Chevron USA, Inc.

Dear [redacted]:   Please see our response to complaint #[redacted] for [redacted] that was received by us on May 25, 2018.  Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.   We had all the calls on file, prior to services being rendered reviewed, back to August of 2017 to confirm the information provided to the member. There was a call on November 06, 2017, where the member was inquiring about [redacted]. The representative advised the member that this place would be out-of-network for his plan. The member asked what providers would be considered in-network and the representative advised the following: o [redacted]
[redacted]
[redacted]    The member then also asked to verify if a provider was participating, [redacted] with [redacted], [redacted] The representative advised this particular provider does not participate with your plan; therefore, he is out-of-network for your plan. The member then asked to check his primary care physician to see if he was in-network, [redacted] with [redacted], zip [redacted]. The representative advised this provider was also out-of-network for the plan.   The member got upset and said he would have to change six of his providers and it wasn’t worth it to have to do all of that for this insurance. The member also asked for costs of out-of-network providers. The representative went over the out-of-network deductible and coinsurance rates, as well as the out-of-network benefits.   We are not able to release call recordings without a court affidavit. Our calls are recorded for training and quality purposes only. They will not be released to a member or an independent company to be reviewed.   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,   Ashley W. Complaint and Appeals Consultant Executive Resolution Team

Complaint: [redacted]
I am rejecting this response because: I did not complain about correspondence regarding policy options, as this dishonest "response" claims. I complained about the advertising junk mail they refuse to stop harassing me with, and I am prepared to Take further action if forced, and if they continue in their refusal to cease and desist. 
[redacted]

Revdex.com: Although Aetna's description of events in not nearly adequate, and is inaccurate. My broker and I have the supporting documents to prove it.The check did arrive today and therefore my overpaid premium funds have been restored.  Aetna has yet to address their horrible handling of the situation, their positioning of the phone system so that customer reps are not available to be reached and their unfettered access to grab whatever money they want out of customer's bank accounts.  It is definitely unethical and should be illegal. Customers should have the right to pay by check or [redacted]. At this time, since my money has been returned, (complaint ID [redacted]), this situation has been resolved.
Sincerely,
[redacted]

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 compliant we immediately reached out to our Health Savings Account...

(HSA) department to have the member’s concerns addressed. We were advised that prior to receiving this complaint the member’s account was already updated with the contribution for December 2015. We confirmed the member’s money was deposited on January 13, 2016, and an email was sent to the member on January 14, 2016, advising her of the deposit.
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 Ms. Stiles’ 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

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 to our
Eligibility department and also reached out to [redacted] to
confirm the coordination of benefits information (COB). We confirmed that the
policy was active through the employer until May 01, 2015, when the member went
to a [redacted] plan. I have listed below when each plan was primary and secondary:
February 09, 2015 through April 30, 2015-- [redacted] primary,
Aetna secondary
May 01, 2015 through August 15, 2015-- Aetna was primary
because [redacted] became the [redacted] plan
August 16, 2015, through October 31, 2015-- [redacted] is primary
because Aetna became the [redacted] policy, so it reverts back to [redacted] primary
The claims in question were after August 16, 2015, therefor
would need to be billed directly to [redacted] to be paid as primary before Aetna is
able to review as the secondary payer. We apologize for any inconvenience this
may have 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 [redacted]
Thank you,
Ashley S.
Complaint and Appeal 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 reached out to our Claims department to have a...

complete review of the member’s 2015 claims. We were advised that there were four claims on file for 2015, and only one date of service required reprocessing. This claim has been finalized and paid any additional money to the provider. All other claims were processed correctly, and were all processed in network.
Please accept my apology for the delay in processing your claim correctly. Unfortunately, in some instances, procedural errors do occur. When they do, we take them very seriously and do our best to understand how and why the errors occurred and determine what we can do to prevent a recurrence.  We continually use feedback like yours to improve our service and prevent issues from reoccurring.  
We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Mr. [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

Thank you for your rejection notice received on 09/14/15 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. 
We apologize for the inconvenience and difficulty this situation has caused you. Aetna strives to provide the highest level of service, quality, and satisfaction, and to continually improve our processes.  We regret that your experience was not a positive one. We 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.
Upon further review, all claims on file have been processed and finalized timely within 10-15 business days of receipt. If the member sees an out-of-network provider, the payment of the claim is going to be based upon a reasonable and customary rate, not determine by Aetna, and will pay the percentage of the allowable.
If there is a specific date of service in question that the member feels was not processed correctly or disagrees with the payment, the member may file an appeal in writing to:
Aetna- CRT Member Appeals [redacted]
The request should include:
Name, Aetna ID, date of birth, claim information (including date of service, billed amount, provider name), and your contact information.
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].

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 have the call pulled to verify the...

benefits that were provided to the member prior to services being rendered. We confirmed that the customer service representative (CSR) quoted that the procedure would be covered when you have a medical condition that covers/warrants the services. At the time the member had not been seen by the provider so was unable to provide the CSR with the diagnosis code to completely verify the coverage under the plan.
When the claims were submitted to Aetna they were denied as not covered based upon the diagnosis that was sent to us. As a one-time exception, we have reprocessed the claims for the two dates in October of 2015 to allow services rendered.
Please allow 7-10 business days for your provider to receive any payment made on the claims.
Going forward if the member wishes to seek these services the member or provider must call our pre-certification department to request a review be completed for coverage under the plan or the member could be responsible for any billed expenses.
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

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...

to have the member’s concerns reviewed. We confirmed that they reached out to the member’s university and the department was advised that the member submitted a waiver on December 31, 2015, but it was rejected as they were unable to verify – “Policy no longer active” – on this date the policy was not active as it was not effective until January 01, 2016. On January 08, 2015, the member contacted the university was able to verify the coverage and process the refund.

The university bills the student’s the insurance premium, the students do not pay Aetna directly. Per the university, they have processed the refund for the student the amount of the Spring insurance premium of $2,099.
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

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 prior authorization request and the...

appeal request. According to our records our pre-certification department was contacted by the provider on September 14, 2015, and the medical records were received by [redacted] on September 22, 2015. Our medical director reviewed the pre-certification request on September 22, 2015 and a determination was made that same day. We mailed a letter to both the member and the provider advising of the resolution on September 22, 2015, and we verified that the address on file for the member was the address the letter was mailed to.

The appeal request was made on November 27, 2015 by the provider on the member’s behalf. The first page of the appeal request included the pre-certification denial letter dated September 22, 2015, and at the top of the page the provider wrote received on September 30, 2015. The provider’s office was waited almost a month to request the first level appeal. The appeal was closed on December 07, 2015, in a timely manner and a resolution letter was mailed to the facility on the same day.
The member was advised of the resolution by a representative of [redacted] on December 10, 2015, and she also emailed the resolution letter. I understand your concerns and recognize this is not the outcome you desired. However, we must make coverage decisions in accordance with your plan of benefits and our medical necessity guidelines. The member and/or the provider can request another level of appeal by contacting our customer service department or sending a request in writing within 60 calendar days.
Concerning the customer service you experienced, our goal is to provide exceptional service to our customers, and immediately resolve issues when they do occur. I sincerely apologize for the frustrations and difficulties you experienced and that we did not provide the level of service that you rightfully expect and deserve. These actions are not consistent with [redacted]’s service standards and we appreciate you notifying us of your experience. We have addressed your customer service concerns directly with the representatives and supervisors who were involved.

We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Mr. [redacted]’s concerns. If you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted]@[redacted].com.
Thank you,
Ashley S.
Complaint and Appeal 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 reached out to our Claims department to have the...

date of service reviewed. We were advised that the member is not responsible for the billed charges because the facility failed to call the Pre-certification department in a timely manner. We confirmed that both the member and the provider’s explanation of benefits (EOB) state that the member is not responsible for the billed charges.
The provider did not call our pre-certification office within one day of discharge, so it will be their responsibility to file an appeal, not the member’s responsibility. We called the facility and left a voicemail with the billing department explaining that they should refer to their EOB which states they are to not balance bill the member. It also went on to explain that claim was denied due to failure to follow Aetna contractual notification requirements. We advised of the address they could send the appeal request to and left a call back number for any questions/concerns. We have also mailed another copy of the explanation of benefits to the provider for their records.
We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Mr. [redacted]’s concerns. If you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted].com.
Thank you,
Ashley S.
Complaint and Appeal Consultant
Executive Resolution Team

During our review, we reached out to our Enrollment department to address [redacted]’* concerns. However, [redacted]’s information was not found in our system which required [redacted] to be contacted.An outbound call was placed to [redacted] by our Enrollment department so we could address [redacted]...

[redacted] concerns. However, there was no answer from [redacted], so a detailed voicemail was left including the nature of the call and a direct call back number ###-###-####. This way [redacted] may call our Enrollment department directly so her concerns may be addressed.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]’s 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] for [redacted]. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you. Upon the receipt of your complaint, we reached out to the [redacted] on May 19, 2016 to discuss his concerns and we have decided to work with the member directly to resolve his issues. 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 you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at [email protected]. Thank you, Tanika K. Complaint and Appeal Consultant Executive Resolution Team

Complaint: [redacted]
I am rejecting this response because:  The doctor's office still has NOT been paid.
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]

Complaint: [redacted]
y.
I am rejecting this response because: Regardless of their policy there should Always be exceptions when it comes to NECESSARY dental work. Basically I feel Aetna has put their policy before my Health and safety. Was I just supposed to wait for their 1 year deadline as my teeth rot out ? I appealed through Aetna and they rejected that appeal.  and I just wanted to give them ample chance to repair the situation before going to less preferable means and causing negative publicity and cost much more in the long run but if that's that it takes to get them to do the right thing so be it.
Sincerely,
[redacted]

Thank you for your inquiry received on 08/12/15 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.
 
We had the phone calls reviewed from the member,...

and the member called and said that she was going to see an allergist today (06/02/15), and wanted to see if [redacted] was covered.  The Customer Service Representative (CSR) asked for the first name and the member said that she was unsure, but had the telephone number.  The CSR clarified that the doctor was an allergist, and the member confirmed.  The CSR then provided the in-network benefits, but did advise the member that this would be for an “in-network” provider, as they were unable to confirm participation of [redacted] without the provider’s first name. 
 
Currently, the member’s concerns are being reviewed under appeal number [redacted]. The member will receive a resolution letter with an explanation under separate cover.
 
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]

Hello,
Thank you for your inquiry, regarding complaint #11129221
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
our [redacted]...

department to have the member’s concerns addressed. We were
advised that the member’s concerns were reviewed and that a resolution letter
is being mailed to the member explaining their findings. If the member has any
additional concerns after reviewing the resolution letter, there is a contact
number and address he can send future concerns to.
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

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 contacted Aetna Student Health (ASH) Claims department to review her claims. We confirmed that the member’s plan has a $250 annual deductible per plan year. The plan renewal date is based on the academic year, not a calendar year. The plan renews on September 01, 2015, therefore the member’s deductible is renewed as well. The visit on July 07, 2015, was for an urgent care visit (sick visit) and was applied to the 2014/2015 plan year deductible in the amount of $224.58. The visit on December 07, 2015, was also an office visit (sick visit) and was applied to the 2015/2016 plan year deductible in the amount of $218.30. The member would be responsible for these amounts because her deductible had not been met. We apologize for the inconvenience this has 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 you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] LaShonda C.Complaint and Appeals Consultant Executive Resolution Team

Complaint: [redacted]
I am rejecting this response because:
Sincerely,
[redacted]