Chevron USA, Inc.

Dear [redacted]
Please
see our response to complaint #[redacted]or [redacted] that was received by us on February 24, 2016.
During our review, we reached out to
our Benefit’s department to address [redacted] concerns. It was determined
that the claims in question were processed correctly in accordance to the
member’s plan benefits. As a member of Aetna, the member or their authorized
representative has the right to file an appeal about coverage for service(s)
when the member is not satisfied with the original coverage decision. Appeals
can be filed in writing to Aetna or by calling Aetna’s Member Services Unit at
the number on the member ID card.
While we understand the member’s concerns
and recognize this is not the resolution [redacted] sought, our decision
remains unchanged. Our actions are solely guided by the plan guidelines in
order to administer fairly and equitably to all participants.
I
apologize for any difficulties or confusion this may have caused [redacted] 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 there are any additional questions regarding this particular matter, please
contact the Executive Resolution Team at [redacted]
Regards,
Julian
C[redacted]
Executive
Resolution Team

Hello,
Thank you for your inquiry, regarding complaint # [redacted] received on 09/23/15 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 contacted our Provider Network...

department and confirmed that this provider is contracted with Aetna. [redacted] applied for credentialing in [redacted] on 11/06/14. The provider was credentialed and approved on 12/26/14. A contract was not sent to this provider until 02/26/15. The provider countersigned on 03/02/15. Based on our review, we will approve the contract as of 01/01/15 to cover the multiple rejected claims on file. We will submit a claims project to reprocess the claims. We have contacted this provider to confirm our findings. We will also terminate the [redacted] service location once we confirm with the provider.
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].
Thank you, LaShonda C. Executive Resolution Team

Dear [redacted]Please see our response to complaint # [redacted] for [redacted] that was received by us on November 7, 2017. 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 contacted...

our Marketing department to address [redacted] concerns. We confirmed that the card was shipped on 11/2/17 and it takes about 5-7 business days to receive. Please note that the card arrives in a plain white envelope from our vendor. 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 there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted]Sincerely,LaShonda C.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]

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] I have sent an email to Aetna as suggested. I'm hoping this can be resolved without further detriment to my credit. Thank you for your assistance in this matter.

Complaint: [redacted]
I am rejecting this response because: I went to the doctor and asked for a preventative care yearly physical. I was told that all tests done were common tests done for preventative care and nothing more.Aetna claims "The benefit states that for diagnostic services billed at a participating lab, 100% is allowed after a $5000.00 deductible is met. The member is responsible for $64.44," but that is simply not true.  Preventative care is 100% covered (I've included an attachment which is highlighted to show this), not 100% - $64.44.Check the tests done vs all common preventative care tests and you will see that nothing out of the ordinary was done. This is insulting that I go for my free 100% covered preventative care annual physical and come out having to pay extra for it even though this is what I pay every paycheck to receive.If everything is not 100% covered in an annual preventative care yearly physical, then we should be notified of this upfront, not after we go to the doctor and have it done. This seems like a bait and switch practice to trick us into getting Aetna insurance only to later find out we are not getting what was promised to us. Had I known I would have to pay out of pocket on top of my regular payments, I would have gone to another provider. Make this right and give what was promised.Sincerely,
[redacted]

Hello,
Thank you for your inquiry, regarding complaint #[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 our Eligibility department and...

requested the policy be terminated per the member’s request as of December 31, 2015. Our records indicate that the policy reflects terminated as of December 31, 2015, and we have also approved the premium refund. Please allow 2-3 business days for the $248.42 refund to be electronic deposited in the member’s bank account.
Please accept my apology that we did not provide the level of service that you rightfully expect and deserve, and my assurance that your concerns are getting the highest level of attention at Aetna. I would also like to thank you for sharing your experience with us. It is feedback like yours that helps us address issues and prevent them from reoccurring.
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]
Thank you,
Ashley S.
Complaint and Appeal Consultant
Executive Resolution Team

Dear [redacted]: Please see our response to complaint #[redacted] for [redacted] that was received by us on December 6, 2017.  Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you. Upon receipt of the member’s policy...

information, it was found that this member’s plan is administered through [redacted], an Aetna company.  We reached out to the [redacted] area to assist with our investigation. It was found that the precertification for the procedures involved had been initiated as a routine or screening procedure, but after the clinical information was reviewed the precertification was approved for the diagnostic procedure. However, when the claims were submitted they were billed as routine.  Also, the benefit for these procedures when done as routine in nature does not begin until the age of 50.  The resolution of this issue would require that the providers of the services submit corrected claims as diagnostic.  The Member Advocacy department of [redacted] has been involved and will be contacting the providers of the services.  Once full resolution is obtained, additional outreach will be made to [redacted].  We regret any frustration or inconvenience 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 [redacted]s concerns.  If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted]   Regards, Chris B. Complaints and Appeals Consultant Executive Resolution Team

Complaint: [redacted]
I am rejecting this response because:Our coverage is supposed to be effective January 1, 2016.  I need this resolved ASAP.
Sincerely,
[redacted]

[redacted]   Please see our response to complaint #[redacted] for [redacted] that was received by us on August 31, 2016.  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 our Pharmacy department to have the member’s concerns reviewed. We were advised that on August 29, 2016 the member’s pharmacy submitted the prescription and it rejected due to his age. A pre-certification was required by the plan and on August 31, 2016, the pre-certification request was received and approved the same day for a one year period for both strengths.   An override was entered effective for a one year period: August 31, 2016, through August 31, 2017, and it included both strengths of the medication. On August 31, 2016, the pharmacy submitted two claims, one for each medication strength. Both were paid and the member is being charged the generic $15 copay per strength dispensed, which is correct - a copay per dispense is the contracted benefit. Our Social Media Resolution Team contacted the member on September 01, 2016, to notify of him directly of the resolution.   Aetna takes seriously the responsibility to ensure that pharmaceuticals are dispensed timely and accurately, realizing that a member’s health and well-being can be dependent on their medication.  We strive to provide the highest level of service and satisfaction for our members, and I sincerely regret that the member did not receive the service he should rightfully expect and deserve.   We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Mr. [redacted].  If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted]   Sincerely,   [redacted] Complaint 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 contacted our Dental Claims department to confirm the member's orthodontic benefit. The total fee billed by the provider was $3716.00. Based on the dental plan benefit, it is to allow 50% which is $1858.00. Based on previous claims, we have already paid a total of $1644.87. The remaining balance due was $213.13. A check for this amount was mailed to your provider on April 22, 2016.Please accept my apology for the delay in processing the claim correctly, and the multiple attempts on your part to resolve your issue. We have provided feedback regarding your customer service concerns.  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] Thank you, LaShonda C.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.    However, I am still waiting for the confirmation of the payment to the provider and the EOB to show that the 2 claims in Oct have been paid in full by Aetna.    I want to make sure that the EOB confirms what Aetna has agreed to do.
Sincerely,
[redacted]

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]

Dear Ms. M[redacted]   Please see our response to complaint #[redacted] for J[redacted] that was received by us on July 27, 2016.  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 our Enrollment and Eligibility department to have the member’s concerns reviewed. We were advised that the member’s employer submitted the coverage request for [redacted]s and his wife on June 28, 2016, and requested that the coverage’s effective date be May 01, 2016. Since we did not receive the request until the end of June that is why there was a delay in receiving ID cards; which were mailed to the member on July 08, 2016. We did confirm that the employer requested the plan be terminated effective July 31, 2016.   If the member and his wife had services rendered within that timeframe the policy was effective they can have their providers submit claims for consideration under the plan. The member is also able to request an itemized bill and bill the insurance directly if any payments were made out of pocket.   Unfortunately, Aetna is only an administrator of the plan and has no control over the plan, when it is created and/or terminated, and what the premium is that is being billed to the member. The member will need to contact the Human Resource department of the employer and request the refund of the premiums and discuss why he and his wife were enrolled without their permission. We do not have access at Aetna to any of this information to assist the member any further.   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]
* Sincerely,   Ashley W. Complaint and Appeals Consultant Executive Resolution Team

Hello,
Thank you for your inquiry, regarding complaint #[redacted]
for Roy Freese. 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
our Eligibility department...

to request a review of the member’s policy on file. We
were advised by the member's employer, [redacted], to terminate the
policy. The member would need to follow up with their Human Resources
department regarding this issue, as Aetna is only an administrator of the plan
and does not control termination requests. I apologize for the inconvenience
and difficulty this situation has caused the member.
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 [email protected].
 
Thank you,
Ashley S.
Complaint and Appeal Consultant
Executive Resolution Team

Dear [redacted]:   Please see our response to complaint #[redacted] for [redacted] that was received by us on May 29, 2018.  Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.   Upon receipt of the...

member’s concerns, we immediately reached out to a representative. They researched this issue and have provided a response. The member’s wife said that her husband had [redacted] surgery on May 18, 2018. She said he was released from the hospital to an inpatient rehabilitation center and taken to one that was not the location that was agreed to.   After review, it seems we received this notification after the issue was resolved. We originally approved for the requested location of [redacted], and we never changed the admission to [redacted]. It appears there was a misunderstanding in the transfer from the hospital. The member has resolved the issue by checking themselves out of the incorrect location and readmitting to the correct one. Aetna has no record of a denial.   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 there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted]   Sincerely,   Michael H.                        Sr. Complaint and Appeal Analyst 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.
This member’s claim was processed and finalized on September 5, 2015. The member’s explanation of benefits was also mailed to the home address on file that day and is available for review on their Aetna Navigator account. The provider has been paid for the services and the member is only responsible for a copay.
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]
 
Thank you,
Ashley S.
Complaint and Appeal Consultant
Executive Resolution Team

Dear Ms. [redacted]:   Please see our response to complaint #[redacted] for [redacted] that was received by us on December 14, 2017.  Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.   Upon receipt of the provider’s complaint I reached out to them directly to obtain additional information. After speaking with the provider, I confirmed they received a call from Aetna’s Recovery department who was able to resolve their concerns. The provider had no additional concerns at this time.   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 there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted].   Sincerely,   Kim B. Complaint and Appeals Consultant Executive Resolution Team

I do not accept the response made by the business to resolve this complaint I did in fact send them copies of the money orders they stated they did not receive.

Hello,
Thank you for your inquiry, regarding complaint #[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 our [redacted] department to have...

the member’s concerns reviewed. We were advised by the [redacted] department, that The Annual Notice of Change (ANOC) and Explanation of Coverage (EOC) The Centers for [redacted] & [redacted] require us to send a combined ANOC and EOC mailing each year. The ANOC describes the changes to the members plan for the upcoming plan year. The EOC is the actual contract that provides the members plan benefits and guidelines. All of our booklets and mailings are approved by [redacted] and are written according to [redacted] guidelines.
We reviewed the members ANOC/EOC and found the following: Page 54 states: Hospice
The member may receive care from any [redacted]-certified hospice program. The member is eligible for the hospice benefit when their doctor and the hospice medical director have given the member a terminal prognosis certifying that the member is terminally ill and has 6 months or less to live if the members illness runs its normal course. The member's hospice doctor can be a network provider or an out-of-network provider.
Covered services include:
- Drugs for symptom control and pain relief
- Short-term respite care
- Home care
For hospice services and for services that are covered by [redacted] Part A or B and are related to the members terminal prognosis: Original [redacted] (rather than our plan) will pay for hospice services and any Part A and Part B services related to the terminal prognosis. While the member is in the hospice program, their hospice provider will bill Original [redacted] for the services that Original [redacted] pays for.
For services that are covered by [redacted] Part A or B and are not related to the terminal prognosis: If the member needs non-emergency, non-urgently needed services that are covered under [redacted] Part A or B and that are not related to the terminal prognosis, the cost for these services depends on whether the member uses a provider in our plan’s network:
-If the member obtains the covered services from a network provider, the member will only pay the plan cost-sharing amount for in-network services
-If the member obtains the covered services from an out-of-network provider, the member will pay the cost-sharing under Fee-for-Service [redacted] (Original [redacted])
When a member enrolls in a [redacted]-certified hospice program, their hospice services and their Part A and Part B services related to their terminal condition are paid for by Original [redacted], not Aetna [redacted] Select Plan (HMO).
Hospice consultations are included as part of Inpatient hospital care. Physician service cost sharing may apply for outpatient consultations.
Aetna Compassionate Care Program This program offers case management and services to members and their families who are managing the complex and emotional issues involved in advanced illnesses. A nurse case manager by the name of Sue L. will be in contact with you.
We strive to provide the best customer service experience possible and we expect that in all of our departments. We have reviewed your concerns and verified the calls made into our Member Services. We forwarded the issue to the representative’s direct supervisor for education and/or re-training.
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.
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].
Thank you,
Ashley S.
Complaint and Appeal Consultant
Executive Resolution Team