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Quejas formales y apelaciones

Filing a grievance

Both in-network and out-of-network providers may file verbal grievances with us. We can resolve them outside the formal appeal and grievance process. Provider grievances could be based on things like:

 

  • Políticas y procedimientos

  • One of our decisions

  • A disagreement about whether a service, supply or procedure is a covered benefit, is medically necessary or is done in the appropriate setting

  • Any other issue of concern

Some provider grievances are subject to the member grievance process. In these cases, we transfer them. These include grievances:

 

  • From a provider on behalf of a member with written consent (except for an expedited request)

  • That don’t require written consent from the member

Filing an appeal

Both in-network and out-of-network providers have the right to appeal our claims determinations within 60 calendar days of receipt of the claim denial. 

 

You can file an appeal if:

 

  • We denied reimbursement for a medical procedure or item you provided for a member due to lack of medical necessity or no prior authorization (PA) when it was required
  • You have a claim that has been denied or paid differently than you expected and wasn’t resolved to your satisfaction through the dispute process

Presente una queja o apelación ahora

 

We have processes designed to let you tell us when you’re dissatisfied with a decision we make. You can file a grievance or appeal:

 

Por correo electrónico

 

You can email your grievance or appeal.

 

LAAppealsandGrievances@aetna.com

Por fax

 

You can fax your grievance or appeal: 860-607-7657.

Por teléfono

 

You can file a grievance or appeal by phone. Just call 1-855-242-0802 (TTY: 711).

Por correo postal

 

You can send your grievance or appeal to:

Aetna Better Health of Louisiana 
Grievances and Appeals  
PO Box 81040 
5801 Postal Rd 
Cleveland, OH 44181 
FAX: 860-607-7657

Reviews of grievances and appeals

Clinical grievances and appeals reviews are completed by health professionals who:

 

  • Hold an active, unrestricted license to practice medicine or in a health profession 
  • Are board certified (if applicable) 
  • Are in the same profession or in a similar specialty as normally manages the condition, procedure or treatment concerned in the case 
  • Are neither the same reviewer that made the original decision nor the subordinate of the person that made the first decision

Payment disputes

Network providers may file a payment dispute verbally or in writing to resolve billing, payment and other administrative disputes for any reason, including:

 

  • Lost or incomplete claim forms or electronic submissions
  • Requests for more explanation as to services or treatment by a health care provider
  • Inappropriate or unapproved referrals initiated by the provider

Payment disputes don’t include disputes related to medical necessity.

 

You can file a verbal dispute any time. Just call us at 1-855-242-0802 (TTY: 711). Or write to:

Aetna Better Health of Louisiana

Attention: Cost containment
PO Box 61808
Phoenix, AZ 85082-1808

 

Be sure to complete and submit the claim resubmission and dispute form (PDF) with any supporting documentation.

Audiencias imparciales estatales

Members or their designated representative, including a provider acting on their behalf with their written consent, can ask for a state fair hearing. This request goes through the Louisiana Division of Administrative Law. The Secretary of the Louisiana Department of Health makes the final decision. Members can ask for a state fair hearing only after they’ve received the Internal Appeal Decision Letter. The member or their representative must complete the request within 120 calendar days of the initial adverse action. 

Member grievance system overview

Members can file a grievance when they’re unhappy with the quality of care or service they received from us or one of their providers, or when they don’t 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. 

 

Members can agree to representation by a health care provider or someone else by completing the personal appeal representative form (PDF). They can also provide authorization to release PHI (PDF) for use during the appeals process.

 

When requested, we help our members complete grievance and appeal forms and take other steps. You can learn more about the member grievance and appeal processes.

 

Member grievance and appeal processes

¿Tiene preguntas?

Just check your provider manual (PDF) for answers about grievances and appeals.