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 youUpon receipt of the complaint, we contacted our Billing department to determine how the member was enrolled with AutopayBased on our review, it indicates that the member enrolled her information on April 26, at 04:39pmAetna did not set up this member's AutopayWe did receive the $payment on July 9, It was applied to the member's May invoice because it was short paid since her premium due for May was $Unfortunately, we can not refund the payment We apologize for the inconvenience however the member would need to contact the Marketplace to dispute the loss of APTC which increased her premium rates.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 concernsIf you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] Thank you, LaShonda CComplaint 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 As addressed in our previous response the ID cards were mailed prior to us receiving the retro-termination request of the policy by the employerWe did not receive the request from the employer until December 30, 2015, which is after the ID cards were issuedAetna is strictly an administrator of the plan and has no control over termination requests made by employersIt is the employer’s responsibility to notify the member of any terminations, not Aetna Aetna also has no control over premium deductions that are made for the policyAetna is never advised the premium rate of a member as it is private information between the member and the employerAgain to reiterate, the member will have to follow up with the Human Resources (HR) department with these questionsAetna will not be able to assistance why the member is paying for a medical policy that is terminated There is a pharmacy policy only, not a medical plan, that is effective for the member only, not his spouseThis is under a Medicare ID and is sponsored by TX PDPThe member used these benefits in the month of April and this may be why the member is being deducted money for a policyThe medical plan that was through the [redacted] , is correctly terminated per the employerTo recap the member will need to follow up with the HR department to have his questions/concerns addressed We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address [redacted] 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
Dear [redacted] ***: Please see our response to complaint # [redacted] for [redacted] that was received by us on January 24, 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 complaint, we reached out to our Dental department to address the member’s concernsAs of July 1, 2017, the member enrolled in a new Dental [redacted] plan which no longer had orthodontic coverageThe member’s prior Dental [redacted] plan effective November 1, through June 30, had coverage for orthodontic treatmentThe member changed plans in the middle of orthodontic treatment, which makes him responsible for the rest of the servicesWe confirmed that the claim was processed correctly based on the member’s new Dental plan The Summary of Benefits (SOB) for the member’s prior Dental [redacted] plan does not mention how we pay the provider because that is the contract between Aetna and the providerWe paid all of the claims up until the member changed dental plans and orthodontic treatment was no longer coveredThe plan documents are always available online through the member’s Aetna [redacted] accountThe member could have verified that his new plan did not cover orthodontics In the SPD section titled, “What The [redacted] Dental Plan Does Not Cover” it states: “Not every dental care service or supply is covered by the plan, even if prescribed, recommended, or approved by your physician or dentistThe plan covers only those services and supplies that are medically necessary and included in the What the Plan Covers sectionCharges made for the following are not covered except to the extent listed under the What the Plan Covers section or by amendment attached to this Booklet-CertificateIn addition, some services are specifically limited or excludedThis section describes expenses that are not covered or subject to special limitations Dental implants, braces, mouth guards, and other devices to protect, replace or reposition teeth and removal of implants Orthodontic treatment except as covered in the What the Plan Covers section.” While we understand the member’s concerns and recognize this is not the resolution he sought, our decision remains unchangedOur 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 [redacted] ***’s concernsIf there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] Sincerely, Kim BComplaint and Appeals Consultant Executive Resolution Team
Thank you for your inquiry received on 08/21/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 reached out to the Flexible Spending Account (FSA) department, and were able to find the system error with the processing of the member’s claims All claims have since been reprocessed correctly as of 08/20/15, and a check was issued on 08/20/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] ’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 We have worked with the member throughout the process to review the surgery and provider performing the surgeryWe have approved the surgery as all criteria have been met and the member and provider have both been informed of the approvalWe are now in negotiations with both the facility and the provider to come to an agreement for the payment of the surgery I will continue to be in touch with the member and the provider’s office throughout the agreement until a decision is made and the surgery date is setI spoke with the member again today to reassure that I will continue to follow this case up until the surgery We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Ms Head’s concernsIf 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 contacted our Claims department and found that the claim was processed out of network as this lab is not apart of Aetna's networkWe made an exception to reconsider the charges because this member did not have a choice in selecting this laboratoryThe claim has been reprocessed and a check will be sent to this provider within 7-days We apologize for any 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 Ms***'s concernsIf you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] Thank you LaShonda C Complaint and Appeals Consultant Executive Resolution Team
Complaint: [redacted] I am rejecting this response because:Clearly we won't mutually agree ever on this point Unless you plan to resolve your billing process I still believe I am correct Sincerely, [redacted]
Dear [redacted] ***: Please see our response to complaint # [redacted] for [redacted] that was received by us on May 21, 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 complaint we reached out to our Claims department to have the member’s concerns reviewedBased on the review, we confirmed a payment was issued to [redacted] in the amount of $on March 07, The member had a $copay responsibility on this claimA recovery letter was sent to [redacted] on January 18, 2018, and January 25, We did recover the payment in the amount of $on February 07, We do not have a claim on file for [redacted] in the amount of $that the member mentions in her complaint Based on the member’s concerns, we had the claim reprocessed for services rendered to her daughter [redacted] , on February 23, 2017, by [redacted] A payment was issued to [redacted] in the amount of $on May 30, There is no copay responsibility on this claimThe member will receive a corrected explanation of benefits for their records Please accept my apologies for the inconvenience and difficulties the member experienced while trying to obtain payment for their claimOur goal is to pay claims timely and accurately, and to promptly resolve issues when they do occurWe regret that the member’s experience with Aetna was less than satisfactory and hope that we can better assist the member in the future We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address [redacted] concernsIf there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] Sincerely, Kim BComplaint and Appeals Consultant Executive Resolution Team
Dear [redacted] Please see our response to complaint # [redacted] *or [redacted] that was received by us on February 24, During our review, we reached out to our Benefit’s department to address [redacted] concernsIt was determined that the claims in question were processed correctly in accordance to the member’s plan benefitsAs 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 decisionAppeals 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 unchangedOur 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
[redacted] Please see our response to complaint # [redacted] for [redacted] that was received by us on March 21, 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 Disability department to have the claimant’s concerns reviewedWe were advised that our Disability department initially called the wrong doctor’s office on January 10, 2017, and January 13, We then were informed [redacted] r was being treated at another Medical Center in Cincinnati and we made several attempts to obtain the information necessary to review the caseWe faxed requests on January 18th, 19th, 27th, 30th, February 01st and March 06, We have obtained the information needed to complete the disability claim review and it has been approvedThe claimant will receive a letter from the Disability department with the claim detailsWe sincerely apologize for any inconvenience this has caused the claimant We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address [redacted] r’s concerns 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
Dear [redacted] Please see our response to complaint # [redacted] for [redacted] that was received by us on June 24, 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 Disability department to have the member’s concerns reviewedWe were advised that the member’s disability claim was approved and the approval has been communicated the memberThe Disability department is also sending a letter with the details of the approval to the member I apologize for any difficulties the member encountered with the disability case manager It is our goal to provide the member with quality service and I regret any incidents that created the perception that we have not provided the member with adequate service These actions are not consistent with Aetna’s service standards and we appreciate you notifying us of the member’s experience I would like to assure the member that we have taken the appropriate actions to address the service issues the member experienced 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 WComplaint 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 this complaint our office had already received a letter from the member regarding the same complaintThe consultant reached out to speak with the member to let him know we would research the issueThe member was advised that his claim was processed correctly according to his coordination of benefitsThere will be no additional payments made on the claim I understand your concerns and recognize this is not the outcome you desiredOur 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 Mr [redacted] ’s concernsIf 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 verify if the claim was denied correctlyWe were advised that the member was within the waiting period of months to have any Type C Services dental work done and the claim was denied correctly As stated in the Benefit Plan Booklet-Certificate: Your Effective Date of Coverage With respect to Type A and B Services, your coverage takes effect on the later of: -- The date you are eligible for coverage; and -- The date you return your completed enrollment information With respect to Type C Services, if you are then in an Eligible Class, will be the Effective Date of this PlanOtherwise, your coverage takes effect after months of continuous service under the Plan Type C Expenses: Major Restorative Care Inlays/Onlays Our records reflect your original effective date is October 1, 2014, with a month waiting periodSince this criterion was not met, benefits are not eligible under the plan for the service performed June 3, Unfortunately, your claim was denied based on your plan's limitation on Type C dental work; therefore, we are unable to pay your claim Aetna does care about the safety and health of our members and I empathize with your situationWhile 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 have attached the member's plan documents which explains the coverage waiting period 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 [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 Claims department to have the member’s concerns reviewedWe were advised that the claim was processed correctly according to the out of network benefitsThe member’s benefit when seen at an out of network urgent care facility is reimbursed at 50% after the deductible is met Our records indicate that the member did visit an urgent care facility in September but it was a different facility than the one the member visited for the November date of service, which is why the claims processed differentlyIt is ultimately the member’s responsibility to verify the participation status of the providerWe did not locate a call on file from either the member or provider prior to services being rendered to confirm the coverage; therefore we are not able to make any exceptions for this claim The member will be responsible for any billed amount from the providerWhile 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 participants We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address [redacted] concernsIf you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] Thank you, XE "Type Name"Ashley S Complaint and Appeal Consultant Executive Resolution Team XE "Title/Business Area"
Revdex.com: I have reviewed the response made by the business in reference to complaint [redacted] 4, and find that this resolution is satisfactory to me 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 complaint, we contacted our Customer Service department to review the phone calls requestedWe reviewed the call dated January 20, 2016, where the customer service representative explained the plan benefits and advised the member that her $deductible would need to be met prior to Aetna paying for the service We also located a call that was placed on February 23, The representative did misquote the member responsibility at the beginning of the callDuring the call, the representative placed the call on hold and contacted the facilityThe CSR confirmed the procedure and billing informationThe CSR then apologized and provided the correct benefits that would apply based on the provider’s billing methodWe assure you that it is not our intent to mislead or misrepresent any benefit that may or may not be available under the member's health planThe claim for services performed on January 22, has been reviewedIt was processed correctly according to her plan benefits We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address [redacted] concernsIf 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
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 Eligibility department to verify if the member should have [redacted] coverage with AetnaWe confirmed that the member’s employer changed health insurance carriers to [redacted] in We have no record of receiving any [redacted] information for medical coverage However for 2016, this member has medical coverage with another employer: [redacted] Her member ID is [redacted] The member ID card has been mailedPlease allow 7-business daysShe can register for Aetna Navigator with the new ID number to get a temporary ID card We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address [redacted] concernsIf you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] Thank you [redacted] 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 meI will file additional complaints if the same "accidental" errors occur again in the future Sincerely, [redacted]
[redacted] Please see our response to complaint [redacted] for [redacted] that was received by us on September 14, Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with youOur goal is to provide exceptional service to our customers, and immediately resolve issues when they do occurI sincerely apologize for the difficulties the member experiencedAs previously stated, the member’s medication required precertificationThis is not [redacted] s way of saying that the member did not need the medication or to cause any delaysPrecertification is required for many different medications Again, the two day delay was due to our Precertification department not being contacted until August 31, The medication was denied at the pharmacy on August 29, 2016, due to the precertification requirementThe provider called two days later to request the precertification and it was approved on the same dayThe member and the provider were notified of the approval and the member picked up the medication that same day Based on our records, we have addressed [redacted] concerns on previous complaintsTherefore, we consider this matter closedWe take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Mr [redacted] s If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] *Sincerely, As [redacted] **Complaint and Appeals ConsultantExecutive 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 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 plan benefitsThere is not coverage under the plan benefits for routine services rendered by an out of network doctorI understand your concerns and recognize this is not the outcome you desiredHowever, our actions are solely guided by the plan guidelines in order to administer fairly and equitably to all participantsThe member may file an appeal, which must be submitted in writing to the following address: Aetna- CRT Member Appeals P.OBox Lexington, KY We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address [redacted] concernsIf you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] Thank you, Ashley SComplaint and Appeal Consultant Executive Resolution Team
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 youUpon receipt of the complaint, we contacted our Billing department to determine how the member was enrolled with AutopayBased on our review, it indicates that the member enrolled her information on April 26, at 04:39pmAetna did not set up this member's AutopayWe did receive the $payment on July 9, It was applied to the member's May invoice because it was short paid since her premium due for May was $Unfortunately, we can not refund the payment We apologize for the inconvenience however the member would need to contact the Marketplace to dispute the loss of APTC which increased her premium rates.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 concernsIf you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] Thank you, LaShonda CComplaint 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 As addressed in our previous response the ID cards were mailed prior to us receiving the retro-termination request of the policy by the employerWe did not receive the request from the employer until December 30, 2015, which is after the ID cards were issuedAetna is strictly an administrator of the plan and has no control over termination requests made by employersIt is the employer’s responsibility to notify the member of any terminations, not Aetna Aetna also has no control over premium deductions that are made for the policyAetna is never advised the premium rate of a member as it is private information between the member and the employerAgain to reiterate, the member will have to follow up with the Human Resources (HR) department with these questionsAetna will not be able to assistance why the member is paying for a medical policy that is terminated There is a pharmacy policy only, not a medical plan, that is effective for the member only, not his spouseThis is under a Medicare ID and is sponsored by TX PDPThe member used these benefits in the month of April and this may be why the member is being deducted money for a policyThe medical plan that was through the [redacted] , is correctly terminated per the employerTo recap the member will need to follow up with the HR department to have his questions/concerns addressed We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address [redacted] 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
Dear [redacted] ***: Please see our response to complaint # [redacted] for [redacted] that was received by us on January 24, 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 complaint, we reached out to our Dental department to address the member’s concernsAs of July 1, 2017, the member enrolled in a new Dental [redacted] plan which no longer had orthodontic coverageThe member’s prior Dental [redacted] plan effective November 1, through June 30, had coverage for orthodontic treatmentThe member changed plans in the middle of orthodontic treatment, which makes him responsible for the rest of the servicesWe confirmed that the claim was processed correctly based on the member’s new Dental plan The Summary of Benefits (SOB) for the member’s prior Dental [redacted] plan does not mention how we pay the provider because that is the contract between Aetna and the providerWe paid all of the claims up until the member changed dental plans and orthodontic treatment was no longer coveredThe plan documents are always available online through the member’s Aetna [redacted] accountThe member could have verified that his new plan did not cover orthodontics In the SPD section titled, “What The [redacted] Dental Plan Does Not Cover” it states: “Not every dental care service or supply is covered by the plan, even if prescribed, recommended, or approved by your physician or dentistThe plan covers only those services and supplies that are medically necessary and included in the What the Plan Covers sectionCharges made for the following are not covered except to the extent listed under the What the Plan Covers section or by amendment attached to this Booklet-CertificateIn addition, some services are specifically limited or excludedThis section describes expenses that are not covered or subject to special limitations Dental implants, braces, mouth guards, and other devices to protect, replace or reposition teeth and removal of implants Orthodontic treatment except as covered in the What the Plan Covers section.” While we understand the member’s concerns and recognize this is not the resolution he sought, our decision remains unchangedOur 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 [redacted] ***’s concernsIf there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] Sincerely, Kim BComplaint and Appeals Consultant Executive Resolution Team
Thank you for your inquiry received on 08/21/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 reached out to the Flexible Spending Account (FSA) department, and were able to find the system error with the processing of the member’s claims All claims have since been reprocessed correctly as of 08/20/15, and a check was issued on 08/20/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] ’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 We have worked with the member throughout the process to review the surgery and provider performing the surgeryWe have approved the surgery as all criteria have been met and the member and provider have both been informed of the approvalWe are now in negotiations with both the facility and the provider to come to an agreement for the payment of the surgery I will continue to be in touch with the member and the provider’s office throughout the agreement until a decision is made and the surgery date is setI spoke with the member again today to reassure that I will continue to follow this case up until the surgery We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Ms Head’s concernsIf 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 contacted our Claims department and found that the claim was processed out of network as this lab is not apart of Aetna's networkWe made an exception to reconsider the charges because this member did not have a choice in selecting this laboratoryThe claim has been reprocessed and a check will be sent to this provider within 7-days We apologize for any 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 Ms***'s concernsIf you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] Thank you LaShonda C Complaint and Appeals Consultant Executive Resolution Team
Complaint: [redacted] I am rejecting this response because:Clearly we won't mutually agree ever on this point Unless you plan to resolve your billing process I still believe I am correct Sincerely, [redacted]
Dear [redacted] ***: Please see our response to complaint # [redacted] for [redacted] that was received by us on May 21, 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 complaint we reached out to our Claims department to have the member’s concerns reviewedBased on the review, we confirmed a payment was issued to [redacted] in the amount of $on March 07, The member had a $copay responsibility on this claimA recovery letter was sent to [redacted] on January 18, 2018, and January 25, We did recover the payment in the amount of $on February 07, We do not have a claim on file for [redacted] in the amount of $that the member mentions in her complaint Based on the member’s concerns, we had the claim reprocessed for services rendered to her daughter [redacted] , on February 23, 2017, by [redacted] A payment was issued to [redacted] in the amount of $on May 30, There is no copay responsibility on this claimThe member will receive a corrected explanation of benefits for their records Please accept my apologies for the inconvenience and difficulties the member experienced while trying to obtain payment for their claimOur goal is to pay claims timely and accurately, and to promptly resolve issues when they do occurWe regret that the member’s experience with Aetna was less than satisfactory and hope that we can better assist the member in the future We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address [redacted] concernsIf there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] Sincerely, Kim BComplaint and Appeals Consultant Executive Resolution Team
Dear [redacted] Please see our response to complaint # [redacted] *or [redacted] that was received by us on February 24, During our review, we reached out to our Benefit’s department to address [redacted] concernsIt was determined that the claims in question were processed correctly in accordance to the member’s plan benefitsAs 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 decisionAppeals 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 unchangedOur 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
[redacted] Please see our response to complaint # [redacted] for [redacted] that was received by us on March 21, 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 Disability department to have the claimant’s concerns reviewedWe were advised that our Disability department initially called the wrong doctor’s office on January 10, 2017, and January 13, We then were informed [redacted] r was being treated at another Medical Center in Cincinnati and we made several attempts to obtain the information necessary to review the caseWe faxed requests on January 18th, 19th, 27th, 30th, February 01st and March 06, We have obtained the information needed to complete the disability claim review and it has been approvedThe claimant will receive a letter from the Disability department with the claim detailsWe sincerely apologize for any inconvenience this has caused the claimant We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address [redacted] r’s concerns 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
Dear [redacted] Please see our response to complaint # [redacted] for [redacted] that was received by us on June 24, 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 Disability department to have the member’s concerns reviewedWe were advised that the member’s disability claim was approved and the approval has been communicated the memberThe Disability department is also sending a letter with the details of the approval to the member I apologize for any difficulties the member encountered with the disability case manager It is our goal to provide the member with quality service and I regret any incidents that created the perception that we have not provided the member with adequate service These actions are not consistent with Aetna’s service standards and we appreciate you notifying us of the member’s experience I would like to assure the member that we have taken the appropriate actions to address the service issues the member experienced 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 WComplaint 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 this complaint our office had already received a letter from the member regarding the same complaintThe consultant reached out to speak with the member to let him know we would research the issueThe member was advised that his claim was processed correctly according to his coordination of benefitsThere will be no additional payments made on the claim I understand your concerns and recognize this is not the outcome you desiredOur 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 Mr [redacted] ’s concernsIf 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 verify if the claim was denied correctlyWe were advised that the member was within the waiting period of months to have any Type C Services dental work done and the claim was denied correctly As stated in the Benefit Plan Booklet-Certificate: Your Effective Date of Coverage With respect to Type A and B Services, your coverage takes effect on the later of: -- The date you are eligible for coverage; and -- The date you return your completed enrollment information With respect to Type C Services, if you are then in an Eligible Class, will be the Effective Date of this PlanOtherwise, your coverage takes effect after months of continuous service under the Plan Type C Expenses: Major Restorative Care Inlays/Onlays Our records reflect your original effective date is October 1, 2014, with a month waiting periodSince this criterion was not met, benefits are not eligible under the plan for the service performed June 3, Unfortunately, your claim was denied based on your plan's limitation on Type C dental work; therefore, we are unable to pay your claim Aetna does care about the safety and health of our members and I empathize with your situationWhile 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 have attached the member's plan documents which explains the coverage waiting period 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 [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 Claims department to have the member’s concerns reviewedWe were advised that the claim was processed correctly according to the out of network benefitsThe member’s benefit when seen at an out of network urgent care facility is reimbursed at 50% after the deductible is met Our records indicate that the member did visit an urgent care facility in September but it was a different facility than the one the member visited for the November date of service, which is why the claims processed differentlyIt is ultimately the member’s responsibility to verify the participation status of the providerWe did not locate a call on file from either the member or provider prior to services being rendered to confirm the coverage; therefore we are not able to make any exceptions for this claim The member will be responsible for any billed amount from the providerWhile 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 participants We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address [redacted] concernsIf you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] Thank you, XE "Type Name"Ashley S Complaint and Appeal Consultant Executive Resolution Team XE "Title/Business Area"
Revdex.com: I have reviewed the response made by the business in reference to complaint [redacted] 4, and find that this resolution is satisfactory to me 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 complaint, we contacted our Customer Service department to review the phone calls requestedWe reviewed the call dated January 20, 2016, where the customer service representative explained the plan benefits and advised the member that her $deductible would need to be met prior to Aetna paying for the service We also located a call that was placed on February 23, The representative did misquote the member responsibility at the beginning of the callDuring the call, the representative placed the call on hold and contacted the facilityThe CSR confirmed the procedure and billing informationThe CSR then apologized and provided the correct benefits that would apply based on the provider’s billing methodWe assure you that it is not our intent to mislead or misrepresent any benefit that may or may not be available under the member's health planThe claim for services performed on January 22, has been reviewedIt was processed correctly according to her plan benefits We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address [redacted] concernsIf 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
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 Eligibility department to verify if the member should have [redacted] coverage with AetnaWe confirmed that the member’s employer changed health insurance carriers to [redacted] in We have no record of receiving any [redacted] information for medical coverage However for 2016, this member has medical coverage with another employer: [redacted] Her member ID is [redacted] The member ID card has been mailedPlease allow 7-business daysShe can register for Aetna Navigator with the new ID number to get a temporary ID card We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address [redacted] concernsIf you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] Thank you [redacted] 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 meI will file additional complaints if the same "accidental" errors occur again in the future Sincerely, [redacted]
[redacted] Please see our response to complaint [redacted] for [redacted] that was received by us on September 14, Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with youOur goal is to provide exceptional service to our customers, and immediately resolve issues when they do occurI sincerely apologize for the difficulties the member experiencedAs previously stated, the member’s medication required precertificationThis is not [redacted] s way of saying that the member did not need the medication or to cause any delaysPrecertification is required for many different medications Again, the two day delay was due to our Precertification department not being contacted until August 31, The medication was denied at the pharmacy on August 29, 2016, due to the precertification requirementThe provider called two days later to request the precertification and it was approved on the same dayThe member and the provider were notified of the approval and the member picked up the medication that same day Based on our records, we have addressed [redacted] concerns on previous complaintsTherefore, we consider this matter closedWe take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Mr [redacted] s If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] *Sincerely, As [redacted] **Complaint and Appeals ConsultantExecutive 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 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 plan benefitsThere is not coverage under the plan benefits for routine services rendered by an out of network doctorI understand your concerns and recognize this is not the outcome you desiredHowever, our actions are solely guided by the plan guidelines in order to administer fairly and equitably to all participantsThe member may file an appeal, which must be submitted in writing to the following address: Aetna- CRT Member Appeals P.OBox Lexington, KY We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address [redacted] concernsIf you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] Thank you, Ashley SComplaint and Appeal Consultant Executive Resolution Team