Complaints, Grievances and Appeals

Member satisfaction

We want you to be happy with us and the care you receive from our providers. Let us know right away if at any time you are not happy with anything about us or our providers. This includes if you do not agree with a decision we have made.

Issue

If you are not happy with us or our providers, you can file a Complaint

If you are not happy with us or our providers, you can file a Grievance

If you do not agree with a decision we made about your services, you can ask for an Appeal

If you think waiting for 30 days will put your health in danger, you can ask for an Expedited or “Fast” Appeal

If you do not agree with our appeal decision, you can ask for a Medicaid Fair Hearing

What You Can Do:

You can:

  • Call us at any time.

1-800-441-5501 (Medicaid) or
1-844-645-7371
(Comprehensive Long Term Care), TTY: 711

You can:

  • Write us or call us at any time.
  • Call us to ask for more time to solve your grievance if you think more time will help.

Aetna Better Health of Florida
Grievance and Appeals
261 N. University Drive
Plantation, FL 33324
1-800-441-5501 (Medicaid) or
1-844-645-7371 (Comprehensive Long Term Care), TTY: 711

You can:

  • Write us, or call us and follow up in writing, within 60 days of our decision about your services.
  • Ask for your services to continue within 10 days of receiving our letter, if needed. Some rules may apply.

Aetna Better Health of Florida
Grievance and Appeals
261 N. University Drive
Plantation, FL 33324

1-800-441-5501 (Medicaid) or
1-844-645-7371 (Comprehensive Long Term Care), TTY: 711

You can:

  • Write us or call us within 60 days of our decision about your services.

Aetna Better Health of Florida
Grievance and Appeals
261 N. University Drive
Plantation, FL 33324

1-800-441-5501 (Medicaid) or
1-844-645-7371 (Comprehensive Long Term Care), TTY: 711

You can:

  • Write to the Agency for Health Care Administration Office of Fair Hearings.
  • Ask us for a copy of your medical record.
  • Ask for your services to continue within 10 days of receiving our letter, if needed. Some rules may apply.

**You must finish the appeal process before you can have a Medicaid Fair Hearing.

What We Will Do:

We will:

  • Try to solve your issue within 1 business day.

We will:

  • Review your grievance and send you a letter with our decision within 90 days.

If we need more time to solve your grievance, we will:

  • Send you a letter with our reason and tell you about your rights if you disagree.

We will:

  • Send you a letter within 5 business days to tell you we received your appeal.
  • Help you complete any forms.
  • Review your appeal and send you a letter within 30 days to answer you.

We will:

  • Give you an answer within 48 hours after we receive your request.
  • Call you the same day if we do not agree that you need a fast appeal, and send you a letter within 2 days.

We will:

  • Provide you with transportation to the Medicaid Fair Hearing, if needed.
  • Restart your services if the State agrees with you.

 If you continued your services, we may ask you to pay for the services if the final decision is not in your favor.

You may ask for a fair hearing at any time up to 120 days after you get a Notice of Plan Appeal Resolution by calling or writing to:
            Agency for Health Care Administration
            Medicaid Fair Hearing Unit
            P.O. Box 60127
            Ft. Meyers, FL 33906
            1-877-254-1055 (toll-free)
            239-338-2642 (fax)
            MedicaidFairHearingUnit@ahca.myflorida.com

If you request a fair hearing in writing, please include the following information:

  • Your name
  • Your member number
  • Your Medicaid ID number
  • A phone number where you or your representative can be reached

You may also include the following information, if you have it:

  • Why you think the decision should be changed
  • Any medical information to support the request
  • Who you would like to help with your fair hearing

After getting your fair hearing request, the Agency will tell you in writing that they got your fair hearing request. A hearing officer who works for the State will review the decision we made.

If you are a Title XXI MediKids member, you are not allowed to have a Medicaid Fair Hearing.

When you ask for a review, a hearing officer who works for the State reviews the decision made during the Plan appeal. You may ask for a review by the State any time up to 30 days after you get the notice. You must finish your appeal process first.

You may ask for a review by the State by calling or writing to:
Agency for Health Care Administration
P.O. Box 60127
Ft. Myers, FL 33906
1-877 254-1055 (toll-free)
239-338-2642 (fax)
MedicaidHearingUnit@ahca.myflorida.com

After getting your request, the Agency will tell you in writing that they got your request.

You may file a grievance when you are dissatisfied about something other than your child’s benefits, such as:

  • A doctor’s behavior;
  • The quality of care or services your child receives; or
  • Long office waiting times.

How do I file a grievance?
To file a complaint or grievance over the telephone, call 1-844-528-5815, (TTY: 711), Monday through Friday, 8 a.m. to 7 p.m. Or, you can write to:
Aetna Better Health of Florida
Grievance & Appeals Department - FHK
261 N. University Drive
Plantation, FL 33324

You can fax your complaint or grievance to us at 1-888-684-4928.

When you file a complaint or a grievance, we will need to know:

  • Your name
  • Your ID number
  • What you are unhappy with
  • What you would like to have happen

The grievance coordinator will send an acknowledgement letter within five (5) business days of the receipt of the grievance. Your grievance will be reviewed and written notice of results will be sent to you no later than ninety (90) calendar days from the date we receive it.

With your permission, a doctor or authorized representative can file a complaint for you. We will make sure that no action is taken against you or a doctor who files a complaint on your behalf.

You may file an appeal when you receive an adverse benefit determination, such as when:

  • A request for service has been limited or denied;
  • An existing service has been decreased or discontinued; or
  • Aetna Better Health has issued a denial of payment.

How do I file an appeal?
You can file an appeal within 60 calendar days from the date Aetna Better Health issued the notice of adverse benefit determination, or denial of a request for service or payment for services. An appeal is a formal request from a member to seek a review of a notice of adverse benefit determination taken by Aetna Better Health.

You can file an appeal over the telephone by calling 1-844-528-5815, (TTY: 711), Monday through Friday, from 8 a.m. to 7 p.m. If you file a verbal appeal, a written request must be filed within ten (10) calendar days after Aetna Better Health’s receipt of the verbal filing.

If you want to file an appeal in writing, send it to:
Aetna Better Health of Florida
Attention: Appeals and Grievance - FHK
261 N. University Drive
Plantation, FL 33324

With your permission, a doctor or an authorized representative can file an appeal for you. We will make sure that no action is taken against you or a doctor who files an appeal on your behalf.

If you need help to file an appeal, call Member Services, toll-free at 1-844-528-5815, (TTY: 711). Aetna Better Health will give you reasonable assistance in completing the forms and other steps, including but not limited to providing interpreter services and interpreter capability.

The appeals coordinator will send you an acknowledgement letter within five (5) business days of getting an appeal.