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Filing a claim to get reimbursed
If you get your vaccines at a doctor’s office, clinic or out-of-network pharmacy, you may need to pay the full cost out of pocket. Then you’ll need to submit a claim to get paid back.
Learn more about how to file a claim and get the forms you need.
Help us better serve you
Help us better serve you
A grievance
You’re unhappy with the quality of care or services you received from:
- One of your providers (for example, vision or dental services providers)
- A pharmacy or hospital
- Your health plan
- 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.
- Your provider or a plan staff member wasn’t sensitive to your cultural needs or other special needs you may have.
Do you have a grievance? Filing a grievance or appeal won’t affect your health care services or benefits coverage. Just let us know right away. We have special processes to help you. And we’ll do our best to answer your questions and resolve your issue.
An appeal
This means 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.
Then, if you 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
What happens next?
What happens next?
Grievances
There's no time limit for filing a grievance. We’ll send you a letter saying that we received it. We’ll try to resolve your grievance right away. We may call you for more info.
Some timelines to note with your grievance
- Within 10 calendar days (for grievances filed by mail or when requested): We’ll send you a letter saying that we received your grievance.
- Within 30 calendar days (all standard grievances): We’ll send you a letter telling you our decision.
Appeals
We’ll send you a letter saying that we received your appeal. We’ll try to resolve your appeal as quickly as your health condition requires. We may call you for more info.
Some timelines to note with your appeal
- Within 60 calendar days from the date on our first decision letter: You or your representative need to file the appeal.
- Within 5 calendar days: We’ll send you a letter saying that we received your appeal.
- Within 30 calendar days (standard appeal): We’ll send you a letter telling you our decision.
Expedited appeal (quick decision)
- Within 72 hours: We’ll tell you our decision if your appeal is for urgent, emergency or hospital care. Or if waiting up to 30 days for a decision could be harmful to your health.
More help with grievances and appeals
If you need more help or don’t agree with our appeal decision, here are some options.
You can have someone else file a grievance or appeal for you. They can also act for you in a Medicaid State Fair Hearing. This person is your member representative. They may be:
- Your provider
- Your family member
- Your friend
- Your legal guardian
- Your attorney
- Another person
You have to give written permission to the person, allowing them to act for you.
- For grievances, you can write a letter.
For appeals, you can write a letter or fill out the grievance and appeal form:
If you write a letter, tell us that you want someone else to act for you to file a grievance or appeal. Be sure to include:
- Your name
- Your member ID number from your ID card
- The name of the person you want to represent you
- What your grievance or appeal is about
Then, sign the letter and send it to:
Aetna Better Health of Oklahoma
PO Box 81139
5801 Postal Road
Cleveland, OH 44181
Is your provider filing on your behalf? If yes, be sure they use this address, not the provider address.
When we get the letter, the person you chose can act for you. If someone else files a grievance or appeal for you, you can’t file one yourself about the same item.
Are you appealing our decision to deny, stop, hold or reduce an ongoing service or treatment you’ve been receiving? If yes, you can request to continue receiving services at the current level during your appeal, as long as:
- You file your appeal on or before the last day of the original authorized period, or within 10 calendar days of our decision letter, whichever is later
- The appeal involves stopping, holding or reducing a treatment that was approved before
- The authorization hasn’t expired
- An authorized provider ordered the services in question
Your services will continue until one of these things happens:
- You withdraw the appeal.
- The original authorization period for your services has been met.
- 10 calendar days have passed since we mailed you our appeal decision
This applies unless you have asked for a Medicaid State Fair Hearing with continuation of services. Read more about this topic under the “State Fair Hearing” tab.
The appeal decision
- If the appeal decision isn’t in your favor: You may need to pay for the disputed services that you continued to receive during your appeal.
- If the appeal decision is in your favor: We’ll approve the disputed services within 72 hours from the date of the appeal decision if you didn’t continue to get these services during the appeal. And we’ll pay for these services if you did continue to get them during the appeal.
You can ask for a fast appeal if waiting up to 30 calendar days is harmful to your health. This is an expedited or quick decision. Just call us — either you or your provider can call. We’ll call you with the decision within 72 hours. We can increase the review period up to 14 days if you ask for an extension or we need more info and the delay is in your interest.
You can also ask for a quick decision in situations that involve:
- Urgent or emergency care
- A new or continued hospital stay
- Availability of care
- Health care services for which you have received emergency services but haven’t yet been discharged from a hospital or other facility
- Any care or service that would be harmful to your health to wait up to 30 calendar days
If we can’t approve an expedited appeal, we’ll call to let you know. We’ll also send you a letter within 2 calendar days. Then, we’ll process your appeal normally, in the usual time frame (30 days).
If you do not agree with our appeal decision, you have the right to request a Medicaid State Fair Hearing. You will have 120 calendar days from the appeal decision to request one. Just call 405-522-7217 or fill out the form online. Or send a letter to:
Oklahoma Health Care Authority
4345 N. Lincoln Blvd
Oklahoma City, OK 73105
Was your appeal based on a decision to deny, stop, hold or reduce an ongoing service or treatment? If so, and you file for a Medicaid State Fair Hearing, you have the right to ask that your services continue while your appeal is pending. Fill out the online form for a Medicaid State Fair Hearing.
You must ask for your services to continue in writing within 10 calendar days of the date of our appeal decision letter. Your services will continue until one of these things happens:
- You withdraw the appeal.
- The original authorization period for your services has ended.
- The Medicaid State Fair Hearing Officer denies your request.
If you miss the 10 calendar-day deadline, we’ll reduce, hold or stop your services by the effective date.
The Medicaid State Fair Hearing decision
If the Medicaid State Fair Hearing decision isn’t in your favor (agrees with our decision): You may need to pay for the disputed services if you continued to get them while your hearing was pending.
If the Medicaid State Fair Hearing decision is in your favor (reverses our decision): We’ll approve the disputed services within 72 hours or as soon as your health condition requires. If you continued to get the disputed services while your hearing was pending, we’ll pay for the covered services.
Your language, your format
You need to understand your rights when it comes to grievances and appeals. Do you need info in another language? Just call us at 1-844-365-4385 (TTY: 711). We’re here for you 24 hours a day, 7 days a week. We’ll share this info in your primary language. You can also get info in other formats, like large print or braille.