Appeals & grievances

Aetna Better Health of Louisiana will try its best to deal with your concerns or issues quickly and bring about a result that is acceptable. You may use our grievance process or our appeal process, depending on what kind of problem you have.

There will be no change in your services or the way you are treated by Aetna Better Health of Louisiana staff or a health care provider because you file a grievance or an appeal. We will maintain your privacy and give you any help you may need to file a grievance or appeal. This includes providing you with interpreter services or help if you have vision and/or hearing problems. You may also choose someone like a relative, friend or provider to act for you.

To file a grievance, appeal a plan action, or request a Fair Hearing, call 1-855-242-0802, TTY 711, fax or write to:
Aetna Better Health of Louisiana
Grievance and Appeals Dept.
2400 Veterans Memorial Blvd., Suite 200
Kenner, LA 70062
Fax:  1-860-607-7657

When you contact us, you will need to give us your name, address, telephone number and the details of the problem.

If you do not agree with an adverse benefit determination that we have taken, you may appeal. When you file an appeal, it means that we must look again at the reason for our action to decide if we were correct.  An appeal is a way for you to ask for someone to review our adverse benefit determinations. The list below includes examples of when you might want to file an appeal.

Aetna Better Health of Louisiana has:

  • Not approved a service your provider asked for
  • Stopped a service that was approved before
  • Not paid for a service your PCP or other provider requested
  • Not given you the service in a timely manner
  • Not approved a service for you because it was not in our network

To file an appeal:

  • Call Member Services at 1-855-242-0802, TTY 711. If you do not speak English, we can provide an interpreter at no cost to you. 
  • Or, you can write to us at:
    Aetna Better Health of Louisiana
    Grievance and Appeals Dept.
    2400 Veterans Memorial Blvd., Suite 200
    Kenner, LA 70062
    Fax:  1-860-607-7657

You can have someone represent you when you file your appeal, such as a family member, friend or provider. You must agree to this in writing. If you want to allow someone to aappeal on your behalf, a "Personal Appeal Representative Form" (PAR) must be sent in with you appeal request before your 30 days are up. You may also send us a letter telling us that you want someone else to represent you and file an appeal for you. This person is called a member representative. Include your name, member ID number from your ID card, the name of the person you want to represent you and what action you are appealing. When we get the letter from you, the person you picked can represent you. If someone else files an appeal for you, you cannot file one yourself for that adverse benefit determination.

You or your representative may start an appeal within 60 calendar days from the date on our notice of adverse benefit determination letter. But if you want your services to continue while we review your appeal, you must file your appeal before or up to 10 days from the date on our notice of adverse benefit determination letter. We can help you write your appeal, if needed. Oral appeal must be followed by a written signed copy, unless the request is expedited.

The person who receives your appeal will record it. The appropriate staff will oversee the review of the appeal. We will send a letter telling you that we received your appeal. It will tell you how we will handle it. Knowledgeable clinical staff reviews your appeal. The staff who reviews your appeal  is not involved in our initial decision or action that you are appealing.

If you are appealing a decision to reduce, suspend, or stop services you are currently authorized to get, you may request to continue to receive these services while we are deciding your appeal. We must continue your service if you make your request to us before or 10 days from the date on our notice to you about our intent to reduce, suspend, or terminate your service, or by the intended effective date of our action. It’s important that the original period covered by the service authorization has not expired. 

What happens if our decision is not in your favor
Your services will continue until you withdraw the appeal, or until the original authorization period for your services has been met. Or services will continue until 10 days after we mail you a notice about our appeal decision. This will happen unless you have requested a Louisiana State Medicaid Fair Hearing with continuation of services. 

Although you may request a continuation of services while your appeal is under review, if your appeal is not decided in your favor we may require you to pay for these services if they were provided only because you asked to continue to receive them while we reviewed your appeal.

  • We will send you a letter within three (3) business days saying we received your appeal. We will tell you if we need more information.
  • We will tell you how to give us more information in person or in writing, if needed. 
  • You can provide more information about your appeal, if needed.
  • You can see your appeal file, medical records or any information concerning your appeal at no cost to you. 
  • You can be there when the Appeals Committee reviews your appeal.
  • The Appeals Committee will review your appeal. They will let you know if they need more information and will make a decision within 30 calendar days. If your appeal required a fast decision, we will call you to tell you the decision. You will receive the results of all appeals in writing. The decision letter will tell you what we will do and why. 
  • A provider with the same or like specialty as your treating provider will review your appeal. It will not be the same provider who made the original decision to deny, reduce, or stop the medical service.
  • The provider who reviews your appeal will not report to the provider who made the original decision about your case.
  • We can extend the time for making a decision about your appeal by up to 14 days. We may extend the time to get more information. If we do this, we will send you a letter explaining the delay.
  • You can also ask for an extension, if you need more time.  

If the Appeals Committee’s decision agrees with the notice of adverse benefit determination; you may have to pay for services you got during the review. If the Appeal’s Committee’s decision does not agree with the notice of adverse benefit determination; we will let the services start right away.

Unless you ask for an expedited review, we will review your appeal of an adverse benefit determination taken by us as a standard appeal. We will send you a written decision as quickly as your health condition requires, but no later than 30 days from the day we receive an appeal. The review period can be increased up to 14 days if you request an extension, or if we need more information and the delay is in your interest. During our review, you will have a chance to present your case in person or in writing. You will also have the chance to look at any of your records that are part of the appeal review.

We will send a notice about the decision we made about your appeal that will identify the decision we made and the date we reached that decision.

If we reverse our decision to deny or limit requested services, or reduce, suspend, or terminate services, and services were not furnished while your appeal was pending, we will provide you with the disputed services no later than 72 hours from the date the appeal is overturned. In some cases you may request an “expedited” appeal.

If you or your provider feels that taking the time for a standard appeal could result in a serious problem to your health or life, you may ask for an expedited review of your appeal of the action.  We will respond to you with our decision within 72 hours and in writing within 2 business days.  The review period can be increased up to 14 days if you request an extension, or we need more information and the delay is in your interest.

If we do not agree with your request for a fast appeal decision, we will make our best efforts to contact you. We will let you know that we have denied your request for an expedited appeal. If we deny your request for a fast decision we will give you a decision in the normal time.  Also, we will send you a written notice of our decision to deny your request for an expedited appeal. We will send it within 2 days of receiving your request.

We will send an appeal decision letter.  If our decision does not fully approve your appeal the letter will explain additional appeal rights. Internal appeals are limited to one level. After this is exhausted you have the right to ask for a State Fair Hearing from Louisiana Department of Health. The letter will tell you who can appear at the Hearing on your behalf. It will also tell you if you can continue to receive services during the appeal process.

You may ask for a State Fair Hearing from Louisiana Department of Health (LDH) within 120 calendar days of the date we sent your appeal decision letter. The Louisiana Division of Administrative Law makes a recommendation about your hearing to the Secretary of LDH. The Secretary of LDH makes the final decision about your appeal.

If your appeal involved reduced, on hold, or stopped services received, you may ask to continue to get these services while you wait for the State Fair Hearing decision. You must check the box on the Fair Hearing form that you want to continue services. State Fair Hearings can also be requested by phone or online. Your request to continue the services must be made within 10 days of the date of our appeal decision letter. If you do not request a State Fair Hearing within the 10 days, your services will be reduced, put on hold, or stopped by the effective date, whichever is later. Your services will continue until the original authorization period for your services has ended. Or if you withdraw the appeal. Or if the State Fair Hearing Officer denies your request. Whichever happens first.

If the State Fair Hearing Officer reverses our decision, we must make sure that you receive the disputed services right away. And as soon as your health condition requires. If you received the disputed services while your appeal was pending, we will be pay for the covered services ordered by the State Fair Hearing Officer.

You may ask to continue services while you are waiting for your State Fair Hearing decision. If your Hearing decision is not your favor, you may be responsible for paying for services that were the subject of the Hearing. 

You can ask for a Fair Hearing by doing one of the following:

 

  • Complete an online appeal request form available at the Division of Administrative Law’s website.
  • Click the Forms link or the Health and Hospitals link.
    • Click the Recipient Appeal Request link.
    • Complete the Recipient Appeal Request Form.
    • Click Submit.
  • OR Print out the online appeal request form, complete the form, sign the form and mail to:

            Division of Administrative Law – HH Section
            P.O Box 4189
            Baton Rouge, LA 70821-4189

  • OR Print out the online appeal request form, complete the form, sign the form and fax to 225-219-9823.
  • OR Call 225-342-5800

A grievance is any communication by you to us of dissatisfaction about the care and treatment you receive from our staff or providers of covered services including vision, transportation and dental services.  For example, if someone was rude to you or you do not like the quality of care or services you have received from us, you can file a grievance with us. Standard grievances can be filed at any time.

Aetna Better Health takes member grievances very seriously. We want to know what is wrong so we can make our services better. If you have a grievance about a provider or about the quality of care or services you have received, you should let us know right away. Aetna Better Health has special procedures in place to help members file grievances. We will do our best to answer your questions or help to resolve your concern. Filing a grievance will not affect your health care services or your benefits coverage. 

These are examples of when you might want to file a grievance.

  • Your provider or an Aetna Better Health staff member did not respect your rights.
  • You had trouble getting an appointment with your provider in an appropriate amount of time.
  • You were unhappy with the quality of care or treatment you received.
  • Your provider or an Aetna Better Health staff member was rude to you.
  • Your provider or an Aetna Better Health staff member was insensitive to your cultural needs or other special needs you may have.

You can make your grievance on the phone or in writing. You can call Member Services for help at 1-855-242-0802, TTY 711. You can also send or fax a letter telling us about your grievance to:

Aetna Better Health® of Louisiana
Grievance and Appeals Dept.
2400 Veterans Memorial Blvd., Suite 200
Kenner, LA 70062
Fax:  1-860-607-4657

In your letter, give us as much information as you can. For example, include the date the incident happened, the names of the people involved and details about what happened. Be sure to include your name and your member ID number. You can ask us to help you file your grievance.

If you do not speak English, we can provide an interpreter at no cost to you.

You can have someone represent you, such as a family member, friend or provider. You must agree to this in writing. Send us a letter telling us that you want someone else to represent you and file a grievance for you. Include your name, member ID number from your ID card, the name of the person you want to represent you and what your grievance is about. When we get the letter from you, the person you chose can represent you. Note that if someone else files a grievance for you, you cannot file one yourself about the same item.

You may file a grievance orally or in writing with us. The person who receives your grievance will record it. The appropriate plan staff will oversee the review of the grievance. We will send you a letter telling you that we received your grievance. The letter will give you a description of our review process. We will review your grievance and give you an answer. We will decide within 90 days after the receipt. The review period can be increased up to 14 days. You can increase the review period if you need more time. We can increase the review period if we need more time. We can only request more time if it is in your best interest.

Our decision letter will describe what we found when we reviewed your grievance. It will tell you our decision about your grievance.