You’re unhappy with the quality of care or services you received from:
One of your providers (for example, vision or dental services providers)
A pharmacy or hospital
Your health plan
Do you have a grievance? Filing a grievance or appeal won’t affect your health care services or benefits coverage. Just let us know right away. We have special processes to help you. And we’ll do our best to answer your questions and resolve your issue. We’ll also keep all your info private.
This means you disagree with a decision we made about your coverage for services your provider believes are medically necessary. You’ll get a letter from us if we deny, stop, hold or reduce an ongoing service or treatment you’ve been receiving. We call this a Notice of Adverse Benefit Determination.
Then, if you like, you can file an appeal. You’d like us to review the decision to be sure we were correct about things like:
There's no time limit for filing a grievance. We’ll send you a letter saying that we received it. We’ll try to resolve your grievance right away. We may call you for more info.
Our letter will include our decision and the reasons for it. We’ll also provide our contact info in case you have questions about the decision.
La persona que reciba su apelación la dejará registrada. Un proveedor con la misma especialidad o similar a la del proveedor que lo está tratando revisará su apelación. This provider won’t:
We’ll send a letter telling you that we received your appeal. It will tell you about next steps. There is no cost to see your:
You’ll be able to present your case to the Appeals Committee in writing or in person. During the COVID-19 pandemic, you may need to do so in writing versus being present physically.
We’ll send the results of your appeal in writing. The decision letter will tell you about:
If you need more help or don’t agree with our appeal decision, here are some options.
You can have someone else file a grievance or appeal for you. They can also act for you in a state fair hearing. This person is your member representative. They may be:
You have to give written permission to the person, allowing them to act for you.
If you write a letter, tell us that you want someone else to act for you to file a grievance or appeal. Be sure to include:
Then, sign the letter and send it to:
Aetna Better Health of Louisiana
Grievance and Appeals Dept.
ATTN: Grievance System Manager
PO Box 81139
5801 Postal Road
Cleveland, OH 44181
Is your provider filing on your behalf? If yes, be sure they use this address, not the provider address.
When we get the letter, the person you chose can act for you. If someone else files a grievance or appeal for you, you can’t file one yourself about the same item.
Are you appealing our decision to deny, stop, hold or reduce an ongoing service or treatment you’ve been receiving? If yes, those services will continue automatically during your appeal, as long as:
Your services will continue until one of these things happen:
This applies unless you have asked for a state fair hearing with continuation of services. Read more about this topic under the “State fair hearing” tab.
You can speed up your appeal if waiting up to 30 calendar days is harmful to your health. This is an expedited or quick decision. Just call us — either you or your provider can call. We’ll call you with the decision within 72 hours. We can increase the review period up to 14 days if you ask for an extension or we need more info and the delay is in your interest.
You can also ask for a quick decision in situations that involve:
If we can’t approve an expedited appeal, we’ll call to let you know. We’ll also send you a letter within 2 days. Then, we’ll process your appeal normally, in the usual timeframe (30 days).
You can ask for a state fair hearing from the Louisiana Department of Health if you don’t agree with our appeal decision. The state’s rules say you must wait for your internal appeal to be complete first.
You must also ask for a state fair hearing in writing within 120 days of the date of the appeal decision letter from your internal appeal.
You have many options to ask for a state fair hearing. Just contact the Louisiana Division of Administrative Law:
Complete the online recipient appeal request form.
You can also mail the online recipient appeal request form. Print the form, complete it and mail it to:
Division of Administrative Law – HH Section
P.O. Box 4189
Baton Rouge, LA 70821-4189
You can also fax the online recipient appeal request form. Print the form, complete it and fax it to 225-219-9823.
Just call 225-342-5800.
The Louisiana Division of Administrative Law makes a recommendation about your hearing to the Secretary of the Louisiana Department of Health. The Secretary makes the final decision about your state fair hearing appeal.
Was your appeal was based on a decision to deny, stop, hold or reduce an ongoing service or treatment? If so, and you file for a state fair hearing, you have the right to ask that your services continue while your appeal is pending. Check the box on the online recipient appeal request form that you want to continue services.
You must ask for your services to continue in writing within 10 days of the date of our appeal decision letter. Your services will continue until one of these things happens:
If you miss the 10-day deadline, we’ll reduce, hold or stop your services by the effective date.
It’s important to understand your rights when it comes to grievances and appeals. Do you need info in another language? Just call us at 1-855-242-0802 (TTY: 711). We’re here for you 24 hours a day, 7 days a week. We’ll share this info in your primary language. You can also get info other formats, like large print or braille.