Complaints, grievances and appeals

You can file a complaint if you’re unhappy with the quality of care or services you received from:

• One of your providers (for example, vision or home care services providers) 

• A pharmacy or hospital

• Your health plan

Here are some things you can file a complaint about:

• You were unhappy with the quality of care or treatment you received.

• Your provider or a plan staff member was rude to you or didn’t respect your rights.

• You had trouble getting an appointment with your provider in a reasonable amount of time.

How to file a complaint

To file a complaint, just call us at:

• Medicaid MMA: 1-800-441-5501 (TTY: 711)
• LTC: 1-844-645-7371 (TTY: 711)

You can call Monday through Friday, 8 AM to 7 PM ET. 

Note: With your permission, a provider or authorized representative can file a complaint or grievance for you. We’ll make sure that no action is taken against you or the provider who files a complaint on your behalf.

What happens next?

Within 1 business day: We’ll try to resolve your complaint.

A grievance is similar to a complaint. You can also file a grievance if you're unhappy about any services or care you received. A representative, including the provider, can file a grievance on behalf of the member.

How to file a grievance

You have a few options:

By phone

Just call us at:

Medicaid MMA: 1-800-441-5501 (TTY: 711)

LTC: 1-844-645-7371 (TTY: 711)

You can call Monday through Friday, 8 AM to 7 PM ET.

By mail

You can file a grievance in writing. Be sure to mail your letter to:

Aetna Better Health® of Florida 
PO Box 81139 
5801 Postal Road 
Cleveland, OH 44181

Need more time to resolve your grievance? 

Just call us to ask for more time:

• Medicaid MMA: 1-800-441-5501 (TTY: 711)

• LTC: 1-844-645-7371 (TTY: 711)

You can call Monday through Friday, 8 AM to 7 PM ET.

Note: With your permission, a provider or authorized representative can file a complaint or grievance for you. We’ll make sure that no action is taken against you or the provider who files a complaint on your behalf.

What happens next?

Within 30 days: We’ll review your grievance and send you a letter with our decision.

If we need more time to resolve your grievance, we’ll send you a letter with our reason. We’ll also tell you about your rights if you disagree.

An appeal is when 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 (NABD). Then, if you’d like, you can file an appeal.

You may file an appeal if you’d like us to review the decision to be sure we were correct about things like:

• Not approving a service your provider asked for

• Stopping a service that was approved before

• Not paying for a service your primary care provider (PCP) or other provider requested

• Not giving you the service in a timely manner

• Not approving a service for you because it was not in our network

How to file an appeal

You can file an appeal within 60 days of our decision about your services. 

You have a few options:

By phone

Just call us at:

Medicaid MMA: 1-800-441-5501 (TTY: 711)

LTC: 1-844-645-7371 (TTY: 711)

You can call Monday through Friday, 8 AM to 7 PM ET.

By mail

You can file an appeal in writing. Be sure to mail your letter to: 

Aetna Better Health® of Florida 
PO Box 81139 
5801 Postal Road 
Cleveland, OH 44181

What happens next?

• Within 5 business days: We’ll send you a letter saying that we received your appeal.

• Within 30 days: We’ll review your appeal and tell you our decision.

You can ask for an expedited appeal if you think waiting up to 30 days is harmful to your health.

How to request an expedited appeal

You can request an expedited appeal within 60 days of our decision about your services.

You have a few options:

By phone

Just call us at:

Medicaid MMA: 1-800-441-5501 (TTY: 711)

LTC: 1-844-645-7371 (TTY: 711)

You can call Monday through Friday, 8 AM to 7 PM ET.

By mail

You can file a grievance in writing. Be sure to mail your letter to:

Aetna Better Health® of Florida 
PO Box 81139 
5801 Postal Road 
Cleveland, OH 44181

What happens next?

Within 48 hours: We’ll call you with our decision. 

If we can’t approve an expedited appeal, we’ll also send you a letter within 48 hours. Then, we’ll process your appeal normally, in the usual time frame (30 days).

You can ask for a Medicaid fair hearing if you don’t agree with our appeal decision. 

Note: You must finish the appeal process before you can have a Medicaid fair hearing.

How to request a Medicaid fair hearing

You can request a fair hearing, in writing, within 120 days of the date of the appeal decision letter. 

Send your letter to the Agency for Health Care Administration (AHCA) Office of Fair Hearings.

Be sure to include this info:

• Your name

• Your member ID number

• Your Medicaid ID number

• A phone number where you or your representative can be reached

• Why you think we should change the decision

• Any medical info to support the request

AHCA contact info 

Address:

Agency for Health Care Administration

Medicaid Fair Hearing Unit

PO Box 7237

Tallahassee, FL 32314-7237

Phone: 1-877-254-1055

Email: MedicaidFairHearingUnit@ahca.myflorida.com

Fax: 239-338-2642

Continuing benefits during an appeal

If you’d like your services to continue during your Medicaid fair hearing, you must ask for them to continue within 10 days of the appeal decision letter. Some rules may apply.

Need a copy of your medical record? Just contact us.

What happens next?

We will:

• Provide you with transportation to the Medicaid Fair Hearing, if needed.

• Restart your services if the state agrees with your Medicaid fair hearing request.

If you continued your services, we may ask you to pay for the services if the final decision is not in your favor.

You can file a complaint if you’re unhappy with the quality of care or services you received from:

• One of your providers (for example, vision or home care services providers) 
• A pharmacy or hospital
• Your health plan

How to file a complaint or grievance

You have a few options:

By phone

Just call us at 1-844-528-5815 (TTY: 711). You can call Monday through Friday, 7:30 AM to 7:30 PM ET.  
 

By mail

You can file your complaint or grievance in writing. Send your letter to:

Aetna Better Health of Florida 
PO Box 81139 
5801 Postal Road 
Cleveland, OH 44181

By fax

You can fax your complaint or grievance to us: 1-888-684-4928.

Include this info with your complaint or grievance:

• Your name

• Your member ID number

• Details about what happened/what you’re unhappy with

• Provider’s name, date of service and any other info about your case

Note: With your permission, a provider or authorized representative can file a complaint or grievance for you. We’ll make sure that no action is taken against you or the provider who files a complaint on your behalf.

What happens next?

• Within 5 business days: We’ll send you a letter saying that we received your complaint or grievance.

• Within 90 calendar days: We’ll send you a letter with our decision. 

An appeal is when you disagree with a decision we made about your coverage for services your provider believes are medically necessary. 

You may file an appeal if you’d like us to review the decision to be sure we were correct about things like:

• Not approving a service you or your provider asked for

• Stopping or reducing an ongoing service or treatment you were receiving

• Not paying for a service your primary care provider (PCP) or other provider requested

How to file an appeal

You have a few options:

By phone

Just call us at 1-844-528-5815 (TTY: 711). You can call Monday through Friday, 7:30 AM to 7:30 PM ET.

By mail

You can file your appeal in writing. Send your letter to:

Aetna Better Health of Florida 
PO Box 81139 
5801 Postal Road 
Cleveland, OH 44181

Note: With your permission, a provider or authorized representative can file an appeal for you. We’ll make sure that no action is taken against you or the provider who files an appeal on your behalf.

What happens next?

• Within 5 business days: We’ll send you a letter saying that we received your appeal.

• Within 30 days: We’ll review your appeal and tell you our decision.

What to do if the appeal decision isn’t in your favor

If your appeal request was not approved, you can ask for an independent review. The appeal decision notice you receive from us will tell you how. Just make sure to do so within 120 days after you get the notice. 

Questions? Just call us at 1-844-528-5815 (TTY: 711).

You can ask for an expedited appeal if you think waiting up to 30 days is harmful to your health.

How to request an expedited appeal
 

You can request an expedited appeal within 60 days of our decision about your services.
 

You have a few options:

By phone

Call us at 1-844-528-5815 (TTY: 711). You can call Monday through Friday, 7:30 AM to 7:30 PM ET.

By mail

You can ask for an expedited appeal in writing. Be sure to mail your letter to:
 

Aetna Better Health of Florida
PO Box 81139
5801 Postal Road
Cleveland, OH 44181

What happens next?

Within 72 hours: We’ll call you with our decision.
 

If we can’t approve an expedited appeal, we’ll also send you a letter within 72 hours. Then, we’ll process your appeal normally, in the usual time frame (30 days).

If you don’t agree with an appeal decision, you can ask for a state review within 120 days of the date of the appeal decision letter. A state hearing officer will review the decision made during the plan appeal.

How to request a state review

You have a few options:

By phone

You can call the Agency for Health Care Administration (AHCA) at 1-877-254-1055.

By mail

Agency for Health Care Administration

Medicare Fair Hearing Unit

PO Box 7237

Tallahassee, FL 32314-7237

What happens next?

• The AHCA will send you a letter saying that they received your request.

• The state will notify you of their decision.