relevant to the claim.
A provider also MAY submit a Health Care Provider Application to Appeal a Claims Determination IF:
- The provider believes we have failed to adjudicate the claim, or an uncontested portion of a claim, in a timely manner consistent with law, and the terms of the provider’s contract (if any)
- Our determination indicates we will not pay because of lack of appropriate authorization, but the provider believes they obtained appropriate authorization from Us or another carrier for the services
- The provider believes we have failed to appropriately pay interest on the claim
- The provider believes Our statement that We overpaid one or more claims is erroneous, or that the amount We have calculated as overpaid is erroneous
Both participating an no participating providers may file a formal written grievance with ABHNJ regarding
- dissatisfaction with our policies and procedures;
- dissatisfaction with a decision made by the ABHNJ;
- Disagreement with the ABHNJ as to whether a service, supply, or procedure is a covered benefit, is medically necessary, or is performed in the appropriate setting;
- Any other issue of concern to the provider
Providers can also file a verbal grievance by calling 1-855-232-3596. To file a grievance in writing, providers should write to:Aetna Better Health of New JerseyPO Box 810405801 Postal RoadCleveland, OH 44181
State Fair Hearing
Members or their designated representative, including a provider acting on their behalf with their written consent, may request a State Fair Hearing through DMAHS only after they have received the Internal Appeal Decision Letter. This request must be completed within twenty (120) calendar days of the initial adverse action.