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Grievances and appeals

We want you to be happy with the care you get from us and our providers. So, if you’re ever unhappy with your plan or a provider, you can file a grievance. And if you’re unhappy with a decision we made, you can file an appeal. 

Help us better serve you

Help us better serve you

grievance is when you’re unhappy with the quality of care or services you received from:

 

  • One of your doctors, like your primary care physician 

  • One of your providers, like a pharmacy or hospital

  • Aetna Better Health® of Illinois 

An appeal is when you want us to review and change a decision we made about your coverage. You’ll get an Adverse Benefit Determination letter from us if a service is reduced, stopped or can’t be approved. Then, you can file an appeal.

File your grievance or appeal here

I want to file a grievance or an appeal

 

We take your concerns seriously. So if you want to file a grievance or appeal, it's important to know the following: 

 

  • There's no time limit for filing a grievance. 

  • You can file an appeal after you receive an Adverse Benefit Determination letter. 

  • You need to file your appeal within 60 days from the date you receive this letter. Or within 10 calendar days of receiving the letter if you want to continue your current treatment.  

  • You can speed up your appeal if waiting 15 calendar days is harmful to your health. 

  • We'll make a decision within 24 hours of receiving your expedited appeal.

 

What happens next?

What happens next?

Grievance

 

We’ll send you a letter after we receive your grievance. Then, we’ll send another letter within 90 days with our decision.

 

Appeal

 

We’ll send you a letter after we receive your appeal. Then, we’ll send another letter within 15 days with our decision. We’ll send our decision in 24 hours if you expedite your appeal.

More options

If you don’t agree with the appeal decision, you can ask for a Medicaid External Independent Review (EIR), a State Fair Hearing or both. An EIR isn’t available for appeals related to services received through the Elderly waiver, the Persons with Disabilities waiver, the Persons with Brain Injury waiver, the Persons with HIV or AIDS waiver or the Supportive Living Facilities waiver. 

You can request a State Fair Hearing within 120 days of getting your appeal decision letter. If you want to continue your current treatment, you’ll need to request a State Fair Hearing within 10 days of getting your letter. You can make your request to the Department of Healthcare and Family Services (HFS):

Online

Just request a State Fair Hearing through the Application for Benefits Eligibility (ABE) site. If you don’t already have an ABE appeals account, you can sign up for free before getting started.

In person

Local staff members can help you request a State Fair Hearing. 

You can request a State Fair Hearing related to your medical services or Elderly waiver (Community Care Program) services: 

By email

You can email HFS.

By phone

You can request a State Fair Hearing by calling HFS at 1-855-418-4421 or 1-800-526-5812 if you have impaired hearing or speech.

By fax

You can fax an appeal to HFS at 312-793-2005.

By mail 

 You can send an appeal to HFS at:

Illinois Department of Healthcare and Family Services 
Bureau of Administrative Hearings
69 W. Washington Street, 4th Floor 
Chicago, IL 60602 

You can also request a State Fair Hearing through the Department of Human Services (DHS) for:

 

  • Mental health services

  • Substance use disorder services

  • Persons with Disabilities waiver services

  • Persons with Brain Injury waiver services 

  • Persons with HIV or AIDS waiver services

  • Home Services Program (HSP) services

You can request a State Fair Hearing from the DHS by:

Email

You can email DHS.

Phone

You can request a State Fair Hearing by calling DHS at 1-800-435-0774 or 1-877-734-7429 if you have impaired hearing or speech.

Fax

You can fax an appeal to DHS at 312-793-8573.

Correo

You can send an appeal to DHS at:

Illinois Department of Human Services 
Bureau of Administrative Hearings
69 W. Washington Street, 4th Floor 
Chicago, IL 60602 

ERs

 

You can request an External Review within 30 days of getting your Aetna Better Health appeal Decision Notice. You must request an ER within 10 calendar days of getting your notice if you want to continue your current treatment. 

 

An ER is a third-party reviewer that is not a part of Aetna Better Health of Illinois.

 

External reviews are not available for appeals related to services received through the Elderly waiver, the Persons with Disabilities waiver, Persons with Brain Injury waiver, the Persons with HIV or AIDS waiver or the Home Services Program.

 

How do I request an External Review?

 

You can request an ER:

By phone

You can request an external review by calling Member Services at 1-866-329-4701 (TTY: 711).

By fax

You can fax an external review request to us at 1-877-668-2076.

By mail

You can send an external review request to us at:

Aetna Better Health of Illinois
Appeals and Grievances
PO Box 81139
Cleveland, OH  44181

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