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Grievances and appeals


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

Filing a dispute

Both in-network and out-of-network providers may file written disputes with us. We’ll try to resolve your dispute in a timely manner. Disputes are settled according to the terms of our contractual agreement. Your dispute could be based on things like:

  • Policies and procedures
  • One of our decisions
  • Claims

At no point will we stop or disrupt a service or procedure as a result of a dispute.

Filing a claim dispute

If you are disputing a claim, you’ll need to complete and submit the Provider Dispute form and any supporting documents to the Provider Relations department. After reviewing your dispute, we’ll let you know our decision via email, fax, phone or mail.

How to file a claim dispute

  1. Download the Provider Dispute form (PDF) or request one via fax or mail.
  2. Be sure to include all required information requested on the form (incomplete submissions lacking all required forms and documentation will be returned to the provider unprocessed).

Mail your claim dispute to:

Aetna Better Health® of Michigan

PO Box 982963

El Paso, TX 79998-2963

If you receive our dispute decision and remain dissatisfied, we may notify you with information about how to start the grievance or appeals process.

Filing a grievance

Filing a grievance

Providers may file verbal grievances with us. We can resolve them outside the formal grievances and appeals process. Your grievances could be based on things like:

  • Policies and procedures
  • 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

If the grievance requires research or another department’s input, we’ll forward the information to the affected department and coordinate with them to research each grievance using applicable statutory, regulatory and contractual provisions, and our written policies and procedures, collecting pertinent facts from all parties. The grievance, with all research included, will be presented to the Grievance Committee for decision. If the grievance is related to a clinical issue, the Grievance Committee will include a provider who has the same or a similar specialty.

Some timelines to note:

  • Within 3 business days: We’ll send you a letter letting you know that we received your grievance with instructions on how to revise or withdraw your grievance.
  • Within 35 calendar days: We’ll resolve your grievance and make a decision.
  • Within 2 business days of our decision: We’ll let you know our decision via phone, email or fax.
  • Within 3 calendar days of our decision: We’ll let you know our decision in writing.

Some provider grievances are subject to the member process. In these cases, we transfer them. These include grievances that you may file on behalf of a member.

Filing an appeal

Both in-network and out-of-network providers have the right to appeal our claims determinations within 45 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 

File a grievance or appeal now

You can file a grievance or appeal:


You can file a grievance or appeal in your Provider Portal. Need help with registration? Just contact Availity at 1-800-282-4548. You can get help from 8 AM to 8 PM, Monday through Friday.

By fax

You can fax your grievance or appeal: 866-889-7517

By phone

You can call us with your grievance or appeal: 1-866-316-3784 (TTY: 711).

By mail

You can send your grievance or appeal to:

Aetna Better Health of Michigan

Attn: Appeals Coordinator

PO Box 81139

5801 Postal Road

Cleveland, OH 44181

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 someone who reports to that person 

Member grievances and appeals overview


When members ask, we help them complete grievance and appeal forms and take other steps.

Member grievances and appeals

Coverage decisions

Coverage decisions

What is a coverage decision?

A coverage decision is the initial decision we make about a member’s benefits and coverage. It also determines the amount we will pay for the member’s medical services or drugs. We make a coverage decision whenever we decide what is covered for an enrollee and how much we’ll pay. If you’re not sure if a service is covered by Medicaid, you or the member can ask for a coverage decision before the service is provided.

Who can I call with questions about coverage decisions?

  • Member Services: To request a coverage decision or an appeal on a member’s behalf, you can call Member Services at 1-866-316-3784 (TTY: 711). You can get help 24 hours a day, 7 days a week. You can also ask for a coverage decision or appeal in writing.
  • The Beneficiary Help Line: This help line helps solve problems for Medicaid enrollees. Just call 1-800-642-3195.

Member representative

Members can also ask another provider, friend or family member to act on their behalf. This person will act as the member's representative to ask for a coverage decision or make an appeal.

Also of interest: