Complaint: ***
I am rejecting this response because: Altius posted information on their website stating that preventive care and child eye exams were covered, then denied payment based on criteria that were not readily availableThis is deceptive and misleadingIt would not have been difficult for Altius to disclose this criteriaIf they could list levels of coverage on the Summary of Benefits, why couldn't they list the two Tier levels? If they could write "If your child needs dental or eye care" why couldn't they write "if your child under needs dental or eye care"? The plans under the ACA were highly touted for covering preventive care and covering members' children up to age They didn't mention that plans would create loopholes to prevent paying for these basic servicesI regret paying over $to Altius and getting not a single penny in healthcare coverageI have also reported their questionable practices to the Utah insurance department
Sincerely,
*** ***
Dear
Revdex.com Complaint Department,
Please
see our response below to the additional concerns reported in complaint # *** for ***
*** that were received by us on December
15,
Upon
our review, it was found that the preventive care claims that were in dispute
for Ms*** have been adjusted and we have paid percent of the allowed
charges. The decision to allow the
claims as if they had been with Level One providers was made during the review
of the case sent by the Utah Insurance Department.
The
denial of the claim for routine vision services for her dependent was upheld as
there were no discrepancies found between the plan documentation and the
benefit for the service. Routine vision
services are only covered through the age of 18. While a person may be covered as a dependent on a policy under their parents through the age of 25, once they reach the age of they are no longer
considered children and are not eligible for the pediatric vision care benefit
mandated by the Patient Protection and Affordable Care Act
The
Outline of Coverage, which is attached to this response, gives additional information
for both benefits in question. The
Summary of Benefits and Coverage that Ms*** is reviewing is intended only
as a summary and has a disclaimer stating the same.
We
take customer complaints very seriously and appreciate you taking the time to
contact us and giving us the opportunity to address Ms
***’s concerns. If you have any
additional questions regarding this particular matter, please contact the
Executive Resolution Team at ***@aetna.com
Regards,
Chris
B***
Complaints
and Appeals Consultant
Executive
Resolution Team
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 reviewed the member’s Evidence of Coverage (EOC)...
and Summary of Benefits Coverage (SBC) to verify the benefits. We confirmed that the EOC states that a deductible and coinsurance apply to tier two providers for any Preventive Care / Screening/Immunization services rendered. The SBC provided online is a short summary of the benefits that is not able to distinguish tiers. There is a disclaimer at the top of the SBC that states: “This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at http://altius.coventryhealthcare.com/ or by calling ###-###-####.” We assure you that it is not our intent to mislead or misrepresent any benefit that may or may not be available under your health plan. We have attached the EOC for the member to review.
We had our Claims department review the claims and were advised they are processed correctly under the member’s tier 2 benefits, so we will not be able to have the claim adjusted. We also reviewed the son’s claim and the services were denied correctly as not covered under benefit plan. The member is of the age of 19 and the plan does not cover routine eye exams for adults; the member only has coverage for pediatric vision less than 19 years of age. I understand your concerns and recognize this is not the outcome you desired. Our actions are solely guided by the plan guidelines in order to administer fairly and equitably to all participants.
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]@aetna.com.
Thank you,
Ashley S.
Complaint and Appeal Consultant
Executive Resolution Team
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and find that this resolution is satisfactory to me.
Sincerely,
[redacted]
Complaint: ***
I am rejecting this response because: Altius posted information on their website stating that preventive care and child eye exams were covered, then denied payment based on criteria that were not readily availableThis is deceptive and misleadingIt would not have been difficult for Altius to disclose this criteriaIf they could list levels of coverage on the Summary of Benefits, why couldn't they list the two Tier levels? If they could write "If your child needs dental or eye care" why couldn't they write "if your child under needs dental or eye care"? The plans under the ACA were highly touted for covering preventive care and covering members' children up to age They didn't mention that plans would create loopholes to prevent paying for these basic servicesI regret paying over $to Altius and getting not a single penny in healthcare coverageI have also reported their questionable practices to the Utah insurance department
Sincerely,
*** ***
Dear
Revdex.com Complaint Department,
Please
see our response below to the additional concerns reported in complaint # *** for ***
*** that were received by us on December
15,
Upon
our review, it was found that the preventive care claims that were in dispute
for Ms*** have been adjusted and we have paid percent of the allowed
charges. The decision to allow the
claims as if they had been with Level One providers was made during the review
of the case sent by the Utah Insurance Department.
The
denial of the claim for routine vision services for her dependent was upheld as
there were no discrepancies found between the plan documentation and the
benefit for the service. Routine vision
services are only covered through the age of 18. While a person may be covered as a dependent on a policy under their parents through the age of 25, once they reach the age of they are no longer
considered children and are not eligible for the pediatric vision care benefit
mandated by the Patient Protection and Affordable Care Act
The
Outline of Coverage, which is attached to this response, gives additional information
for both benefits in question. The
Summary of Benefits and Coverage that Ms*** is reviewing is intended only
as a summary and has a disclaimer stating the same.
We
take customer complaints very seriously and appreciate you taking the time to
contact us and giving us the opportunity to address Ms
***’s concerns. If you have any
additional questions regarding this particular matter, please contact the
Executive Resolution Team at ***@aetna.com
Regards,
Chris
B***
Complaints
and Appeals Consultant
Executive
Resolution Team
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 reviewed the member’s Evidence of Coverage (EOC)...
and Summary of Benefits Coverage (SBC) to verify the benefits. We confirmed that the EOC states that a deductible and coinsurance apply to tier two providers for any Preventive Care / Screening/Immunization services rendered. The SBC provided online is a short summary of the benefits that is not able to distinguish tiers. There is a disclaimer at the top of the SBC that states: “This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at http://altius.coventryhealthcare.com/ or by calling ###-###-####.” We assure you that it is not our intent to mislead or misrepresent any benefit that may or may not be available under your health plan. We have attached the EOC for the member to review.
We had our Claims department review the claims and were advised they are processed correctly under the member’s tier 2 benefits, so we will not be able to have the claim adjusted. We also reviewed the son’s claim and the services were denied correctly as not covered under benefit plan. The member is of the age of 19 and the plan does not cover routine eye exams for adults; the member only has coverage for pediatric vision less than 19 years of age. I understand your concerns and recognize this is not the outcome you desired. Our actions are solely guided by the plan guidelines in order to administer fairly and equitably to all participants.
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]@aetna.com.
Thank you,
Ashley S.
Complaint and Appeal Consultant
Executive Resolution Team
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and find that this resolution is satisfactory to me.
Sincerely,
[redacted]