Grievances and appeals

You can have someone else file a grievance or appeal for you. They can also act for you in a Medicaid State Fair Hearing. This person is your member representative. They may be:
 

• Your provider
• Your family member
• Your friend
• Your legal guardian
• Your attorney
• Another person 

You have to give written permission to the person, allowing them to act for you.

• For grievances, you can write a letter.

• For appeals, you can write a letter or fill out the grievance and appeal form:
   

  Grievance and appeal form – English (PDF)
  Grievance and appeal form – Spanish (PDF)
  
  Or call us at 1-844-365-4385 (TTY: 711). We can send you the right form to fill out.

• For Medicaid State Fair Hearings, you can write a letter to the Oklahoma Health Care Authority and include it with your Medicaid State Fair Hearing request.

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:

• Your name
• Your member ID number from your ID card
• The name of the person you want to represent you
• What your grievance or appeal is about

Then, sign the letter and send it to:

Aetna Better Health of Oklahoma

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, you can request to continue receiving services at the current level during your appeal, as long as:
 

• You file your appeal on or before the last day of the original authorized period, or within 10 calendar days of our decision letter, whichever is later
• The appeal involves stopping, holding or reducing a treatment that was approved before
• The authorization hasn’t expired
• An authorized provider ordered the services in question

Your services will continue until one of these things happens:

• You withdraw the appeal.
• The original authorization period for your services has been met.
• 10 calendar days have passed since we mailed you our appeal decision

This applies unless you have asked for a Medicaid State Fair Hearing with continuation of services. Read more about this topic under the “State Fair Hearing” tab.

The appeal decision

• If the appeal decision isn’t in your favor: You may need to pay for the disputed services that you continued to receive during your appeal.
• If the appeal decision is in your favor: We’ll approve the disputed services within 72 hours from the date of the appeal decision if you didn’t continue to get these services during the appeal. And we’ll pay for these services if you did continue to get them during the appeal.

You can ask for a fast 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:
 

• Urgent or emergency care
• A new or continued hospital stay
• Availability of care
• Health care services for which you have received emergency services but haven’t yet been discharged from a hospital or other facility
• Any care or service that would be harmful to your health to wait up to 30 calendar days

If we can’t approve an expedited appeal, we’ll call to let you know. We’ll also send you a letter within 2 calendar days. Then, we’ll process your appeal normally, in the usual time frame (30 days). 

If you do not agree with our appeal decision, you have the right to request a Medicaid State Fair Hearing. You will have 120 calendar days from the appeal decision to request one. Just call 405-522-7217 or fill out the form online. Or send a letter to:
 

Oklahoma Health Care Authority

4345 N. Lincoln Blvd

Oklahoma City, OK 73105 

Was your appeal based on a decision to deny, stop, hold or reduce an ongoing service or treatment? If so, and you file for a Medicaid State Fair Hearing, you have the right to ask that your services continue while your appeal is pending. Fill out the online form for a Medicaid State Fair Hearing.

You must ask for your services to continue in writing within 10 calendar days of the date of our appeal decision letter. Your services will continue until one of these things happens:
 

• You withdraw the appeal.
• The original authorization period for your services has ended.
• The Medicaid State Fair Hearing Officer denies your request.

If you miss the 10 calendar-day deadline, we’ll reduce, hold or stop your services by the effective date.

The Medicaid State Fair Hearing decision

• If the Medicaid State Fair Hearing decision isn’t in your favor (agrees with our decision): You may need to pay for the disputed services if you continued to get them while your hearing was pending.

• If the Medicaid State Fair Hearing decision is in your favor (reverses our decision): We’ll approve the disputed services within 72 hours or as soon as your health condition requires. If you continued to get the disputed services while your hearing was pending, we’ll pay for the covered services.