Grievances and appeals online form

I want to file a grievance or appeal

1. Grievance details

Please provide details of the grievance or appeal in the fields below. All fields marked with an asterisk (*) are required.

*Check the one that applies

I am filing a grievance

I am filing an appeal

*Date For grievances, give the date of the issue or incident. For appeals, give the date on the Notice of Adverse Benefit Determination letter you received.

*Description

Describe your grievance or appeal. You can send us medical records or other info to support your appeal. Use one of the methods at the bottom of this form.

2. Member information

Please provide the following information. All fields marked with an asterisk (*) are required.

*Name

*Date of birth

*Address 1

Address 2

*City

*State

*Zip Code Example: 12345

*Phone Number Example: 1234567890

*member plan id number.

*Are you filing this grievance or appeal on behalf of someone else?

Yes, I am a representative

No, I am the member

Representatives include family members, friends, caregivers or providers. This is someone the member authorized to act on their behalf in writing. Or others legally able to act on behalf of the member, such as the member’s legal guardian or someone who holds power of attorney. If you haven’t already sent it, you’ll need to send us this proof of representation. You can send it using one of the methods at the bottom of this form.

3. Your information

Please provide your information in the following fields. All fields marked with an asterisk (*) are required.

*Name

*Relationship Your relationship to member

*Date of birth

*Address 1

Address 2

*City

*State

*Zip Code Example: 12345

*Phone Number Example: 1234567890

Important note: Expedited decision

If you or your provider believes our standard time frame of 30 days to make a decision on your appeal will seriously jeopardize your life or health, you can ask for an expedited appeal.

Check this box if you believe you need a decision within 72 hours. If you have a supporting statement from your provider, you can send it using one of the methods at the bottom of this form.

*Signature

*Date Today's date

*Signature Type

Contact us

You can send us more information by:

Fax: 1-844-321-9566
Email: NJAppealsandGrievances@AETNA.com
Mail: Aetna Better Health® of New Jersey
Attn: Grievance and Appeals
PO Box 81139
5801 Postal Road
Cleveland, OH 44181

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Grievances and appeals online form

I want to file a grievance or appeal

Important note: Expedited decision

Contact us