Appeals & grievances

Aetna Better Health of Louisiana will try its best to deal with member concerns or issues as quickly as possible and to their satisfaction. Members may use our grievance process or our appeal process, depending on what kind of problem they have.

To file a member appeal:

  • The member can call Member Services at 1-855-242-0802, TTY 711.
  • 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

Members can have someone represent them when they file an appeal, such as a family member, friend or a provider such as yourself. The member must send us a letter telling us that they want someone else to represent them and file an appeal for them. This person will be his or her member representative. Members need to include their name, member ID number, the name of the person they want to represent them and what adverse benefit determination they are appealing. If the member wants to allow someone to appeal on their behalf, a "Personal Appeal Representative Form" (PAR) must be sent in with the appeal or before the 30 days processing time are up. When we get the letter or PAR from them, the person they picked can represent them. If someone else files an appeal for them, they cannot file one themselves for the same adverse benefit determination.

Internal appeals are limited to one level. After this is exhausted the member will have the right to request a State Fair Hearing from Louisiana Department of Health. If we reverse our decision to deny or limit requested services, or reduce, suspend, or terminate services, and services were not furnished while the member’s appeal was pending, we will provide the member with the disputed services no later than 72 hours from the date the appeal is overturned. In some cases the member may be able to request an “expedited” appeal. Oral appeals must be followed by a written, signed copy, unless the request is expedited. Members have 60 days to file an appeal.

Expedited appeal process
If you, as the provider, feels that taking the time for a standard appeal could have a serious impact on your patient’s health or life, the member may ask for an expedited review of their appeal of the action.  We will respond to them 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 the member’s request to expedite their appeal, we will make our best efforts to contact them in person to let them know that we have denied their request for an expedited appeal and will handle it as a standard appeal.  Also, we will send them a written notice of our decision to deny their request for an expedited appeal within 2 days of receiving their request.

If we did not decide the appeal totally in the member’s favor, they may request a State Fair Hearing from Louisiana State within 120 days of the date we sent them the notice about our decision on their appeal. The Louisiana Division of Administrative Law makes a recommendation about their hearing to the Secretary of the Louisiana Department of Health (LDH). The Secretary of LDH makes the final decision about their appeal.

If the State Fair Hearing Officer reverses our decision, we must make sure that the member receives the disputed services promptly and as soon as their health condition requires. If they received the disputed services while their appeal was pending, we will be responsible for payment for the covered services ordered by the State Fair Hearing Officer.

Although members may request to continue services while they are waiting for their State Fair Hearing decision, if their State Fair Hearing is not decided in their favor they may be responsible for paying for the services that were the subject of the State Fair Hearing.

Members 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 Complete, print out and sign the form and mail to:

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

  • OR Complete, print out and sign the form and fax to 225-219-9823.
  • OR Call 225-342-5800

A grievance is any communication by members to us of dissatisfaction about the care and treatment they receive from our staff or providers of covered services including vision, transportation and dental services.  For example, if someone was rude to them or they do not like the quality of care or services they have received from us, they 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 members have grievances about a provider or about the quality of care or services they have received, they 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 their questions or help to resolve their concern. Filing a grievance will not affect their health care services or their benefits coverage. 

Members can make your grievance on the phone or in writing. They can call Member Services for help at 1-855-242-0802, TTY 711. They can also send or fax a letter telling us about their 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 the letter, members need to give us as much information as they can. For example, they need to include the date the incident happened, the names of the people involved and details about what happened. They must also include their names and their member ID numbers. They can ask us to help file their grievance.

They can have someone represent them, such as a family member, friend or provider. They need to send us a letter telling us that they want someone else to represent them and file a grievance for them. They must include their name, member ID number from their ID card, the name of the person they want to represent them and what their grievance is about. When we get the letter from them, the person they chose can represent them. If someone else files a grievance for them, they cannot file one themselves about the same item.

A provider may file an appeal. A formal request to reconsider a decision (e.g. a utilization review recommendation or administrative action) with Aetna Better Health of Louisiana within thirty (30) calendar days from the date of the Aetna Better Health of Louisiana Notice of adverse benefit determination. The expiration date to file an appeal is included in the Notice of adverse benefit determination.

  • Written appeals should be sent to the following address:
    Aetna Better Health of Louisiana
    Grievance System Manager
    2400 Veterans Memorial Blvd, Suite 200
    Kenner, LA 70062
    FAX: 1-860-607-7657
  • You can also file an appeal by calling Aetna Better Health of Louisiana at 1-855-242-0802.

 

 

Network providers may file a payment dispute verbally or in writing directly to Aetna Better Health of Louisiana to resolve billing, payment and other administrative disputes for any reason including, but not limited to:

  • Lost or incomplete claim forms or electronic submissions
  • Requests for additional explanation as to services or treatment rendered by a health care provider
  • Inappropriate or unapproved referrals initiated by the provider
  • Any other reason for billing disputes

Note: Provider payment disputes do not include disputes related to medical necessity.

Providers can file a verbal dispute with Aetna Better Health of Louisiana by calling Provider Services Department at 1-855-242-0802. To file a dispute in writing, providers should write to:

Aetna Better Health of Louisiana

Attention: Cost containment
P.O. Box 61808
Phoenix, AZ. 85082-1808

Providers need to complete and submit the dispute form with any appropriate supporting documentation.

Both network and out-of-network providers may file a verbal complaint with Aetna Better Health of Louisiana.  Provider complaints are expressions of dissatisfaction filed with Aetna Better Health of Louisiana in regard to our policies, procedures or any aspect of our administrative functions, including dissatisfaction with the resolution of a payment dispute, or a provider complaint that is not requesting review of an action. 

Providers can also file a verbal complaint by calling 1-855-242-0802. To file a complaint in writing, providers should 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

Aetna Better Health of Louisiana

Attention: Cost containment P.O. Box 61808 Phoenix, AZ. 85082-1808

Providers need to complete and submit the dispute form with any appropriate supporting documentation.

 

Note: Provider payment disputes do not include disputes related to medical necessity.