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Grievances and appeals

Questions?

Just check your provider manual (PDF) for answers about grievances and appeals. Or contact us.

Filing a grievance

Both in-network and out-of-network providers may file verbal or written grievances with us. Your grievance could be based on things like:

 

  • Policies and procedures
  • One of our decisions
  • A disagreement about whether a service, supply or procedure is a covered benefit, or is done in the appropriate setting
  • Any other issue of concern that is not requesting a review of a denial or notice of action within 180 of the denial/notice date.

Some provider grievances are subject to the member process. In these cases, we transfer them. These include grievances that you may file on behalf of a member.

You have a few options:
 

By phone 

You can call us with your grievance: 1-855-221-5656 (TTY: 711). We’re here for you Monday through Friday, 8 AM to 5 PM. 

 

By mail 

You can send your written grievance to: 

Aetna Better Health of Kansas 

PO Box 81040

Cleveland, OH 44181 

 

What happens next?

  • Within 10 calendar days: We’ll send you a letter saying that we received your grievance, including instructions on how to:

    • Revise the grievance within the time frame specified in the letter
    • Withdraw a grievance at any time until the Grievance Committee review
  • Within 30 calendar days: We’ll review your case and tell you our decision.

If the grievance requires research or input by another department, we’ll forward the information to the affected department and coordinate with them to thoroughly research each grievance using applicable statutory, regulatory and contractual provisions and our written policies and procedures, collecting pertinent facts from all parties.  

 

The grievance with all research will be presented to the Grievance Committee for decision. The Grievance Committee will include a provider with same or similar specialty if the grievance is related to a clinical issue. The Grievance Committee will consider the additional information and will resolve the grievance. 

 

Clinical grievances reviews are completed by health professionals who:
   

  • Hold an active, unrestricted license to practice medicine or in a health profession   
  • Are board certified (if applicable)   
  • Are in the same profession or in a similar specialty as normally manages the condition, procedure or treatment concerned in the case   
  • Are neither the same reviewer that made the original decision nor someone who reports to that person   

You may request a reconsideration if you’d like us to review an adverse payment decision. A reconsideration, which is optional, is available prior to submitting an appeal.
 

Reconsideration requests must be submitted within 120 calendar days from the date of the notice of the adverse action.
 

You can request a reconsideration by fax, phone or mail:

 

By fax

You can fax your request to 1-833-857-7050.

 

By phone

You can call us with your request at 1-855-221-5656 (TTY: 711). We’re here for you Monday through Friday, 8 AM to 5 PM.
 

By mail

You can send your request to:

Aetna Better Health of Kansas

PO Box 81040

Cleveland, OH 44181

 

What happens next?
 

  • Within 10 calendar days: We’ll send you a letter saying that we received your reconsideration request.
  • Within 30 calendar days: We’ll review your request and tell you our decision.

 

Filing an appeal

Both in-network and out-of-network providers have the right to file an appeal in writing if:
 

  • A service, supply or procedure is medically necessary (include documentation)
  • A payment decision wasn’t in their favor
  • They aren’t satisfied with the outcome of the reconsideration determination
  • They wish to bypass the reconsideration process

Providers have 60 calendar days from the date of the notice of adverse action or reconsideration decision letter to file an appeal. Post service items or services are standard appeal and are not eligible for expedited processing.

You have a few options:

 

By fax

You can fax your appeal to 1-833-857-7050.

 

By mail

You can send your appeal to:

Aetna Better Health of Kansas

PO Box 81040

Cleveland, OH 44181
 

What happens next?

 

  • Within 10 calendar days: We’ll send you a letter saying that we received your appeal, including instructions on how to:

    • Revise the appeal within the time frame specified in the letter
    • Withdraw an appeal at any time until the Appeal Committee review
  • Within 30 calendar days: We’ll tell you our decision.

The appeal along with all research will be presented to the Appeal Committee for decision. The Appeal Committee will include a provider with same or similar specialty. They’ll consider any additional information provided and send you their written appeal decision.
 

Clinical appeals reviews are completed by health professionals who:
 

  • Hold an active, unrestricted license to practice medicine or in a health profession
  • Are board certified (if applicable)
  •  Are in the same profession or in a similar specialty as normally manages the condition, procedure or treatment concerned in the case
  • Are neither the same reviewer that made the original decision nor someone who reports to that person  

More help with grievances and appeals

If you need more help or don’t agree with our appeal decision, here are some options.

 

You can ask for a state fair hearing from the Office of Administrative Hearings 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 may ask for a state fair hearing regarding things like: 
 

  • A denial of payment for covered and non-covered services
  • An incorrect payment by us or a notice from us regarding an overpayment 

State fair hearings must be requested in writing within 120 days of the date of the appeal decision letter from your appeal. You can find more information on how to submit a state fair hearing request in the appeal decision letter.
  

You must send your written request to: 

State of Kansas 

Office of Administrative Hearings 

1020 South Kansas Avenue 

Topeka, KS 66612-1327 

You may ask for an EITPR for denial of a new health care service or a claim for reimbursement following a provider appeal through us after the appeal with us. This request must be completed within 60 calendar days, following the date of the appeal decision letter.  

 

You can find information on how to submit an EITPR request in the appeal decision letter. It’s not required to request an EITPR before requesting a state fair hearing. You may go directly through the state fair hearing process.  

 

Your EITPR request must include: 

  • Your name, mailing address, phone, fax and email 
  • Details about the specific issue or dispute in question and explain why our decision is incorrect 

 

How to submit a request for an EITPR

Complete the EITPR request form (PDF) and send it to us by email, fax or mail.  

 

By email

You can email us your completed form.  


By fax

You can fax your completed form to 1-833-857-7050

 

By mail

You can send your completed request form to: 

Aetna Better Health of Kansas  

Attn: Appeal and Grievance Department 

PO Box 81040 

5801 Postal Road  

Cleveland, OH 44181 

 

What happens next?

 

  • Within 5 business days: We’ll send you a letter saying that we received your EITPR request and notify the Kansas Department of Health & Environment, Division of Health Care Finance (KDHE-DHCF) about your request as well as the affected member.  
  • Within 15 business days: If we appeal the review, we’ll send all documentation that you submitted to the KDHE-DHCF or, if applicable, notify them that you did not complete the appeal process. 
  • Within 30 calendar days: The external reviewer will review your case and notify you, Aetna and KDHE-DHCF of their decision. 

If the EITPR decision reverses the decision to deny, we'll authorize or provide the disputed payment right away. If the final result of the EITPR is to uphold our decision, you can request a state fair hearing within 30 calendar days from the date of the EITPR decision letter.

Questions? Just call us at 1-855-221-5656 (TTY: 711). We’re here for you Monday through Friday, 8 AM to 5 PM.

*By signing this form, you acknowledge that you will be held responsible for the costs associated with the External Independent Third-Party Review in the event the reviewer upholds the Aetna Better of Kansas decision. Forms that are not signed will not be processed.

Member grievances and appeals overview

 

When members ask, we help them complete grievance and appeal forms and take other steps.

 

Member grievances and appeals

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