Aetna, Inc.

Review: My health insurance coverage was briefly terminated and then reinstated under [redacted] in December 2014. Immediately after my coverage was reinstated, I attempted to purchase my regular medications at my pharmacy, but they were declined. I was about to leave town for vacation and assumed this was because of the transition to[redacted], so I paid from my own funds. I filed a paper claim when I returned the first week of January, which I had done previously under a similar circumstance with Aetna. Now I have learned that my claim for reimbursement was denied. It is not clear why this has happened. Aetna has paid for these same drugs every month for quite a while. There were no changes to my coverage plan that I am aware of. I am using the same pharmacy as I have used for a long time. Their EOB is not at all clear what is the problem, and there is no reason for this action by them, it is causing unnecessary expense and effort for me.Desired Settlement: I have paid for health insurance coverage and it was effective on the date that I purchased medications. I should immediately be refunded for my out-of-pocket expenses.

Business

Response:

Please see our response to the complaint #[redacted] for [redacted] received on January 21, 2015.

Review: I am writing today because I have been out of work for almost year now. My last day at work was May 24th 2012. I have been diagnosed with [redacted] and this has prevented me from working. It is a very painful disease and there is NO cure for it. I had filed a disability claim with Aetna and they had denied me. I appealed their decision and they denied me again. My next step is to file a law suit against them, but I do not make enough money per hour for an attorney to take my case. Each one of them has stated there is not enough money in the case for them to take it. I had given Aetna ALL my medical records. My MRI's, X-rays, blood work, doctors visits and notes, everything to prove that I am disabled, and I do not understand how I can be denied my disability benefits. I have now lost my insurance because I have been unable to pay the premiums, my kids are now not insured. I can not support my family. I am not able to pay my medical bills and any other bills that I have. My credit is destroyed. The worst part is now I am not receiving any medical attention. I haven't seen my doctor since the middle of last year. I am not able to get any medication that I need to be taking. It has just been a big mess. I don't know if your organization can help me, but I sure hope so. I have 38 pages for supporting documentation. How can I get these to you?

Product_Or_Service: Medical Insurance

Account_Number: WXXXX XXXXX

Desired Settlement: Honestly, to be paid my disabilty payments the way Aetna had stated they would when I signed up with them. It is stated in my policy that if I were to become disabled, that they would pay 50% of my pay. I would like them to do what they have stated they would do in their policy.

Business

Response:

Business Response /* (1000, 10, 2013/05/30) */

Thank you for your inquiry received on May 16, 2013. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

We reached out to the Disability department for resolution. They advised the claim went through the appeals process and a decision was completed on November 6, 2012. The decision was to uphold the claim denial. The file was reviewed by a board certified orthopedic surgeon who concluded that the medical evidence did not support functional impairment that would prevent the member from performing the material duties of his own occupation. The appeal decision letter advised him of his right to pursue civil litigation under ERISA. At this time he has exhausted his administrative remedies under the plan.

We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the chance to address these concerns. If you have any more questions about this particular matter, please contact the Executive Resolution Team at [redacted].com.

Review: I have a health fund through my work. after my health fund has been drained I then have to pay an 800 $ deductible. my wife went to see a doctor and they wrongly billed us 700$. we figured this out and made them fix it. the doctor of course took their time fixing this error. meanwhile we continued seeing other medical professionals about other things and assumed they would retro on those bills once we got our 800$ back to out health fund.... instead they insist that these were applied to our deductible and our health fund is just plus that money and they wont pay for the bills that should have been paid with it. this is sure to effect my credit because I don't have the money for these other accumulated bills they have my money and wont cough it up.

Product_Or_Service: health insurance

Account_Number: wXXXXXXXXX

Desired Settlement: I want aetna to pay my bills with my healthfund.

Business

Response:

Business Response /* (1000, 5, 2013/05/10) */

Thank you for your inquiry received on April 26, 2013. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

We reached out to the Claims department for assistance with the member's issue. In the beginning of the year, 2013, there was $2,250 put in the member's Health Fund and there was a rollover of $850 on February 15, 2013, which gave the member a total of $3,100 to use for 2013. Currently, the member has used all of the $2,250 monies that are deposited each year and of the $850 rollover about half of that has been used. Right now, the member only has $422.84 available in the fund. We would pay from the fund for claims going forward but we are not able to go back and reprocess claims from 2012, under the fund.

We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the chance to address these concerns. If you have any more questions about this particular matter, please contact the Executive Resolution Team at [redacted].com.

Review: I have an insurance plan with [redacted] - aetna. The plan ID is: [redacted]. There are three separate Group IDs due to some convoluted issue with my tax credit at [redacted] but my plan remains the same. I've spoken with aetna's Pharmacy Advisor, the pharmacy precertification plan line, pharmacy management, aetna customer care, and prior authorization. I keep getting the proverbial runaround. All I need is a form faxed to my doctor's office so I can get a pre-authorization for a brand name medication. Immediately. The generic results in adverse reactions such as [redacted] and [redacted], both of which are totally unacceptable.Desired Settlement: I need SOMEONE from aetna to fax my doctor's office, [redacted], Attn: Dr. [redacted], a pre-authorization form so that he can request the brand name of the medication be covered by my plan. I've had this approved in the past. My doctor's office fax number is: [redacted].

There is no reason why this has been so difficult. I've done it before. Incompetence is not all that is at play here and I feel that aetna does not want to pay for my medication when it is allowed on my plan (although in generic form) given a ** is present.

Thank you. [redacted]

Business

Response:

Hello,

Review: Aetna has improperly and fraudulently debited my bank account for three months worth of premiums, aggregating $1,398. Aetna failed to send me any open enrollment information or contact me on how to continue my coverage into 2015. As a result, and because the coverage was poor anyhow, I obtained new insurance through [redacted]. Then suddenly in the last week of December Aetna sends a letter saying "we neglected to send you information but are going to extend your coverage into 2015." I immediately contacted them by both phone and email to indicate I did NOT want that extension, that I already had new insurance. They assured me my account was flagged with a 12/31/14 termination and no further debits would be made from my account. I confirmed that no deductions were made in January. But in reviewing my February statement I noticed that they deducted TWO months of coverage totaling $932. I IMMEDIATELY contacted Aetna and said such deducts were to cease and desist and the money should be returned to my account immediately. Instead, the very next day, they deducted another $466....?! Astounding. This is egregious fraud against an already beleaguered healthcare consumer. I would like Revdex.com to help with a return of my $1,398 in stolen funds, and also a $200 charge to Aetna for the time and effort I have/will spend to get my money back and shut down my checking account to prevent future deductions. This is costing me time and money to deal with this, and Aetna should have to pay for that. Thank you for your assistance in righting this truly staggering case of outright fraud against a consumer. Product_Or_Service: Individual Health Insurance Account_Number: [redacted]Desired Settlement: DesiredSettlementID: Refund Refund of $1,398 in money stolen from my account, plus a $200 "penalty". This penalty represents the time away from my business in order for me to deal with Aetna and to shut down my business checking account so that they will not be able to further defraud me.

Business

Response:

Hello,

Thank you for your inquiry, regarding complaint #[redacted] for [redacted]. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

Upon receipt of the complaint we immediately reached out to Individual Plan Services department to verify why the money was taken out of the member’s bank account after her plan was terminated. We were advised this was done in error. We have since reimbursed the member the $1,398.00 taken from the account. [redacted] also requested we cover a $200 fee for her to open a new bank account. We approved the $200 and it is being mailed to the member’s home address on March 12, 2015.

Aetna strives to provide the highest level of service, quality, and satisfaction, and to continually improve our processes. I want you to know that we appreciate your feedback because it gives us the opportunity to listen to our customers and make any improvements to our processes and the service we provide. Your opinion is valued at Aetna, and I trust that you will not hesitate to contact us when you need assistance. If you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted]

Thank you,

[redacted] <

Consumer

Response:

I have reviewed the response made by the business in reference to complaint ID [redacted], and find that this resolution is satisfactory to me. After an initial rocky start, Aetna then went above and beyond to resolve this matter fairly, and I applaud their customer service.Sincerely, [redacted]

Review: My husband had [redacted] for a[redacted]. Our health insurance was Aetna, through my (his wife) employer, [redacted] Hospital. Prior to my husband's surgery, I called Aetna member services to determine if there was any pre-authorization required & to verify that the provider we had chosen was in network. The Aetna representative stated that there was no pre-authorization required, that we were $411 away from meeting our deductible, & that the provider was in network. My husband had the surgery & then we received an [redacted] showing that all the surgery charges were processed as out of network. I called Aetna back & spoke to a different rep & was told that the charges were processed incorrectly & that the providers were in network & she would start the reprocessing process. She placed me on hold, & then came back & stated that she was incorrect & the providers were out of network. I filed two appeals with Aetna that were both denied. In their denial letters, they state that I was given the wrong information, but there was no intent to mislead & that they are not liable. I am now stuck with around $7000 in medical bills. If I had been given the correct information, I would have found a different provider for my husband. I also called my HR & had the advocacy center look into this, but she was unable to change the outcome with Aetna as well. Besides for the medical bills, I hate to think that this will continue to happen to others. Anything you could do would be greatly appreciated. Thanks, [redacted]Desired Settlement: a billing adjustment or at least some kind of action against Aenta so this doesn't happen to others

Business

Response:

Thank you for your inquiry received on 02/13/2015 regarding complaint #10448342 for Tamara Mainquist. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

The member’s concerns were reviewed under appeal number [redacted]. Based on review of the information submitted, the previous decision was upheld as the claims were processed correctly according to the terms of the plan for out-of-network services. The member was mailed a resolution letter dated 01/21/2015, with a detailed explanation. Enclosed with the resolution letter were “Member Rights” and next steps for appeal options. The member can submit a voluntary appeal to his/her plan sponsor for further review. We regret the decision could not be more favorable.

We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address [redacted] concerns. If you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted]

Review: For the past year, I have had two health Aetna insurance policies. Every time I have visited a doctor, gotten a test done, or used some other medical service while covered by both thess polices, the insurance payments have been screwed up, always ending in nothing being paid by Aetna to the provider, and leaving me to cover the whole bill. In the process of trying to sort this out, I have contacted my providers and Aetna multiple times, and it never gets fixed. It seems the two policies dont "talk" to each other, and the expectation is that I act as the go-between for policy 1 and policy 2. Both policies have been given each other's information from me, yet the billing issues still have not been resolved. Now I am getting calls from collectors from bills over half a year old that I thought were setttled. And the collectors are demanding the full amount, rather than the usual after insrance payment amount. Who only knows what this is doing to my credit score.Aetna, your service in the past 12 months is making a decent case for a single payer health care system.Desired Settlement: Do your job and pay these providers so I can pay whats my responcibility and get these collectors off my back.

Business

Response:

Thank you for your inquiry received on December 30, 2013. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

Review: Initially, we received a letter from the FLEX plan, along with a 1099, stating that we needed to substantiate some charges that we made using the debit card that the carrier had issued to us for that purpose. It turns out that we had originally tried improperly to pay for a bill that came from a previous year, so, in accordance with AETNA's request, we submitted a new claim to use the remainder of our benefit. AETNA accepted this and sent us a revised 1099 indicating 0.00 in additional income. Several weeks later we called them because we still had not received a reimbursement check for the funds they now owed us for medical expenses that we paid out of pocket (the charges on the debit acct being previously denied). After many phone calls and faxes of documents, we were informed that our claim was too late (started in March, now June) and was going to appeals. We provided still more info by fax as requested and were told we should have a decision within 90 days. 120 days later and we have heard nothing. They owe us 286.80, and I believe they should pay interest since our attempt to correct this dates back to mid-February. I believe what they have done is tantamount to petty theft and is utterly ridiculous and inexcusable...the government should revoke their right to administer such a scam (plan).

Product_Or_Service: Medical Flexible Spending Account

Account_Number: [redacted]Desired Settlement: DesiredSettlementID: Refund

286.80+ Interest if possible

Business

Response:

Thank you for your inquiry received on November 20, 2013. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

Review: In Oct 2013, I filed a "1st level appeal" with Aetna requesting that it reconsider denying full-coverage 80% payment for medically necessary surgeries in July 2012. At the time, the only reason given for the denial was that in cases of multiple surgeries it would only pay the full 80% for one procedure. Unable to identify this rule in my plan, nor determine why Aetna chose the least expensive procedure to pay the full 80%, I requested details on the basis of the denial in order to adequately address them in my appeal. I was told that info could only come with the answer to my 1st appeal, which I then filed by phone.Aetna policy is to answer 1st level appeals within 30 days, after which, I have 60 days from 'when I receive it' (not when Aetna thinks I did) to file a 2nd level appeal. I received Aetna's denial of my 1st appeal a few days past its own 30-day deadline despite the writer having dated it several days prior to when the post marked envelope indicated it was mailed. I received this in December - without any answers to my request for details on the basis that my claim was denied (contrary to Aetna's expressed policy). After gathering medical details that clearly showed the preliminary surgery (for which Aetna chose to pay the full 80%) was essential in performing the more expensive surgery, I filed a 2nd-level appeal around Jan. 28. Shortly afterward, I received a certified letter from Aetna with some details related to my Oct 2013 query - this time the writer had dated the letter more than 2-3 months prior to when it was post marked, much less when I received it.Now, Aetna is denying its obligation to consider this 2nd level appeal and enclosed medical info based on its claim that it did not get this appeal within the required 60 days. I receive and send mail via the US military postal service in [redacted], which may contribute to slower mail. But Aetna is also disingenuous in not keeping its own deadlines and fraudulently dating letters in an apparent attempt to hide the fact.Desired Settlement: 1) Aetna should pay the full 80% of the the aforementioned surgeries as required by my health care policy (to the healthcare provider, or if by the time this is resolved I've paid out of pocket, refund me accordingly).2) At the very least, Aetna should accept and seriously consider my 2nd level appeal - IN GOOD FAITH - and cease its disingenuous, hypocritical and misleading (i.e., fraudulently dated correspondences) practices regard seemingly arbitrary deadlines.

Business

Response:

Thank you for your inquiry received on March 19, 2014. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

We reached out to Aetna’s Complaint and Appeal unit for assistance with the member’s concerns. After careful review, it was determined to allow a second level appeal request on March 27, 2014, under case number [redacted]. The second level appeal is currently under review, and an appeal decision will be completed within 30 calendar days of when we allowed the reconsideration on March 27, 2014.

Review: I was wrongfully terminated from my short term disability (STD). My appeal was wrongfully denied, as well. It's clear that I still qualified from STD and Aetna refuses to pay. My surgeon supported me by writing a letter to AETNA, explaining I was not released back to work and that an error was made. Aetna refuses to accept my surgeons limitations and has terminated my STD 6 weeks early. When I was terminated, I was on crutches and clearly unable to perform my job duties. I work as an ICU nurse and cannot have any kind of physical limitations. Aetna acknowledged that I was on crutches, and according to their policy, I clearly qualify for disability, yet they terminated me and denied my appeal.Desired Settlement: I want them to pay the 6 weeks of STD that I qualified for.

Business

Response:

Thank you for your inquiry received on December 05, 2014, regarding complaint # [redacted] for [redacted]. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

Review: I gave birth to my son, [redacted], on 11/13/2013. From the time of the first doctor visit of my pregnancy through the months leading up to the delivery date, my husband and I called Aetna on several occasions in an attempt to gain proper expectations for the billing that we would be incurring. It was very concerning (and quite confusing) that we would seem to get different info and estimate amounts each time we called during the pregnancy, however what we have dealt with since the birth has been far more frustrating.

Starting around a week after our son was born, we began receiving a number of doctor bills and continued to notice inconsistencies on what was being covered on each bill, what was being applied to our deductibles, what was being considered in-network and how much we were being expected to pay. Furthermore, when calling the billing parties to discuss these matters, we were usually told that we needed to contact Aetna directly as the errors were on their end. When we would then contact Aetna, the explanations varied depending on who we spoke with and the specific area of concern that day, but we were typically lead to believe the issues would be resolved. As it pertains specifically to the in-network issue, we were told numerous times by Aetna that any out-of-network provider that the hospital used during the labor/delivery would be billed as in-network since the hospital itself was in-network and we wouldn’t always have a choice of a specific provider. A couple of examples referenced were the anesthesiologist used to administer an epidural or even the lab where bloodwork was sent.

In addition to the issues referenced above, we specifically remember asking Aetna as early as January of 2014 if it was safe to assume all claims related to the delivery had been processed because we were concerned more new doctor bills might still show up. While Aetna indicated we should have received all related bills at that time, we have been getting new bills almost monthly that are still dating back to the delivery. Note these are not the same bills being sent to us numerous times or past-due notices, but actually brand NEW bills with charges that we had not seen before. The latest NEW bill came to us on 10/5/2014, nearly 11 months after our son was born!

While we received a number of estimates from Aetna leading up to our son’s birth, what we have been billed for (and in many cases already paid to avoid collection) is far beyond what we were lead to expect. Unfortunately, with the amount of bills that we have received and still continue to receive, trying to figure out exactly what issues within each claim were mishandled has become increasingly frustrating and almost impossible.

Please also note, that each time I've attempted to submit this message on Aetna's site the following error message has come up. "We are unable to submit your message at this time. Please copy any information that you may have entered and try again later."Desired Settlement: We are asking that a supervisor or escalation team please assist us in clearing up all of these matters. As a first step, we are hoping this person or team can assist with a full line-by-line review of each of our bills related to the pregnancy and delivery to determine exactly where these processing issues may have occurred. Please realize that we have been paying every bill to avoid collections despite the fact that we don't believe we should be responsible for the amounts in many cases. While there are legal avenues and services we could utilize to escalate this matter further, we are hoping Aetna can finally give us the level of support that we need.

Business

Response:

Thank you for your inquiry received on December 02, 2014, regarding complaint #[redacted] for [redacted]. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

Review: I became employed with [redacted] and thus was given benefits as of September 7th, 2014. [redacted] gave me benefits through Aetna, the same health care provider I had through [redacted]. For the period of 9/7 through 9/30, I was double covered for exact same coverage for the exact same people.

I am getting the run around as to how to get my money back for the double coverage.

I have talked with countless benefits folks at Aetna, [redacted] and [redacted]. Everyone points to the other one as the one to provide the reimbursement. Ultimately, Aetna was paid twice for the exact same service. I logged into Aetna's site and was not informed I had two almost identical policies until October when the system's caught up. At that point I called in and was told I could only cancel my [redacted] policy in that month, which by than was October. If Aetna did not realize that they were double covering me until October, than why should I be penalized for this by paying twice.

Please let me know what process I need to go though to get reimbursed for the portion of September where I was paying twice for the same service.Desired Settlement: I would like to be refunded/credited for the portion of September in which Aetna was covering me twice for the same service for the same people.

Business

Response:

Thank you for your inquiry received on 10/23/2014 regarding a refund or credit for the month of September in which Aetna has two active policies for [redacted]. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

We reached out to both [redacted] and [redacted]’s eligibility department for assistance. Based on [redacted]’s review they determined that the member was covered beginning 01/01/2014 moved to [redacted] on 02/08/2014 and that policy terminated on 09/30/2014. After [redacted]’s review they have confirmed that coverage became effective on 09/01/2014 to current, for Ms. [redacted]. Even though both companies carry Aetna for their insurance and the policies may be similar, they are two different companies with two different policies and the member would be responsible for both premiums for the month of September with no refund or credit.

We regret that our response cannot be more favorable and apologize for any difficulties this situation has caused. We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Ms. [redacted]’s concerns. If you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted].

Consumer

Response:

This is a completely unacceptable response. You have not even gotten the basics of this case correct.

Review: I am seeking y $70 reimbursement for a doctor's appointment co-pay and prescription purchased.

I recently went to the Dr. and was prescribed a particular medicine. I called Aetna to see if the medicine was fully covered under my health insurance plan, which I was told it was. I was also told that my co-pay for the doctor's visit was also covered and that I would need to file a form for reimbursement for the co-pay I had already paid. Later, I went to pick up my prescription from the pharmacy and was told I had to pay $50 for the prescription. Knowing that multiple Aetna representatives had told me that I could get the prescription for free, I didn't pay for it then and left the pharmacy empty handed. I've had issues with Aetna previously when paying for meds, so this was no surprise to me. I called Aetna again and was told that yes the prescription should be free to me, but that I would have to purchase the prescription for $50 and send in a form for reimbursement for the meds and for the doctor's appointment ($20). I asked the representative to help me find the correct forms, which they did. A week or so has passed and now I am ready to send in the forms after collecting receipts I had lost from my pharmacy and doctor's office. I called Aetna again just to make sure I had the correct forms and was told that my prescription was not covered by Aetna because it is a name brand. However, Aetna will cover my $20 co-pay for the doctor's appointment. After speaking with this agent for a while I explained that previously I was told it would be covered so I don't understand why I am receiving different information now. This agent connected me to the "pharmacy" where I was hung up on. I called again and spoke with another agent who immediately hung up on me after hearing me explain that I wanted to speak with someone higher up, because I have been receiving false information from Aetna agents who don't know what they are talking about. I have receipts to prove all of my purchases and expect to be refunded for the full $70 amount.

I am now aware that your policies state that you don't cover for name brands, but that is not what I was told originally and that is the reason I went ahead and paid $50 for what I thought would actually be free! I expect the full $70 to be reimbursed. I am tired of dealing with Aetna agents who are lacking education on basic policies and regulations. The customer service is horrible and no longer have the patience to deal with agent's who feel it is ok to just hang up on people.Desired Settlement: I am seeking $70 reimbursed to my debit card.

Business

Response:

Thank you for your inquiry received on November 19, 2014, regarding complaint # [redacted] for [redacted]. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

Review: I had A long term Disability claim with Aetna which I was able to Close on 08/28/2015 . on 08/29/ 15 they placed me into collection with a company call [redacted] without any notification I called Aetna to have them remove the collection so I could start the repaying the over payment amount. I was rudely accused by the service Manager Darlen W[redacted] of making threats because she couldn't answer my questions and used this as a form of getting me off the phone. Aetna Had originally placed my account on hold while the case manager Jasmine W[redacted] investigated the documentations. I am asking Aetna to remove the collections Actions Against me they are unfairly ruining my credit.Desired Settlement: Have The Business Contact me,And Have Ms Darlene W[redacted] Apologize for her accusations.

Business

Response:

Thank you for your inquiry received on 09/01/15 regarding complaint #[redacted] for [redacted]. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

Review: Date of service 3/25/15 Dr [redacted] I was billed as OUT OF NETWORK. HE IS IN NETWORK.

I have contacted both [redacted] and the person in charge of physician contracts and Aetna and ONLY THE FORMER has informed me that there is no way that they could submit a tax ID number from [redacted]. Aetna has never resolved the issue. They allege that Dr. [redacted] is not an in network provider which contradicts the signed contracts and Aetna's own records. This is what they wrote me on 7/10/15:

"We received your inquiry

The claim we received was billed under the [redacted] tax

identification number (TIN). Our records indicate that John [redacted] is

not contracted under this TIN."Desired Settlement: Aetna MUST adjust the OUT OF NETWORK CHARGES DEDUCTIBLE($285.80)already made and place them into the IN NETWORK CHARGES DEDUCTIBLE AND REFUND MONIES I HAVE PAID NEEDLESSLY, something like $41.12 AND cancel the balance they reported to Eisenhower that they say I owe [redacted], $46.93.

Business

Response:

Dear Ms. [redacted],

Please see our response to complaint #[redacted] for [redacted] that was received by us on July 15, 2015.

We contacted our Medicare department and asked them to review Mr. [redacted] concerns. They advised that the claim submitted by Dr. [redacted] for March 25, 2015, was processed correctly. Dr. [redacted] billed the claim with a nonparticipating tax identification number (TIN), which does not accept the Aetna Medicare PPO plan. Dr. [redacted] is participating under a different TIN than the one used on the claim. However, we cannot tell providers how to bill their claims. The Medicare department sent Mr. [redacted] a letter on August 04, 2015, which includes a detailed explanation of their review and his next steps.

I apologize for any difficulties this situation has caused Mr. [redacted]. We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Mr. [redacted] concerns. If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted]

Regards,

Executive Resolution Team

Consumer

Response:

Review: [redacted]

I am rejecting this response because: I contacted [redacted] Billing today 3 times, was put on hold each time and then an automated message asked that I leave my name and number. I have already, months ago, contacted the person in charge of physician contracts and TIN numbers and she assured me that the matter would be resolved. Her name is [redacted] and her number is [redacted]. I spoke to her and her office at least twice beginning in April. She assured me that Dr. [redacted] has ONLY ONE TIN.Aetna on both occasions was cited as having made the error since Eisenhower does not even have the TIN Aetna claims to have used.

Sincerely,

[redacted] NAME CORRECTION PLEASE NOTE

Review: My son was born October 11, 2011, and at the time, my wife and I were covered by AETNA's health insurance through my employer at that time. Throughout the year 2011, we racked up more than enough medical bills including my son's birth to more than meet our maximum out of pocket expense for the year. However, we are STILL getting bills pertaining to my son's birth that ask us to pay more money. We now have a collection agency after us, and I'm not able to refinance my mortgage. I'm at the point where I feel like I have no other choice than to pay part of AETNA's share just so I can move on with my life. I have gone around and around with AETNA to try to get them to take care of it with the hospital, and no one is willing to help us. I have sent them copies of bills. I have sent them copies of the payments we have made. I took the matter all the way to their Executive Resolution Team, who is no longer responding to me.

Desired Settlement: I just want them to provide the service for which I paid during the time when they were my insurance provider. I paid the amount that I should have been required to pay. I paid my monthly premiums. All I ask is that they hold up their end of the bargain. If they want to fight the hospital on what the hospital is charging, by all means, go ahead. But I shouldn't be charged more than the agreed-upon amount. They need to pay their share and show a little urgency.

Business

Response:

Business Response /* (1000, 5, 2013/05/21) */

Thank you for your inquiry received on May 7, 2013. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.

We reached out to the Claims department for assistance with the member's concerns. The Executive Response Team received a complaint on April 3, 2013 from Mr. [redacted], about his claims. A response letter was sent to Mr. [redacted] on May 3, 2013. The Claims department reviewed the issue again and advised before adding the baby in October 11, 2011, the member had two people coverage with $1,600 deductible and $3,100 out of pocket (includes deductible). When the baby was added to the policy on his date of birth, the member moved to a family plan with the $2,000 deductible and $4,000 out of pocket. The deductible of $204.49 and $500.00 coinsurance was applied to the baby claim correctly. The $2,000 deductible and $4,000 out of pocket was met with [redacted]'s hospital claim.

We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the chance to address these concerns. If you have any more questions about this particular matter, please contact the Executive Resolution Team at [redacted].com.

Review: Aetna paid my obgyn bill from last year. Then decided to take the money back a year later claiming that I did not have coverage.

Aetna took money back from my obgyn [redacted] a year later. I got a bill in the mail from my doctors office saying that I owed $88.00. So I called and that when the billing lady [redacted] ###-###-####.. said that Aetna took their money back a year later claiming that I had no coverage. Well I called then and they are saying that it doesnt show in their system that they took the money back. Please help me! They did this to me one another claim recently. But praying that the other claim gets paid.Desired Settlement: I want them to pay what they owe my Obgyn $ 88.00.

Review: In July of 2014, I had Aetna insurance. I asked if [redacted] was a covered service provider, and Aetna customer service told me it was, and that I would be reimbursed the full amount if I bought from [redacted] and sent Aetna the receipt/invoice. After I did all of these things, Aetna told me that my service had been canceled shortly before due to the [redacted], but that I could pay for one more month with Aetna (for $78) in order to have $100 for my contact lenses (rather than the full amount, as previously promised) reimbursed. I accepted these terms and paid the extra $78. I called Aetna more than five months later to ask when I could expect to receive the $100 check they had promised to send me, and was told that my deductible was applied to out-of-network coverage because [redacted] was not a covered provider, even though I had previously been told it was; because of this, I was told that Aetna would not send me the refund they had promised. I have been given false information by Aetna several times, which has resulted in unnecessary and fraudulent charges.Desired Settlement: I wish for the original cost of the contact lenses to be reimbursed to me. If this is not possible, I feel I should at least be reimbursed the $78 that I was charged for the extra month of coverage that did not provide the benefits I was promised. Aetna should have all of the paperwork that I sent to them, including copies of the invoice/receipt for the contact lenses that I received from [redacted] when I received the lenses I had ordered. I received a rebate from [redacted] along with the contact lenses themselves and I informed Aetna of this when I first mailed them my invoice/receipt, to allow them to reduce my own reimbursement by that amount. If the amount of the rebate is deducted from the cost of the contact lenses to be refunded to me (not the $78 for the additional month of coverage), I will be satisfied.

Business

Response:

Please see our response to the complaint # [redacted] for [redacted] received on January 16, 2015.

Review: I filed a previous claim with the Revdex.com #[redacted] which is now closed. Here is the response from Aetna: MESSAGE FROM BUSINESS: Please see our response to the complaint # [redacted] for [redacted] received on December 18, 2014. Based on our review; we have found that our previous decision was correct. Unfortunately, we cannot make an exception to pay the claim, the member was advised that the [redacted] appliance would be considered as a medical expense, however, [redacted] treatment can be covered under her medical plan only if medical necessity is proven; otherwise [redacted] appliances are excluded from coverage. We take customer complaints very seriously. If you or the member has any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted]. However, when I emailed the Executive Resolution Team at the above email address--they never responded. I emailed them with additional documentation on January 23, 2015 and I have not received a reply after 7 days. I would like them to respond to my email with the additional information!Desired Settlement: I would like Aetna Executive Resolution Team to respond by email to my email sent on January 23, 2015. My email address is [redacted]

Business

Response:

Please see our response to the complaint # [redacted] for [redacted] received on February 03, 2015.

Based on our review, we have found that our previous decision cannot be changed. Unfortunately, we cannot make an exception to pay the claim. We must administer the plan as written in the plan document. Please refer to an excerpt from the Associate Handbook, in the chart on page 21, which states:

“Services for the disorder of the [redacted]

In network

Plan pays 100% of covered services after applicable office visit copayment if performed in physician’s office; otherwise, Plan pays 80% of covered services after deductible when medically necessary; excluding crowns, inlays, bridgework and appliances

Out of network

Plan pays 60% of covered services after deductible when medically necessary; excluding crowns, inlays, bridgework and appliances”

We are also showing a final appeal on file, under case #[redacted], that was upheld explaining the same determination. This plan does not cover crowns, inlays, bridgework and appliances related to TMJ. In the final appeal decision letter, we outlined that if [redacted] did not agree with the decision to contact the Employee Benefits Security Administration at[redacted]

We take customer complaints very seriously. If you or the member have any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted]

&n

Review: In 2014 I had Part D Rx coverage with [redacted] and change effective Jan 1, 2015 to Atena Insurance[redacted]. I take several different medicati

and now both Part B Health Plans are stating I have no insurance coverage for my medications and on 1/3/2015 I paid my co payment to[redacted] and no one received the co payment of $116.00. I cannot be without my heart and diabetic medications and[redacted] saids I have Atena and Atena saids I have [redacted]. Now, [redacted] said I have no insurance coverage. I will die without medications and I have called all day these two health plans and gotten no where. Can you please help me find out who is my Part D health plan.Desired Settlement: Coverage by one of these health plans.

Business

Response:

Please see our response to the complaint # [redacted] for [redacted] received on January 12, 2015.