Provider appeals and grievances

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).

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. 

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.

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