Chevron USA, Inc.

Complaint: ***
I am rejecting this response because: same reason as stated previouslyAll you (Aetna) are doing is putting your nose in front of a computer screen to get the informationNot calling your client (ME) regarding this issue is VERY unprofessionalWhen someone (ME) says that they only had Aetna btw this and this date that is exactly what I mean. Between the last rejection and this one, I called Aetna and I actually got BCBSNC phone number and called themApparently, when I called *** to cancel the policy back in January (dates run from 16th of month to 15th of the next) they have failed to do soThat caused all this craziness.You need to pay our claimsI am getting nasty letters from healthcare providers, because of something I have no control overWhen I use a new insurance, I always hand the healthcare provider the new cardSo, I don't see why and/or how messed this up
Sincerely,
*** ***

Dear Ms***,
Please see our response to complaint #*** for *** ** that was received by us on October 21,
Upon receipt of the complaint rejection, we immediately reached out to our Authorization and Claims departments and requested an exception to allow coverage for the applied behavior analysis claimsAn approval was issued to cover the affected claimsThe total additional payment is $Summary of the claims payment is **sted below:
• Claim# *** paid an additional $for a total of $
• Claim# *** paid an additional $for a total of $
• Claim# *** was reprocessed on September 25, and issued an additional amount of $for a total of $
I apologize for any difficulties this situation has caused Mr**We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Mr**’s concernsIf there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at ***
Regards,
Julian C***
Executive Resolution Team

Hello,
Thank you for your inquiry, regarding complaint #***
for *** *** 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 had all the
member’s records
reviewed including the phone calls to provider and member
services, the per-certification requests, and the appeal requestWe were able
to confirm that the provider sent a fax to Aetna with the per-authorization
request on October 08, 2015, and a letter was mailed back the same day advising
the provider we need a new request with the correct ICD codes, not ICD
codesOur records indicate that the provider did not fax the new authorization
request with ICD codes until October 29,
The per-certification department was contacted on October
22, 2015, by the provider’s office based upon a voicemail left by a customer
service representative (CSR) that called on behalf of the member on October 21,
The per-certification request was started the same day, October 22, 2015,
and the fax received October 29, 2015, was added to the authorization request
for review
The per-certification department has calendar days to
render a decision for the surgeryA decision was rendered on November 05,
2015, and a voicemail was left on same day with Jane in surgery at the facility
were services were to be renderedWe advised the office of their option of
appeal and that they could request a peer to peer be completedBoth the
provider and the member were mailed letters with the decision on November 5,
2015, with the appeal rights and next steps the member or provider could take
An appeal request was received by the member on January 20,
2016, and the case was resolved timely on February 04, within the
calendar days Aetna is allowed by law to resolve appealsThe member was mailed
a resolution letter on February 04, 2016, with the decision and her second
level appeal rightsThe provider to date has not appealed the servicesThe
member will be able to request a second level appeal within calendar days of
February 04, 2016, by calling customer service or sending the request to:
Aetna Customer Resolution Team
*** *** ***
*** ** ***
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 Aetna’s
service standards and we appreciate you notifying us of your experience. We have addressed your customer service
concerns directly with the representatives who handled your callsI
hope that going forward we will be able to regain your confidence in us
We take customer complaints very seriously and appreciate
you taking the time to contact us and giving us the opportunity to address ***
*** concernsIf you have any additional questions regarding this
particular matter, please contact the Executive Resolution Team at ***
Thank you,
Ashley S
Complaint and Appeal Consultant
Executive Resolution Team

Hello,
Thank you for your inquiry, regarding complaint #*** for *** ***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 back out to our Aetna’s Individual Plans and Eligibility department to have our records again and we have confirmed we do not have the copies of the money ordersWe sent an email to the member on August 12, 2015, requesting the member to send in copies of the money orders for our records but we have not heard back from the member as of todayI sincerely apologize for any inconvenience this has caused for the member
We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Mrs*** concernsIf you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at ***
Thank you,
*** **
Complaint and Appeal Consultant
Executive Resolution Team

Hello, Thank you for your inquiry, regarding complaint# *** for *** *** ***Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with youUpon receipt of your complaint, we contacted our Claims department and reviewed the file
We reviewed the claim and determined that the alternate benefit would applyWe confirmed that the provider did not call prior to the serviceThe provider also did not request a predetermination, which is recommended to any provider for a service that may require reviewThe member states she does not want the removable partial denture, and we don’t dispute thatWe are paying the cost of that service towards the one she wants; the bridgeWhen there are multiple missing teeth in the same area, Aetna will pay for the least costly service to address all the teeth at the same timeAny other treatment would be considered electiveAetna will pay for the least costly treatment, and that payment can be used towards the cost of the elective procedureWe apologize for any difficulties and inconvenience this has caused the memberWe take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address *** *** concernsIf you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at *** LaShonda CComplaint and Appeal Consultant Executive Resolution Team

Dear
*** ***
Please
see our response to complaint #***
for *** *** that was received by us on March 08,
During our review, we reached out to
our Benefits department to address *** *** concernsIt was determined that
under the plan, ultrasounds are not part of
the routine prenatal care and are subject
to the plan cost sharingThe claims in question were processed correctly
On the member’s plan, Routine prenatal or antepartum care
includes:
The initial
and subsequent history, Physical exams, Monthly visits up to weeks
gestation, Biweekly visits to weeks gestation, Weekly visits until delivery,
Post-partum visit (approximately days after delivery), Recording of weight, Blood
pressures, Fetal heart tones and Routine chemical urinalysis
On the
member’s plan, Items not considered preventive include (but may not be limited
to):
Inpatient
admissions, High Risk Specialist Visits, Ultrasounds, Amniocentesis, Fetal
Stress Tests, Certain Pregnancy diagnostic lab tests and Delivery including
Anesthesia
I
apologize for any difficulties or confusion this may have caused *** ***We
take customer complaints very seriously and appreciate you taking the time to
contact us and giving us the opportunity to address *** *** concerns. If there are any additional questions
regarding this particular matter, please contact the Executive Resolution Team
at ***
Regards,
Julian
C***
Executive
Resolution Team

Thank you for your inquiry, regarding complaint #*** for Joan H***Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with youWe contacted our Life coverage department to address the complainant concerns regarding a policy for ***
***. On May 10, we received the claims information and an Assignment of Benefits to ***l Funeral HomeWe allow up to 30-business days for claim processingThe claim was approved for payment and a check was issued in the amount of $on July 06, 2016.We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address *** *** concernsIf you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at ***LaShonda C.Complaint and Appeal Consultant Executive Resolution Team

Hello,
Thank you for your inquiry, regarding complaint #***
for *** ***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 member’s claims reviewedWe were advised
that they were processed incorrectly so we had both claims
reprocessed, and there is no patient responsibility on either oneThese are
Aetna providers so we are obligated to pay them directlyIf the patient was
charged for the entire visit, then the provider(s) would need to refund the
member directlyThe member and the provider will have new explanation of benefits in 7-
business days or within hours on Aetna Navigator
Please accept my apology for the
delay in processing the claims correctly. Unfortunately, in some
instances, procedural errors do occurWhen 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 *** *** concernsIf you have any additional questions regarding this
particular matter, please contact the Executive Resolution Team at ***
Thank you,
Ashley S
Complaint and Appeal Consultant
Executive Resolution Team

Hello,
Thank you for your inquiry received on July 31, 2015, regarding complaint #*** for *** ***. 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 Claims department regarding facility charges from June 11, We confirmed that Aetna has not received any claim from *** or any other hospital facilityWe contacted *** billing office on July 31, and spoke with *** who confirmed that the member did not provide his insurance card at the time of serviceThe provider explained that the member contacted their billing office on November 4, and provided the details regarding his health coverage
The provider confirmed that they have not billed Aetna for this date of service because they assumed it was past the timely filing limitTherefore, the facility would need to resubmit the claim to Aetna for considerationWe will review the claim once receivedThe member also inquired about a second claim for $from *** *** ***There is no claim on file from this providerWe cannot locate a provider by this name to contact them directlyPlease be advised that we must receive the claim in order to process the charges toward the plan benefits
We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Mr*** concerns. If you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at ***
*** *
Complaints and Appeals Consultant
Executive Resolution Team

Hello,
Thank you for your inquiry, regarding complaint #***
for *** *** 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 claims in question reviewedWe were advised
that both claims were processed correctly according to the plan benefits and
how the provider billed services rendered
The claim billed by the anesthesiologist was not billed as
an urgent care facility, so the specialist copay was appliedIf services truly
took place in the emergency room, as the facility has presented, the provider
will have to submit a corrected claimPer the facility bill, services took
place in the emergency room, so it applied the emergency room benefit and
applied $copay as the allowable was less than the $emergency room
copayUnfortunately, we are unable to advise the provider how to bill services
that are rendered, but they will be able to send a corrected claim if billed
incorrectly
We take customer complaints very seriously and appreciate
you taking the time to contact us and giving us the opportunity to address ***
*** concernsIf you have any additional questions regarding this
particular matter, please contact the Executive Resolution Team at ***
Thank you,
Ashley S
Complaint and Appeal Consultant
Executive Resolution Team

Hello,
Thank you for your inquiry, regarding complaint #***
for *** ***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
Billing department to have the member’s concerns reviewed
We were advised that the policy is currently effective for the family effective
February 01, 2016, per the file received from the MarketplaceThe member
called on March 03, 2016, to inquire about the policy and it was confirmed that
there was active coverage
The member can do one of two things to be reimbursed for any
out of pocket expenses they have occurredThe pharmacy can reprocess the claim
and reimburse the member at the pharmacy counterIf they are unable to
complete the reimbursement at the counter, the member can submit the pharmacy receipt
that is stapled to the top of the prescription (not a credit card receipt) with
a pharmacy reimbursement request to our Pharmacy department for review
It was also confirmed with the Claims and Benefits
department that the member is reflecting active in all systems and that the deductibles
update to show the correct amount applied to each tierPlease keep in mind
this does not yet include any services that need to be reviewed for
reimbursement
Please accept my apologies for the difficulties the member
has encountered with AetnaI’m sorry that our representatives were not able to
assist the member when they calledOur goal is to provide quality service and
satisfaction to our members, and I sincerely regret that the member did not
receive the service they should rightfully expect and deserveThe member’s
concerns have been forwarded to our management team for improvement
opportunities
We take customer complaints very seriously and appreciate
you taking the time to contact us and giving us the opportunity to address *** *** concernsIf 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

Hello,
Thank you for your inquiry, regarding complaint #*** for *** ***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 Billing department to
verify why the member was being charged different premium amountsAccording to the files received from the Marketplace the initial file shows an Advance Premium Tax Credit (APTC) of $and a Member Responsibility Amount (MRA) of $A change was then received effective May 12, 2015, which removed the APTC leaving the full $as the MRAThe file indicated that the member failed to provide financial information required by the MarketplaceThe last file received from the Marketplace shows an APTC of $and an MRA of $39.68, received effective July 01,
Aetna does not have access to the member’s financial records and does not determine APTC eligibility; the paperwork the member mentions would have gone to the Marketplace, not AetnaSince the member is disputing the loss of APTC she would need to contact the Marketplace to have this reviewedAetna has no control over the premium amount for a plan purchased through the Marketplace
A review of billing shows the member did not pay the full MRA for May and JuneThe member continued to pay the $for those months which left a balance of $per monthIn reviewing the paid vsdue amount Aetna billed the member correctly, but since the member did not pay May and June in full when the autopay was set up for August the full amount due of $was draftedThe member paid online every month except for the August which shows it was an autopay, set up by the member not Aetna
Concerning the customer service the member experienced, our goal is to provide exceptional service to our customers, and immediately resolve issues when they do occurI sincerely apologize for the frustrations and difficulties the member experienced and that we did not provide the level of service that the member should rightfully expect and deserveThese actions are not consistent with Aetna’s service standards and we appreciate you notifying us of the member’s experienceWe have addressed the customer service concerns directly with the representatives who handled your calls
We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Ms***’s concernsIf you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at ***
Thank you,
Ashley S
Complaint and Appeal Consultant
Executive Resolution Team

Dear *** *** ***: Please see our response to complaint #*** for *** *** that was received by us on December 22, 2017. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you Based on our review
of the member’s concerns, we confirmed that we follow the National Association of Insurance Commissioners (NAIC) On-Board Diagnostics (OBD) rules to determine primary coverage responsibilityThese rules were not established or put into place by Aetna and most insurance plans including B*** *** *** *** *** utilize these OBD rules A plan that covers a person as a subscriber pays benefits before a plan that covers the individual as a dependentWe confirmed Aetna is *** ***’s primary insurance due to him being the subscriber on the policy*** ***’s wife is the subscriber of the *** plan and he is listed as a dependentBased on the OBD rules, we cannot designate the Aetna plan as secondary to *** At this time, there are no denied claims on file for the December 27, procedure that *** *** mentions in his complaintIf Aetna denies a claim, *** *** can submit the Explanation of Benefits (EOB) to *** and they will determine if they will pay the claim as the secondary insurance carrier We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address *** ***’s concerns. If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at *** Sincerely, Kim BComplaint and Appeals Consultant Executive Resolution Team

Complaint: ***
I am rejecting this response because: Your advertising and marketing of this plan is misleading and deceptive
Sincerely,
*** ***

Hello, Thank you for your inquiry, regarding complaint #*** for *** ***Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with youUpon receipt of the complaint we immediately reached out to our Claims department to have the
member’s concerns reviewedWe were advised that the claim is processed correctly according to the benefitsWe understand that you feel this should be covered as a preventative service, but this is not considered a routine or preventative laboratory testingThe claim was appropriately applied to the member’s deductible under the laboratory testing benefitAetna is not able to comment on how another insurance covers services rendered as benefits are issued in accordance with the specific plan that the member is covered under, which varies with every planI empathize with your situation and regret that our decision could not be more favorableWhile we understand your concerns and recognize this is not the resolution you sought, our decision remains unchangedOur actions are solely guided by the plan guidelines in order to administer fairly and equitably to all participantsWe take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address *** *** concernsIf you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at *** Thank you, Ashley SComplaint and Appeal Consultant Executive Resolution Team

Hello, Thank you for your inquiry, regarding complaint # *** *** *** ***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 Benefits department to determine the
member’s fertility coverageWe confirmed the benefits for IVF at 100% up to a $15,maximum per year and no more than cycles per lifetimeThe services are subject to medical necessity guidelinesThe fertility drugs are covered by *** *** *** ** ***Our records show that the member was provided coverage details on 06/22/by our customer service teamWe take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address *** *** ** concernsIf you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at ***
Thank you,
LaShonda C
Complaint and Appeal Consultant
Executive Resolution Team

Hello, Thank you for your inquiry, regarding complaint #for Elizabeth BirnbaumOur Executive Resolution Team researched your concerns, and I would like to share the results of the review with youUpon receipt of the complaint we immediately reviewed the member’s authorization requests
on file and our records show that we approved the MRI request on April 26, 2016, and the provider’s office was notified of the approvalOur claims records indicate the procedure was completed on April 29, 2016, and has been paid in full to the provider for services rendered, with no member responsibilityWe also reviewed the x-ray claim and show that the member only has a $copay responsibility for the date of serviceIf the member disagrees with how services were paid, she can submit an appeal request to: Appeals Resolution Team P.OBox Lexington, KY To clarify, Aetna does not bill members any amount that may be due as a result of a deductible, copay or coinsurance We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address *** *** concernsIf you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at ***Thank you, Ashley SComplaint and Appeal Consultant Executive Resolution Team

Dear *** ***
Please see our response to complaint #*** for *** *** that was received by us on January 27,
During our review, we reached out to our Claims department and also reached out to *** *** *** *** *** to confirm the coordination of benefits information (COB)It was determined that Aetna is the secondary payer for this memberMsMartin’s claims will have to go through *** first
The *** plan was in force for MsMartin during the time period in question, as it became effective for this member on May 31, to the presentOur policy for MsMartin was in force from February 09, through October 31, 2015, Blue Cross Blue Shield of North Carolina is the primary payer over the Aetna policy due to the National Association of Insurance Commissioner’s (NAIC’s) Longest in Effect Rule
I apologize for any difficulties or confusion this may have caused MsMartinWe take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address MsMartin’s concernsIf there are any additional questions regarding this particular matter, please contact the *** *** *** ** ***
Regards,
Julian C***
Executive Resolution Team

Hello,
Thank you for your inquiry, regarding complaint #*** for *** ***Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you
We have sent the copy of the check to our Investigation department for reviewAt this
time we are still reviewing all of our records to try and locate the department the check came from and confirm its authenticityOnce we receive notification of the resolution to the review, either Tiffany or myself will email the member directly to explain the outcome
We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Mr***’s concernsIf you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at ***
Thank you,
Ashley S
Complaint and Appeal Consultant
Executive Resolution Team

Dear Ms*** *** Please see our response to complaint #1*** for *** *** that was received by us on June 17, 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 Claims department to have the member’s concerns reviewedWe were advised that the claim is processed correctly per the benefits and what the provider billedThe service was billed as an office visit and not as an urgent care visitThe provider group is not set up as a recognized urgent care facility based on the claim submitted to AetnaThe member has appealed the determination and has exhausted all levels of appeals We do apologize that the member did not receive their ID card timely but the member or the provider would have been able to call and verify the member ID by providing our customer service with the member’s name and date of birthAetna would have also been able to provide any benefits that were available at the time of serviceI empathize with the member’s situation and regret that our decision could not be more favorableI want to assure the member that we reviewed all the documents and available information before issuing this response We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address MsGuida’s concerns. If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at [email protected] Sincerely, Ashley WComplaint and Appeals Consultant Executive Resolution Team