Grievances and appeals online form

I want to file a grievance or appeal

1. Grievance details

Tell us about the grievance or appeal in the fields below. Fill in all fields.

Check one:

I’m filing a grievance.

I’m filing an appeal.

Date For grievances, give the date of the issue or event. For appeals, give the date on the Notice of Adverse Benefit Determination letter you received.

Description

Tell us about the grievance or appeal. You can send us medical records or other info to support your appeal. Use one of the methods at the bottom of this form.

2. Member info

Share your info in the fields below. Fill in all fields.

Name

Date of birth

Address

City

State

ZIP code Example: 12345

Phone Example: 1234567890

Member plan ID number

Are you filing this grievance or appeal for someone else?

Yes, I’m a representative.

No, I’m the member.

Representatives are family members, friends, caregivers or providers. This is someone the member approved in writing to act for them. Or others legally able to act for the member. It can be the member’s legal guardian. Or someone who holds power of attorney. You’ll need to send us this proof of representation if you haven’t already. You can send it using one of the methods at the bottom of this form.

3. Representative info

Share the representative’s info in the fields. Fill in all fields.

Name

Relationship Your relationship to member

Date of birth

Address

City

State

ZIP code Example: 12345

Phone Example: 1234567890

Expedited (quick) appeals

You can ask for an expedited (quick) appeal if you or your provider believes our standard time frame of 30 days to make an appeal decision will risk your life or health.

Check this box if you believe you need a decision within 72 hours. If you have a supporting statement from your provider, you can send it using one of the methods at the bottom of this form.

Fill in all fields:

Sign (type your name)

Today’s date

Who are you?

Contact us

You can send us more info by:

Fax: 1-866-889-7517
Email: MIAppealsandGrievances@Aetna.com
Mail: Aetna Better Health® of Michigan
Attn: Grievance and Appeals
PO Box 81139
5801 Postal Road  
Cleveland, OH 44181

What's covered?

Apply or renew

For members

Health and wellness

Grievances and appeals online form

I want to file a grievance or appeal

Expedited (quick) appeals

Contact us

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