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Before you file a complaint with the Illinois Department of Healthcare and Family Services (HFS), you’ll need to complete the managed care organization (MCO) dispute process. This is part of HFS’ rules.
During the process, we’ll assign the dispute a reference number for tracking. If you feel we didn’t address the dispute adequately, use the MCO tracking number to file a complaint with HFS.
Dispute by phone: Just call us at 1-866-329-4701 (TTY: 711). The agent will give you a tracking/reference number (for example, #PDXGR1234567).
Dispute to Network Relations: The consultant will give you a reference number (for example, #1234).
Dispute or reconsideration by mail or Provider Portal: Complete the requested info and attach or upload any supporting documentation. We’ll send the dispute decision in a provider remittance. The tracking/reference number is the adjusted claims number from that remittance (that is, the claim number ending in A1, A2, A3, etc.).
When filing an appeal or grievance, you’ll receive an appeal or grievance number in the acknowledgment and resolution letters (for example, APXXXX or GRXXXX).
As a network provider, you can file a dispute verbally or in writing to resolve disputes about a claim we denied in whole or in part:
As a duplicate
As untimely filed
Due to a coding edit or missing info (for example, itemized bill, coordination of benefits or proof of timely filing)
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In writing
You’ll want to resubmit your claim with the missing info. Mark it “DISPUTE” and send it to:
Aetna Better Health of Illinois
P.O. Box 982970
El Paso, TX 79998-2970
Facts to know about disputes
Provider claim disputes don’t include pre-service disputes that we denied due to not meeting criteria for medical necessity.
We process pre-service denials as member appeals, subject to member policies and time frames.
We may ask you to complete and submit the dispute and resubmission form (PDF) with any supporting documentation. We can also mail or fax you the form. Just call 1-866-329-4701 (TTY: 711) for help.
If the dispute is about claim resubmission or reconsideration, we may refer it to the Claims Inquiry Claims Research (CICR) department.
We’ll let you know about all dispute resolutions by phone, email or fax or through the remittance advice.
Disputes about medical necessity
You can submit a provider appeal about medical necessity for authorization-related denials.
In writing
Send your appeal by mail, fax or email to:
Aetna Better Health
Appeal and Grievance Department
PO Box 81040
5801 Postal Road
Cleveland, OH 44181
Fax: 1-844-951-2143
Email: ILAppealandGrievance@Aetna.com
A provider can appeal any post-service, authorization-related denials within 60 days of the denial date. You’ll want to do so within 60 calendar days of the claim processing date. Post-service items are always standard appeals and aren’t eligible for expedited processing.
Send your appeal to:
Aetna Better Health
Appeal and Grievance Department
PO Box 81040
5801 Postal Road
Cleveland, OH 44181
Fax: 1-844-951-2143
Email: ILAppealandGrievance@Aetna.com
We’ll acknowledge your appeal verbally or in writing within 5 business days of receipt. We’ll respond to standard provider appeals within 30 business days.
The Appeal and Grievance department will thoroughly research and seek input from other departments, if necessary. We’ll use any statutory, regulatory or contractual provisions that apply, as well as our written policies and procedures.
We’ll review the appeal and research. Reviewers won’t have been involved in any prior decisions related to the appeal. If your appeal concerns a clinical issue, a provider with the same or a similar specialty will take part and make the final decision.
Both in-network and out-of-network providers can file a grievance verbally or in writing about our policies, procedures or any of our administrative functions.
In writing
You can submit a grievance by mail, fax or email to:
Aetna Better Health
Appeal and Grievance Department
PO Box 81040
5801 Postal Road
Cleveland, OH 44181
Fax: 1-844-951-2143
We’ll acknowledge your grievance verbally or in writing within 5 business days of receipt. We’ll respond to standard provider grievances within 30 business days of receipt.
The Appeal and Grievance department will thoroughly research and seek input from other departments, if necessary. We’ll use any statutory, regulatory or contractual provisions that apply, as well as our written policies and procedures.
We’ll review the grievance and research. Reviewers won’t have been involved in any prior decisions related to the grievance. If your grievance concerns a clinical issue, a provider with the same or a similar specialty will take part and make the final decision.
If you disagree with our decision, you can file a complaint with HFS through the state portal. You can do this after trying to resolve the issue with our dispute process. The state complaint:
Can include a single claim or multiple claims, regardless of members, as long as they involve a common question of fact or policy
Must include the date you submitted the claims in disagreement to our appeal process
Must include the tracking number we provided
You must submit the state complaint either:
No sooner than 30 calendar days after submitting an appeal and no later than 30 calendar days after the unsatisfactory resolution
Or 60 calendar days after submitting the appeal to us
Next steps for state complaints
Once HFS receives your complaint, they’ll submit the issue to us within 10 calendar days. We’ll review all documentation and create a written resolution within 30 calendar days of receipt. If we need more info, we’ll ask for it within 5 days of receipt. If we don’t receive the info, we can ask for one extension through the portal of up to 30 calendar days. If we don’t receive the info and don’t ask for an extension, the case will be closed.
At any point in the process, anyone (the provider or the plan) can ask for one extension through the portal, of up to 30 calendar days. This can happen no later than 7 calendar days before the original 30-day time frame.
HFS will review all documentation and will notify everyone of the decision.
If the decision disagrees with our previous decision, we’ll authorize items or services within 10 calendar days of receipt of the decision.
If the decision agrees with our previous decision, the decision notification will include info on how to submit to HFS for review.
You can request a department review if you:
Don’t receive our written resolution to the state complaint
Disagree with the written resolution
Everyone (the provider and the plan) must submit all relevant materials to the department within 30 calendar days. This includes contact info for knowledgeable personnel. The department will review the request against applicable contract terms, policies, procedures, and state and federal regulations. They’ll make a final decision within 30 days of receipt of all info.
If the decision disagrees with our previous decision, we’ll authorize items and services within 10 calendar days of receipt of the decision.
The Appeal and Grievance Manager is responsible for management of the appeal and grievance processes. They must:
Document individual appeals and grievances
Coordinate resolutions
Maintain the data for all appeals and grievances in the Appeal and Grievance Application
Track and review grievance and appeal data for trends in quality-of-care or other service-related issues
Report all data to the Service Improvement Committee (SIC) and Quality Management Oversight Committee (QMOC)
You can file a grievance or appeal on behalf of a member with their consent. The consent has to be in writing. The exception is for an expedited appeal, which you can file without written consent. When you file on behalf of a member, we consider the case a member appeal or grievance. This means it’s subject to the member appeal or grievance time frames and policies in all cases.
You can find details about the member appeal and grievance system processes in your provider manual (PDF). You can also visit the member grievances and appeals page.
We don’t take actions to punish or retaliate against:
Members who ask for an appeal or grievance
Providers who ask for an expedited resolution on a member appeal
Providers who file a provider appeal or grievance
Providers can’t discriminate against or initiate disenrollment of a member because they filed an appeal or grievance with us.
Our grievances and appeals processes are part of our Quality Improvement program.
Our quality management responsibility for the grievance system processes includes:
Review of individual quality-of-care grievances
Aggregation and analysis of appeals and grievances trend data
Use of the data for quality improvement activities, including collaboration with credentialing and recredentialing processes, as required
Identification of opportunities for improvement
Recommendation and implementation of corrective action plans, as needed
Our processes ensure that:
The people with the authority to take corrective action actively engage in the appeal and grievance process
Data from member and provider appeals and grievances are routinely reviewed to find opportunities for improvement and to apply continuous quality improvement principles