Refehtl §— ZozI-l/ ~04 2att Vena Mont Sh Se 200 eg aetna’ Kenner, LA 70062 i 10/28/2021 If you need this in larger print or another format, call Member Services at REY T BODIN 528 BEAU CHENE DR MANDEVILLE, LA, 70471 s Llame hoy mismo al 1-855-242-0802, TTY 7-1-1 si usted desea recibir esta carta en Subject: Grievance Acknowledgment . espafiol. Member Name: JEFFREY BODIN Member ID: 5794038645696 'Y BODIN: Aetna Better Health of Louisiana re 10/28/2021 ived your grievance about your medication concerns on A committee of one or more Aetna Better Healtl: of Louisiana staff will review your case. The committee may include a licensed doctor or peer reviewer. The committee will not include anyone that is involved in your complaint. A decision will be made by 1/26/2022 and a letter will be mailed to you telling you each reason for the decision. Atany time during the grievance process, you can have someone you know represent you or act on your behalf. This person will be "your representative." If you decide to have someone represent you or act for you, tell us in writing, the name of that person and how we can reach him or het. You or your representative may ask us to see any information we reviewed about your grievance. You may also send information taat you have about your grievance to us at: Aetna Better Health of Louisiana Grievance System Manager PO Box 81139 Postal Road Cleveland, Chio 44181 Phone: 1-855-242-0802 Fax: 1-844-410-8655 www.s Pege 3 of 7 “Issued: 02-01-2015 LA-14-10-17 orreae-1972ormeants972b Repeed §=Zpz{(-li-04 Ace ae Het mts gaetna’ Kenner, LA 70062 If your grievance is described correctly at the top of this letter, please sign below and return this letter in the envelope provided. If your grievance is not described correctly, please call us at 1-855-242-0802. (Members and representatives with hearing impairments call Louisiana Relay 1- -1) Need more help? Ifyou have questions or need help with your grievance, including interpreter and translation services, at no cost to you call us at 1-855-242-0802.) (Members and representatives with heating impairments call Louisiana Relay 7-1-1) We will assign a staff person who has not been involved in your grievance issue to help you. Sincerely, Aetna Better Health of Louisiana ce: T agree that my grievance is described correctly Member or Member Representative Signature Date LA-14-10-17 Fage 4 of 7 Issued: 02-01-2015