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Help us better serve you
Help us better serve you
An appeal
An appeal is an action you can take when you disagree with a decision we made about coverage for services. You may consider taking this action if you get a letter from us, officially called a Notice of Action, that says we’ve denied, stopped, held, or reduced an ongoing service or treatment (otherwise referred to as an "adverse benefit determination”).
If you disagree with a decision we made that negatively affects your benefits, you can also ask for an appeal. An appeal is a review and reconsideration of both coverage and non-coverage decisions. If your services were previously authorized and the appeal involves termination, suspension, or reduction of services prior to you receiving the previously authorized services, your services may continue while your appeal is pending.
You can file an appeal if you would like us to review the decision to be sure we were correct about things like:
- Not approving a service your provider asked for
- Stopping a service that was approved before
- Not paying for a service your provider asked for
- Not giving you the service in a timely manner
- Not approving a service for you because it was not in our network
Your appeal will be reviewed by a provider with the same or like specialty as your treating provider. The reviewer won’t:
- Be the same provider who made the original decision to deny, reduce or stop the service
- Report to the provider who made the original decision about your case
A grievance
A grievance is an action you can take when you are dissatisfied with any matter other than an adverse benefit determination.
Here are some things you may file a grievance about:
- You were unhappy with the quality of care or treatment you received.
- Your provider or a plan staff member was rude to you or didn’t respect your rights.
- You had trouble getting an appointment with your provider in a reasonable amount of time.
- Your provider or a plan staff member wasn’t sensitive to your cultural needs or other special needs you may have.
- You can’t get the service or item you want because it’s not covered.
- You haven’t gotten services that we approved.
Do you have an appeal or grievance? Filing an appeal or grievance won’t affect your healthcare services or benefits coverage. Just let us know right away. We have special processes to help you. And we’ll do our best to answer your questions and resolve your issue.
What happens next?
What happens next?
Appeals
A provider with the same or like specialty as your treating provider will review your appeal.
- Within 60 calendar days from the date on our Notice of Action letter: You or your representative need to file the appeal.
- Within 15 calendar days (standard appeal): We’ll tell you our decision.
- Within 72 hours (expedited or quick appeal): We’ll tell you our decision if your appeal is for urgent, emergency or hospital care. Or if waiting up to 15 days for a decision could be harmful to your health.
Your decision letter
With either time frame, you’ll receive a letter that includes:
- Our decision and the reasons for it.
- Your right to request a state hearing and how to do it.
Grievances
There's no time limit for filing a grievance. We’ll send you a letter saying that we received it. We’ll try to resolve your grievance right away. We may call you for more information.
We’ll decide on your grievance within these time frames:
- Within two business days of receipt if the grievance is regarding access to services.
- Within thirty calendar days of receipt for non-claims-related grievances.
- Within sixty calendar days of receipt for claims-related grievances.
We’ll send a letter with:
- The decision
- Supporting reasons
- Any action we’ll take to resolve your grievance
- Our contact info, so you can ask questions
For grievances that require an expedited or quick decision, you may also get a phone call from us with the decision.
More help with appeals and grievances
Here are some options if you need more help.
You can have someone else file an appeal or grievance for you. They can also act for you in a state hearing. This person is your member representative. They may be:
- Your provider
- Your family member
- Your friend
- Your legal guardian
- Your attorney
- Another person
You have to give written permission allowing the person to act for you. Use this form (PDF) or send us a letter with this information:
- Your name
- Your ID number
- The name of the person you want to represent you
- Information about the grievance or action you want to appeal
Then, sign the letter and send it to:
Aetna Better Health of Ohio
Grievance System Manager
P.O. Box 81139
5801 Postal Road
Cleveland, OH 44481
When we get the letter from you, the person you picked can represent you. If someone else files an appeal or grievance for you, you can’t file your own appeal for that action.
You can speed up your appeal if waiting up to 15 calendar days could be harmful to your health. This is an expedited or quick decision. Just call us — either you or your provider can call. We’ll call you with the decision within 72 hours. We can increase the review period up to 14 days if you ask for an extension or if we need more information and the delay is in your interest.
You can also ask for a quick decision in situations that involve:
- Urgent or emergency care.
- A new or continued hospital stay.
- Availability of care.
- Healthcare services for which you have received emergency services but haven’t yet been discharged from a hospital or other facility.
If we can’t approve an expedited appeal, we’ll call to let you know. We’ll also send you a letter within 1 business day. Then, we’ll process your appeal using the standard time frame of 15 calendar days.
You can ask for a state hearing if you don’t agree with our appeal decision. The state’s rules say you must wait for your appeal to be complete first.
You must ask for a state hearing within 90 days from the mail date of your appeal decision letter.
You have options to ask for a state hearing. Just contact the Bureau of State Hearings at the Ohio Department of Job and Family Services (ODJFS):
By phone
Just call 1-866-635-3748.
By mail
You can also mail your state hearing request letter to:
Ohio Department of Job and Family Services Bureau of State Hearings
P.O. Box 182825
Columbus, Ohio 43218-2825
Your language, your format
You need to understand your rights when it comes to appeals and grievances. Do you need information in another language? Just call us at 1-833-711-0773 (TTY: 711) from 7 a.m. to 8 p.m. Monday through Friday. We’ll share this information in your primary language. You can also get information other formats, like large print or braille.
Spanish
Para ayudarle a comprender este aviso, se encuentran disponibles a pedido asistencia lingüística, servicios de interpretación, ayudas auxiliares y otros servicios sin costo alguno. Los servicios disponibles incluyen, entre otros: traducción oral, traducción escrita y ayudas auxiliares. Puede solicitar estos servicios o ayudas auxiliares llamando a Aetna al 1-833-711-0773; las personas con discapacidad auditiva pueden llamar al TTY 711.
Nepali
यो सूचना बुझ्न सहायता गनन, भाषा सहायता, व्याख्या सेवा, र सहायक उपकरण तथा सेवा तपाईंको अनुरोधमा ननिःशुल्क रूपमा उपलब्ध छन्। उपलब्ध सेवाहरूमा मौखिक अनुवाद, ललखित अनुवाद, र सहायक उपकरणहरू समावेश छन्, तर नयनीसँग मात्र सीलमत छैन। तपाईंले Aetna मा 1-833-711-0773 मा फोन गरेर यी सेवा र/वा सहायक सहायता अनुरोध गनन सक्नुहुन्छ; श्रवणशक्क्त कमजोर भएका व्यक्क्तले TTY 711 मा फोन गनन सक्छन्।
Arabic
لمساعدتك في فهم هذا الإخطار، تتوفر خدمات المساعدة اللغوية وخدمات الترجمة الفورية والمساعدات الإضافية عند الطلب دون أي تكلفة. تشمل الخدمات المتاحة، على سبيل المثال لا الحصر: الترجمة الشفوية والترجمة التحريرية والمساعدات الإضافية. يمكنك طلب هذه الخدمات أو المساعدات الإضافية أو كلتيهما عن طريق الاتصال بـ Aetna على الرقم التالي 0773-711-833-1؛ وبوسع الأفراد الذين يعانون من ضعف السمع الاتصال بخدمة الهاتف النصي على الرقم التالي 1-1-7.
Haitian French Creole
Pou ede w konprann avi sa a, gen asistans lengwistik, sèvis entèpretasyon, èd oksilyè ak sèvis ki disponib gratis, lè ou fè demann pou sa. Sèvis ki disponib yo gen ladan yo, men se pa sa sèlman: tradiksyon oral, tradiksyon alekri ak èd oksilyè. Ou kapab mande sèvis sa yo ak/oswa èd oksilyè lè w rele Aetna nan 1-833-711-0773; moun ki gen pwoblèm tande yo ka rele TTY 711.
Somali
Si lagaaga caawiyo inaad fahanto ogaysiiskan, kaalmada luqadda, adeegyada tarjumaada, iyo kaalmooyinka iyo adeegyada ayaa la heli karaa marka la codsado lacag la'aan adiga. Adeegyada la heli karo waxaa ka mid ah, laakiin aan ku xaddidnayn: tarjumaada afka, turjumaadda qoran, iyo qalabyada caawinta. Waxaad codsan kartaa adeegyadan iyo/ama kaalmaynta caawimada adiga oo wacaya Aetna 1-833-711-0773; Shakhsiyaadka maqalka liidata waxay wici karaan TTY 711.
Ukrainian
Щоб допомогти вам зрозуміти зміст цього повідомлення, за запитом ви можете отримати безоплатну мовну допомогу, послуги усного перекладу, а також допоміжне обладнання та додаткові послуги. Доступні послуги включають, зокрема, усний переклад, письмовий переклад і допоміжне обладнання. Ви можете замовити ці послуги та/або допоміжне обладнання, зателефонувавши на лінію Aetna за номером 1-833-711-0773; для людей із вадами слуху працює номер TTY 711.
Russian
Чтобы помочь вам понять смысл этого уведомления, по запросу вы можете получить бесплатную языковую помощь, услуги устного перевода, а также вспомогательное оборудование и дополнительные услуги. Доступные услуги включают, в частности, устный перевод, письменный перевод и вспомогательное оборудование. Вы можете запросить эти услуги и/или вспомогательное оборудование, позвонив на линию Aetna по номеру 1-833-711-0773; для людей с нарушениями слуха предусмотрен номер TTY 711.
Swahili
Ili kukusaidia kuelewa notisi hii, usaidizi wa lugha, huduma za ukalimani, na visaidizi na huduma za ziada zinapatikana unapoomba bila gharama kwako. Huduma zinazopatikana ni pamoja na, lakini sio tu: tafsiri ya mdomo, tafsiri ya maandishi, na visaidizi vya ziada. Unaweza kuomba huduma hizi na/au visaidizi kwa kupiga simu Aetna 1-833-711-0773; watu walio na ulemavu wa kusikia wanaweza kupiga simu TTY 711.
Kinyarwanda
Kugira ngo tugufashe gusobanukirwa iri tangazo, ubufasha bujyanye n'indimi, serivisi z'ubusemuzi, n'ibikoresho na servisi bifasha abafite ubumuga mu kumva biraboneka nta kiguzi utanze iyo ubisabye. Serivisi ziboneka zikubiyemo, ariko si gusa: ubusemuzi mu mvugo, ubusemuzi mu nyandiko, n'ibikoresho bifasha abafite ubumuga mu kumva. Ushobora gusaba izi serivisi na/cyangwa ibikoresho bifasha abafite ubumuga mu kumva binyuze mu guhamagara Aetna 1-833-711-0773; abantu bafite ibibazo mu kumva bashobora guhamagara TTY 711
French
Pour vous aider à comprendre cet avis, une assistance linguistique, des services d'interprétation et des aides et services auxiliaires sont disponibles sur demande et sans frais. Les services disponibles comprennent, sans toutefois s’y limiter, la traduction orale, la traduction écrite et les aides auxiliaires. Vous pouvez demander ces services et/ou ces aides auxiliaires en appelant Aetna au 1-833-711-0773 ; les personnes malentendantes peuvent appeler le TTY 711.
Pashtu
ستاسو په دې خبرتيا د ښه درک کولو (پوهیدو) لپاره، د ژبې مرستې، د شفاهي ژباړې خدمتونه، او اضافي مرستندويه وسایل او خدمتونه ستاسو د غوښتنې پر بنسټ بې لګښته شتون لري. په شته خدماتو کې شفاهي ژباړه، په ليکلې بڼه ژباړه، او مرستندويه وسايل شامل دي، خو يوازې په دې پورې محدود نه دي. تاسو کولی شئ د دې خدماتو او/یا مرستندویه وسايلو غوښتنه Aetna ته په 1-833-711-0773 شمېره د زنګ وهلو له لارې وکړئ؛ هغه کسان چې د اورېدلو کمزورتیا لري کولی شي TTY 711 ته زنګ ووهي.
Dari
برای کمک به شما در درک این اطلاعیه، کمک های زبانی، خدمات ترجمه شفاهی و کمک ها و خدمات اضافی بر اساس درخواست شما بطور رایگان برای شما ارائه می گردد. خدمات موجود شامل موارد ذیل میباشد، اما محدود به آنها نیست: ترجمه شفاهی، ترجمه کتبی و وسایل کمکی. شما میتوانید این خدمات و/یا وسایل کمکی را با تماس با Aetna از طریق 1-833-711-0773 درخواست دهید، افراد دارای اختلال شنوایی میتوانند با شماره TTY 711 تماس بگیرند.
Uzbek
Bu bildirishnomani tushunishingizga yordam berish uchun so‘rovingiz asosida bepul til yordamchi xizmatlari, og‘zaki tarjima xizmatlari va qo‘shimcha yordamchi vositalar taqdim etiladi. Mavjud xizmatlar qatoriga og‘zaki tarjima, yozma tarjima hamda yordamchi vositalar kiradi. Siz ushbu xizmatlar va/yoki qo‘shimcha yordamni Aetna dasturining 1-833-711-0773 raqamiga qo‘ng‘iroq qilib so‘rashingiz mumkin; Eshitish qobiliyati cheklangan shaxslar TTY 711 raqami orqali bog‘lanishlari mumkin.
Vietnamese
Để giúp bạn hiểu thông báo này, hỗ trợ ngôn ngữ, dịch vụ phiên dịch, phương tiện trợ giúp và dịch vụ phụ trợ được cung cấp miễn phí theo yêu cầu. Các dịch vụ có sẵn bao gồm, nhưng không giới hạn ở: dịch bằng lời nói, dịch bằng văn bản và phương tiện phụ trợ. Bạn có thể yêu cầu các dịch vụ và/hoặc phương tiện phụ trợ này bằng cách gọi cho Aetna theo số 1-833-711-0773; người khiếm thính có thể gọi TTY 711.
Tigrinya
ነዚ ምልክታ ክትርደእዎ ንኽሕግዘኩም፣ ሓገዝ ቋንቋ፣ ኣገልግሎታት ትርጉም፣ ከምኡ'ውን ተወሰኽቲ ሓገዛትን ኣገልግሎታትን ኣብ ዝሓተትክምዎ ብዘይ ክፍሊት ይርከቡ። ዘለው ኣገልግሎታት፣ ናይ ዘረባ ትርጉም፣ ናይ ጽሑፍ ትርጉምን ተወሰኽቲ ሓገዛትን ዘጠቓልሉ ኮይኖም፣ በዚ ጥራሕ ዝድረቱ ኣይኮኑን። ናብ Aetna 1-833-711-0773 ብምድዋል፣ ነዞም ኣገልግሎታትን/ወይ ተወሰኽቲ ሓገዛት ክትሓቱ ትኽእሉ ኢኹም፤ ናይ ምስማዕ ጸገም ዘለዎም ውልቀ-ሰባት ናብ TTY 711 ክድውሉ ይኽእሉ እዮም።