Grievance & Appeals

A Utilization Management (UM) appeal is a way for a member to ask us to reconsider our decisions with regard to medically necessary services. If we deny your request for a service (or request for us to pay for a service), or if we decide to reduce, suspend, or stop an ongoing service or a course of treatment a member has been receiving, a member can request an appeal. Members can request an appeal verbally or in writing. However, if a member calls, he/she must follow up by sending us a written, signed appeal request. Members have sixty (60) calendar days from your Notice of Adverse Benefit Determination to request an appeal.

Members or their designated representatives can file an appeal with Aetna Better Health of New Jersey either orally or in writing. Representatives must be designated in writing. Services will continue automatically while the appeal is pending, as long as the appeal is asked for on or before:

  • The last approved day a member is receiving the services, or
  • Within 10 days of receiving the notice that the services will be stopping, whichever is later. A member does not need to ask for the services to be continued.

There are two types of appeal

Internal Appeal

  • Utilization Management Appeals
  • Expedited Utilization Management Appeals

External Appeal

  • Independent Utilization Review
  • Expedited Independent Utilization Review

The member or authorized representative may also appeal directly to DMAHS through the State fair hearing process. State fair hearing appeals may be submitted at the same time as, instead of, or after the completion of the member appeal with Aetna Better Health of New Jersey. 

Please refer to the Member Grievance & Appeals webpage for additional information.

A grievance is when a member tells us he or she is unhappy with us or their provider or they do not agree with a decision we have made.

Some things you may file a grievance about:

  • He/she is unhappy with the care you are getting.
  • He/she has not gotten services that the Plan has approved.
  • His/her provider or a plan staff member did not respect your rights.
  • He/she had trouble getting an appointment with your provider in a reasonable amount of time.
    His/her provider or a plan staff member was rude to you.
    His/her provider or a plan staff member was not sensitive to your cultural needs or other special needs you may have.

If a member disagrees with our decision to deny coverage for a service or item that he/she or their provider asked for, this is an appeal, and it will be automatically transferred to the Utilization Management Appeal process. The received date will be the same.

We will try to resolve your grievance right away. We may call you for more information. The grievance committee will make a decision within the following timeframes:

  • Thirty (30) calendar days of receipt for a standard grievance
  • Three (3) business days of receipt for an expedited grievance

For grievances that require an expedited (quick) decision, you may get a phone call from us with the decision. You will get a letter from us within three (3) business days of receipt. The letter will include the decision reached and the reasons for the decision, along with our contact information if you have questions about the decision. 

For more information about filing a grievance, please visit our member webpage.

A provider may file a formal appeal in writing, a formal request to reconsider a decision (e.g., utilization review recommendation, administrative action), with Aetna Better Health of New Jersey within sixty (60) calendar days from the Aetna Better Health of New Jersey Notice of Adverse Outcome Letter. The expiration date to file an appeal is included in the Notice of Action. All written appeals should be sent to the following address:

Aetna Better Health of New Jersey
Provider Services
3 Independence Way, Suite 400
Princeton, NJ 08540-6626

Both network and out-of-network providers may file a formal grievance in writing directly with Aetna Better Health of New Jersey 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 grievance by calling 1-855-232-3596. To file a grievance in writing, providers should write to:

Aetna Better Health of New Jersey
Provider Services
3 Independence Way, Suite 400
Princeton, NJ 08540-6626

Network providers may file a payment dispute verbally or in writing directly to Aetna Better Health of New Jersey 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 New Jersey by calling Provider Services Department at 1-855-232-3596. To file a dispute in writing, providers should write to:

Aetna Better Health of New Jersey
Provider Services
PO Box 61925 
Phoenix, AZ 85082 

Providers need to complete and submit the Dispute Form with any appropriate supporting documentation.

Members or their designated representative, including a provider acting on their behalf with their written consent, may request a State Fair Hearing through DMAHS only after they have received the Internal Appeal Decision Letter.  This request must be completed within twenty (120) calendar days of the initial adverse action.