Appeals and complaints

Questions?

Just check your provider manual (PDF) for answers about appeals and complaints. Or, call Provider Relations at 1-833-711-0773 (TTY: 711). We’re here for you 7 a.m. to 8 p.m. Eastern Time, Monday through Friday.

Filing an appeal

Both in-network and out-of-network providers have the right to appeal our claims determinations within 60 calendar days of receipt of the claim denial.

You can file an appeal if:

We denied reimbursement for a medical procedure or item you provided for a member due to lack of medical necessity or no prior authorization (PA), when it was required.
You have a claim that has been denied or paid differently than you expected and wasn’t resolved to your satisfaction through the dispute process.

Filing a complaint

Both in-network and out-of-network providers may file verbal and written complaints with us. Your complaints could be based on things like:

Administrative issues
Payment and reimbursement issues
Dissatisfaction with the resolution of a dispute
OhioRISE staff service or actions
Vendor staff service or actions

When submitting a grievance on behalf of a member, the requirements of the member grievance process will apply. You can learn more about the process on our member appeals and grievances page.

File an appeal or complaint now

You can file an appeal or complaint:

Online

You can file an appeal or complaint in your Provider Portal. Need help with registration? Just contact Availity at 1-800-282-4548. You can get help from 8 a.m. to 8 p.m. Eastern Time, Monday through Friday.

By email

You can email us your appeal or complaint.

By fax

You can fax your appeal or complaint to:

toll-free fax number: 1-833-928-1259

By phone

You can call us with your appeal or complaint: 1-833-711-0773 (TTY: 711) from 7 a.m. to 8 p.m. Eastern Time, Monday through Friday.

By mail

You can send your appeal or complaint to:

Aetna Better Health of Ohio

Grievance System Manager
PO Box 81040
5801 Postal Road
Cleveland, OH 44181

Reviews of appeals and complaints

Clinical appeals and complaints reviews are completed by health professionals who:

Hold an active, unrestricted license to practice medicine or another health profession.
Are board certified (if applicable).
Are in the same profession or in a similar specialty as normally manages the condition, procedure or treatment concerned in the case.
Are neither the same reviewer that made the original decision nor someone who reports to that person.

External medical review (EMR)

If you’re dissatisfied with our decision on your appeal, you may request an EMR within 30 days after the date of the decision letter. This involves a third-party reviewer that isn’t connected with our plan.

Expedited EMR

You also may request an expedited EMR if waiting for a decision could cause harm to a member’s health.

How to request an EMR

To learn more about how to request an EMR, you can check the information on your decision letter. Or, call Provider Relations at 1-833-711-0773 (TTY: 711).