California HMO GRIEVANCE FORM - California residents can use this electronic form to file an HMO grievance, appeal or complaint. Printable versions (in PDF format) of this grievance form are available in English (3 pages) and Spanish (3 pages). A one-page printable document with information about member rights and responsibilities, as well as complaint and appeal procedures, is available in English (1 page) and Spanish (1 page).
Right to Appeal For your information, you have the right to appeal to the Connecticut Insurance Commissioner after you have exhausted all appeals provided by Aetna. Your appeal to the Insurance Commissioner would have to be filed within 30 days of your having received notice of a final determination from Aetna. The Insurance Commissioner's address is P.O. Box 816, Hartford, CT 06142, and the telephone number is (860) 297-3910.
New Jersey
Extension of Benefits
A subscriber or dependent may be eligible for continued coverage under the Aetna benefits plan if the subscriber's plan would otherwise terminate but the plan includes a provision for continued coverage for total disability and the subscriber or dependent initiates a request for continued coverage by contacting Aetna Member Services.
The individual who is totally disabled must meet the extension eligibility requirements on the date that coverage would otherwise end.
If the request for continued coverage is approved, the continued coverage applies only to the individual who is disabled and not to other family members. In addition, the terms of coverage at the time of the approved extension remain in effect and the continued coverage would be subject to all plan provisions and limitations.
The following forms must be completed and submitted to Aetna Member Services for consideration. Contact Aetna Member Services using the phone number listed on back of the Aetna Member ID card to obtain the mailing address.
(2 pages)