Dear [redacted] *** Please see our response to complaint # [redacted] for [redacted] that was received by us on November 02, 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 authorization on file had to be updated to correct how the claims were being processing under the member’s planWe updated the authorization on file to have the claims processed at the full billed amountWe also had any claims on file that were not allowed at the full billed amount of $210.00, correctedAdditional payments will be released within 7-business days and a corrected explanation of benefits will also be sent to the member for her recordsIf the member has any other claims that process incorrectly in the future she can email me directly at the email address listed below and I will have them handled immediately Please accept my apology for the delay in processing the member’s claim correctly, and that it required multiple attempts on her part to resolve the issueUnfortunately, in some instances, 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 recurrenceWe continually use feedback like this 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 [redacted] ’s 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
Dear [redacted] Please see our response to complaint # [redacted] for [redacted] that was received by us on March 01, During our review, we reached out to our Billing and Enrollment department to address [redacted] concernsIt was determined that the member had a policy that became effective for the month of January with a premium of $254.16; the policy was termed as of January 30, A new policy became effective for this member as of February 01, and has been effective since, this policy has a premium of $and is the policy the member elected to have active A total of three payments were received from the member, one for $254.16, another one for $and another one for $The member was reimbursed to her MasterCard on February 12, for $ + $295.14= $The other premium payment of $was applied to the current policy paying the month of February In order for the member to be current in the premium payments, [redacted] would need to provide payment for January ($254.16) + March ($295.14) 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 [email protected] Regards, Julian C [redacted] 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 reviewedWe were advised that the policy will be re-opening with the effective date of January 01, The member stated he made a payment, however the payment never posted on the policy causing the policy to cancel as never in force The member would need to make his binder payment allowing 24-48hrs to post in the accountThen the member could call back to make a payment for February and MarchThe member could reach us at ###-###-#### and speak directly to a customer care associate to be able to take his premium payment and be provided with a confirmation numberPlease have the member reference case number [redacted] when calling to make his binder paymentOnce the payment is processed and posted in the account the welcome packet and the member ID card will be sent to the member within 7-business days after payment posts 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 AetnaI would also like to thank you for sharing your experience with usIt 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] 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 youUpon receipt of your complaint, we contacted our Claims department and confirmed that we have not received a claim from [redacted] We contacted the provider’s office and confirmed the member’s health coverageWe also verified that the location is participating with the member’s planThe provider will resubmit the claim to AetnaOnce we receive the claim, we will process and send an explanation of benefit to the memberWe 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 [redacted] concernsIf you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] LaShonda C.Complaint and Appeal Consultant Executive Resolution Team
Dear [redacted] ***: Please see our response to complaint # [redacted] for [redacted] that was received by us on December 5, 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 Claims department to address the member’s concernsWe reviewed the October 16, claim and found that the claim originally processed under the incorrect contract for [redacted] The claim initially allowed $and was applied to the member’s deductibleHowever, Aetna determined that an error was made and reprocessed the claim at the correct provider contract rate on December 2, The correct allowed amount for the service should have been $This resulted in an increase of the member responsibility by $ The member is responsible for the $because his deductible was not met.We apologize for the inconvenience that 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 [redacted] ***’s concernsIf there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] Sincerely,LaShonda C.Complaint and Appeal Consultant Executive Resolution Team
Dear Ms [redacted] ***: Please see our response to complaint # [redacted] for [redacted] that was received by us on November 10, Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you Upon receipt of the complaint we immediately reviewed the member’s file to have the member’s concerns addressedI requested that a Supervisor who handles this member’s account through the employer contact her directly to attempt to resolveAt this time we discovered that the doctor that referred her son referred them to [redacted] The member went to the center in [redacted] ** and the sign read [redacted] and also [redacted] It appears that the services were actually performed by [redacted] which does the billing through [redacted] HospitalThe member understands that we quoted her the correct rate for [redacted] and that the issue lies with the bill that was received from [redacted] Hospital not [redacted] The member asked to the Supervisor to contact [redacted] to clarify the billing and to follow up with her on the findingsWe did advise the member that in order for us to make any changes to this billing we would have to have a corrected bill from [redacted] The Supervisor spoke to a representative at [redacted] She advised that if an [redacted] provider refers the patient to them it is then billed as an [redacted] provider [redacted] HospitalIf a non [redacted] provider refers the patient to them it is billed by [redacted] The representative also advised there are signs within the facility to warn the patientsHowever, she was going to escalate the issue to her manager and will follow up with the Supervisor the week of November 27, The Supervisor followed up with [redacted] and shared the above information with her and advised her we would follow up with her the same week after talking to the facilityWe will continue to work directly with this member in an attempt to resolve this to the member’s satisfaction 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] Sincerely, Ashley WComplaint and Appeals 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 Premium and Billing department to have the member’s concerns reviewedWe were advised that the member was not terminated for nonpayment; she was terminated for no longer being eligible by the [redacted] ExchangeThe member would have received several letters from the [redacted] prior to the member’s terminationAetna has no control over the policies that are created under the [redacted] Exchange; we are strictly administrators of the member’s planAetna has no control over a member’s termination The member was drafted two months in error for November’s premium due to a system errorA refund was issued on November 06, 2015, for the $that was withdrawn in errorThe member’s plan was terminated correctly per information received from the MarketplaceIf the member is wishing to dispute the termination she will need to contact the [redacted] to inquire why her plan was terminatedI sincerely apologize for any inconvenience this has caused the member We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Ms [redacted] 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
From: [redacted] m] Sent: Tuesday, June 28, 4:PMTo: [redacted] Subject: Aetna Executive Team- Regarding Complaint # [redacted] Hey Madelyn, I was able to get a resolution for this caseI believe this is another one that we did not get the first notification onCan you reopen this case so I can put my resolution comments in it? I just don’t want it to go unresolved or affect the ratingIf you are not able to reopen the case below is my resolution to the member: Dear Ms [redacted] ***Please see our response to complaint # [redacted] for Angelique A [redacted] that was received by us on June 18, 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 and Enrollment department to have the member’s concerns addressedWe were advised that the member’s plan was effective June 01, 2016, and they are covered by the Aetna Leap Specialty with a monthly premium due of $The policy premium of $is correct, as the primary policy holder listed himself as a smoker and the dependent a non-smokerCurrently the policy is active and paid through June 30, The original policy quote of $was based on both members being non-smokers but when the application was processed, the primary listed himself as a smoker; causing the premium to go up to $If this incorrect, please contact us immediatelyWe take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address MrsAllen’s concerns If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at s [redacted] Sincerely,Ashley W.Complaint and Appeals ConsultantExecutive Resolution Team
Complaint: [redacted] I am rejecting this response because: The response did not address the fact that tens of thousands of dollars of x-Rays and MRIs were not covered from a recent hospital stay, and those services were covered at s rate of 100% per my plan policyAdditionally, there's a $3,out of pocket maximum, therefor, Aetna should not be sending me bills for anything in excess of the $3,out of pocket maximumThis includes a bill I received from Aetna for in excess of $119,that I received this week for a portion of that hospital stayPlease re-review these claims and adjust Sincerely, [redacted]
Dear [redacted] ***: Please see our response to complaint # [redacted] for [redacted] that was received by us on March 15, 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 reached out to the contact within Aetna who is the liaison between Aetna and the plan sponsor who offers [redacted] ’s policy, [redacted] *** We were advised that [redacted] has selected [redacted] as the pharmacy benefits manager who administers the prescription coverage for their employees As such, Aetna is not involved in determining benefits for his prescription medications or in setting the requirements for coverage of maintenance medications Aetna only administers the benefit plans that cover medical and behavioral health services We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address [redacted] ’s concerns If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] Regards, Chris BComplaints and Appeals Consultant Executive Resolution Team
Thank you for your inquiry received on 08/12/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]
Thank you for your inquiry received on 06/30/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 Aetna’s Eligibility department for assistance, and the member was on a low deductible plan from 04/01/to 03/25/Then, transferred to a [redacted] plan effective 03/22/2014, until 03/25/2015, and was on the correct planThe member was only on the high deductible plan from 04/01/to 04/30/ There is only one outstanding claim for both Mrand Mrs [redacted] , which have been sent for reconsiderationA new Explanation of Benefit (EOB) will be mailed under separate cover within 7-days 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]
Dear [redacted] ***: Please see our response to complaint # [redacted] for [redacted] that was received by us on May 29, Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you Upon receipt of the member’s concerns, we immediately reached out to a representativeThey researched this issue and have provided a responseThe member stated that she submitted a claim for her short term disability to be processed, and that she has called Aetna or more times with no one returning her calls In reviewing the member’s concern, we see that the claim was reported on May 09, 2018, and records were requested from the providerA representative spoke with [redacted] on May 29, 2018, and the claim was approved through June 06, We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address [redacted] concerns If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] Sincerely, Michael H SrComplaint and Appeal Analyst Executive Resolution Team
Dear [redacted] ***: Please see our response to complaint # [redacted] for [redacted] that was received by us on December 6, Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with youUpon receipt of the member’s policy information, it was found that this member’s plan is administered through [redacted] , an Aetna company We reached out to the [redacted] area to assist with our investigationIt was found that the precertification for the procedures involved had been initiated as a routine or screening procedure, but after the clinical information was reviewed the precertification was approved for the diagnostic procedureHowever, when the claims were submitted they were billed as routine Also, the benefit for these procedures when done as routine in nature does not begin until the age of The resolution of this issue would require that the providers of the services submit corrected claims as diagnostic The Member Advocacy department of [redacted] has been involved and will be contacting the providers of the services Once full resolution is obtained, additional outreach will be made to [redacted] We regret any frustration or inconvenience this situation has caused We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address [redacted] s concerns If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] Regards, Chris BComplaints and Appeals Consultant Executive Resolution Team
Complaint: [redacted] I am rejecting this response because: Sincerely, [redacted] I called them because I wanted to go to a local facility to have the ultrasound done they told me that facility was out of networkI asked them where can I go that is in network they gave me the information I provided in the complaint they confirmed to me that that’s what they told me the address and the phone number I went to that location per their instructions which were was out of my way but I had it down there because that’s where they told me to goThen they’re claiming the facility they sent me to was out of networkI would like an independent party To review the recording because they will not let anybody else listen to it that should solve the problemThey will not give me access to the recording of me and the representative In the two appeals I made they never said that they told me it was out of network in that conversation they are flat out lying I have a feeling this is a common practice there and they have procedures to cover this up I have a feeling this is a common practice there and they have procedures to cover this up If independent party can review the conversation I will happily except their findingsThe representative did read to me Word for Word what I was told and agreed with me that I was told to go to that facility by address and phone number as they are in networkWhy won’t they let anybody else listen to the recording that will solve the whole matter
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 the Billing department to verify if the member was due a refund for overpaid premiums after she was no longer employed with the prevoius employerWe were able to verify that the member is due a refund as the premium was overpaidThe City of [redacted] is aware of the situation and they are currently working on refunding the member as quickly as possibleSince the City of [redacted] creates these deductions, please contact them for any questions about the amount of refund that is due and when they expect to have this refund to the member We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Ms [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
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 confirmed that both dates of service were processed correctly The claims are being allowed at the in-network benefit but the member is responsible for a deductible prior to the claims paying at 80% when billed as outpatient hospital visitsThe member would have been responsible for a specialist copay only if she was seen at a doctor’s officeI understand your concerns and recognize this is not the outcome you desiredHowever, we must make coverage decisions in accordance with your plan of 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] LaShonda C Complaint and Appeal Consultant Executive Resolution Team
Hello, Thank you for your inquiry, regarding complaint# [redacted] for Robert C [redacted] 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 for claim reviewWe determined that the services should allow up to the 80th percentile of Fair Health for emergent servicesThe emergency claims for date of service: July 30, have been reprocessedThe member and provider will receive an explanation of benefits within 7-daysThe claim for date of service August 27, was determined that it processed correctlyThe member’s plan states that follcare is not considered an emergency or urgent condition and is not covered as part of any emergency or urgent care visitWe 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 MrC [redacted] concernsIf you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] LaShonda CComplaint and Appeal Consultant Executive Resolution Team Tell us why here
Thank you for your rejection notice received on 07/17/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 Plan Sponsor Liaison contact for assistance, and were advised that our records show coverage for the period 05/24/through 07/04/15, which will be refundedThe refund amount of $will be included on this Friday’s (07/24/15) paycheck and no additional deductions have been taken We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Ms [redacted] concerns If you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted]
Complaint: [redacted] I am rejecting this response because: This is not entirely resolving my problem with Aetna I am still being harassed by AETNA RX home delivery for a balance of $ My tier exception should have been applied to this order according to different associates spoken to in the last few months Since a mistake was made in applying a prescription against my deductible when it should not have been, this problem needs to be fixed as well According to the different representatives I spoke to, I paid more than I should have for my prescription back in January because of the tier exception which backdates to January the first of this year The response from Aetna does not explain what the reimbursement consists of Am I receiving a reimbursement for paying too much for the medication back in January? Or, am I receiving one for the emergency medication I had to purchase from a local pharmacy back in January because your company was negligent and left me without medication? I am tired of being harassed by these letters I am so tired and stressed from this mess, I cannot take it anymore! Your company does not even understand or care how much stress and anguish you have caused me since December This entire mess needs to be fixed, not just part of the problem but the whole! Lastly, I want to make sure that the person that responded to this complaint from Aetna understands that I am a female! I am not [redacted] ***I am [redacted] That really shows me how much Aetna cares about their customers' complaints when they cannot even address the customer by their appropriate gender Sincerely, [redacted] ***
Dear [redacted] *** Please see our response to complaint # [redacted] for [redacted] that was received by us on November 02, 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 authorization on file had to be updated to correct how the claims were being processing under the member’s planWe updated the authorization on file to have the claims processed at the full billed amountWe also had any claims on file that were not allowed at the full billed amount of $210.00, correctedAdditional payments will be released within 7-business days and a corrected explanation of benefits will also be sent to the member for her recordsIf the member has any other claims that process incorrectly in the future she can email me directly at the email address listed below and I will have them handled immediately Please accept my apology for the delay in processing the member’s claim correctly, and that it required multiple attempts on her part to resolve the issueUnfortunately, in some instances, 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 recurrenceWe continually use feedback like this 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 [redacted] ’s 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
Dear [redacted] Please see our response to complaint # [redacted] for [redacted] that was received by us on March 01, During our review, we reached out to our Billing and Enrollment department to address [redacted] concernsIt was determined that the member had a policy that became effective for the month of January with a premium of $254.16; the policy was termed as of January 30, A new policy became effective for this member as of February 01, and has been effective since, this policy has a premium of $and is the policy the member elected to have active A total of three payments were received from the member, one for $254.16, another one for $and another one for $The member was reimbursed to her MasterCard on February 12, for $ + $295.14= $The other premium payment of $was applied to the current policy paying the month of February In order for the member to be current in the premium payments, [redacted] would need to provide payment for January ($254.16) + March ($295.14) 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 [email protected] Regards, Julian C [redacted] 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 reviewedWe were advised that the policy will be re-opening with the effective date of January 01, The member stated he made a payment, however the payment never posted on the policy causing the policy to cancel as never in force The member would need to make his binder payment allowing 24-48hrs to post in the accountThen the member could call back to make a payment for February and MarchThe member could reach us at ###-###-#### and speak directly to a customer care associate to be able to take his premium payment and be provided with a confirmation numberPlease have the member reference case number [redacted] when calling to make his binder paymentOnce the payment is processed and posted in the account the welcome packet and the member ID card will be sent to the member within 7-business days after payment posts 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 AetnaI would also like to thank you for sharing your experience with usIt 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] 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 youUpon receipt of your complaint, we contacted our Claims department and confirmed that we have not received a claim from [redacted] We contacted the provider’s office and confirmed the member’s health coverageWe also verified that the location is participating with the member’s planThe provider will resubmit the claim to AetnaOnce we receive the claim, we will process and send an explanation of benefit to the memberWe 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 [redacted] concernsIf you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] LaShonda C.Complaint and Appeal Consultant Executive Resolution Team
Dear [redacted] ***: Please see our response to complaint # [redacted] for [redacted] that was received by us on December 5, 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 Claims department to address the member’s concernsWe reviewed the October 16, claim and found that the claim originally processed under the incorrect contract for [redacted] The claim initially allowed $and was applied to the member’s deductibleHowever, Aetna determined that an error was made and reprocessed the claim at the correct provider contract rate on December 2, The correct allowed amount for the service should have been $This resulted in an increase of the member responsibility by $ The member is responsible for the $because his deductible was not met.We apologize for the inconvenience that 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 [redacted] ***’s concernsIf there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] Sincerely,LaShonda C.Complaint and Appeal Consultant Executive Resolution Team
Dear Ms [redacted] ***: Please see our response to complaint # [redacted] for [redacted] that was received by us on November 10, Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you Upon receipt of the complaint we immediately reviewed the member’s file to have the member’s concerns addressedI requested that a Supervisor who handles this member’s account through the employer contact her directly to attempt to resolveAt this time we discovered that the doctor that referred her son referred them to [redacted] The member went to the center in [redacted] ** and the sign read [redacted] and also [redacted] It appears that the services were actually performed by [redacted] which does the billing through [redacted] HospitalThe member understands that we quoted her the correct rate for [redacted] and that the issue lies with the bill that was received from [redacted] Hospital not [redacted] The member asked to the Supervisor to contact [redacted] to clarify the billing and to follow up with her on the findingsWe did advise the member that in order for us to make any changes to this billing we would have to have a corrected bill from [redacted] The Supervisor spoke to a representative at [redacted] She advised that if an [redacted] provider refers the patient to them it is then billed as an [redacted] provider [redacted] HospitalIf a non [redacted] provider refers the patient to them it is billed by [redacted] The representative also advised there are signs within the facility to warn the patientsHowever, she was going to escalate the issue to her manager and will follow up with the Supervisor the week of November 27, The Supervisor followed up with [redacted] and shared the above information with her and advised her we would follow up with her the same week after talking to the facilityWe will continue to work directly with this member in an attempt to resolve this to the member’s satisfaction 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] Sincerely, Ashley WComplaint and Appeals 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 Premium and Billing department to have the member’s concerns reviewedWe were advised that the member was not terminated for nonpayment; she was terminated for no longer being eligible by the [redacted] ExchangeThe member would have received several letters from the [redacted] prior to the member’s terminationAetna has no control over the policies that are created under the [redacted] Exchange; we are strictly administrators of the member’s planAetna has no control over a member’s termination The member was drafted two months in error for November’s premium due to a system errorA refund was issued on November 06, 2015, for the $that was withdrawn in errorThe member’s plan was terminated correctly per information received from the MarketplaceIf the member is wishing to dispute the termination she will need to contact the [redacted] to inquire why her plan was terminatedI sincerely apologize for any inconvenience this has caused the member We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Ms [redacted] 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
From: [redacted] m] Sent: Tuesday, June 28, 4:PMTo: [redacted] Subject: Aetna Executive Team- Regarding Complaint # [redacted] Hey Madelyn, I was able to get a resolution for this caseI believe this is another one that we did not get the first notification onCan you reopen this case so I can put my resolution comments in it? I just don’t want it to go unresolved or affect the ratingIf you are not able to reopen the case below is my resolution to the member: Dear Ms [redacted] ***Please see our response to complaint # [redacted] for Angelique A [redacted] that was received by us on June 18, 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 and Enrollment department to have the member’s concerns addressedWe were advised that the member’s plan was effective June 01, 2016, and they are covered by the Aetna Leap Specialty with a monthly premium due of $The policy premium of $is correct, as the primary policy holder listed himself as a smoker and the dependent a non-smokerCurrently the policy is active and paid through June 30, The original policy quote of $was based on both members being non-smokers but when the application was processed, the primary listed himself as a smoker; causing the premium to go up to $If this incorrect, please contact us immediatelyWe take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address MrsAllen’s concerns If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at s [redacted] Sincerely,Ashley W.Complaint and Appeals ConsultantExecutive Resolution Team
Complaint: [redacted] I am rejecting this response because: The response did not address the fact that tens of thousands of dollars of x-Rays and MRIs were not covered from a recent hospital stay, and those services were covered at s rate of 100% per my plan policyAdditionally, there's a $3,out of pocket maximum, therefor, Aetna should not be sending me bills for anything in excess of the $3,out of pocket maximumThis includes a bill I received from Aetna for in excess of $119,that I received this week for a portion of that hospital stayPlease re-review these claims and adjust Sincerely, [redacted]
Dear [redacted] ***: Please see our response to complaint # [redacted] for [redacted] that was received by us on March 15, 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 reached out to the contact within Aetna who is the liaison between Aetna and the plan sponsor who offers [redacted] ’s policy, [redacted] *** We were advised that [redacted] has selected [redacted] as the pharmacy benefits manager who administers the prescription coverage for their employees As such, Aetna is not involved in determining benefits for his prescription medications or in setting the requirements for coverage of maintenance medications Aetna only administers the benefit plans that cover medical and behavioral health services We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address [redacted] ’s concerns If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] Regards, Chris BComplaints and Appeals Consultant Executive Resolution Team
Thank you for your inquiry received on 08/12/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]
Thank you for your inquiry received on 06/30/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 Aetna’s Eligibility department for assistance, and the member was on a low deductible plan from 04/01/to 03/25/Then, transferred to a [redacted] plan effective 03/22/2014, until 03/25/2015, and was on the correct planThe member was only on the high deductible plan from 04/01/to 04/30/ There is only one outstanding claim for both Mrand Mrs [redacted] , which have been sent for reconsiderationA new Explanation of Benefit (EOB) will be mailed under separate cover within 7-days 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]
Dear [redacted] ***: Please see our response to complaint # [redacted] for [redacted] that was received by us on May 29, Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you Upon receipt of the member’s concerns, we immediately reached out to a representativeThey researched this issue and have provided a responseThe member stated that she submitted a claim for her short term disability to be processed, and that she has called Aetna or more times with no one returning her calls In reviewing the member’s concern, we see that the claim was reported on May 09, 2018, and records were requested from the providerA representative spoke with [redacted] on May 29, 2018, and the claim was approved through June 06, We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address [redacted] concerns If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] Sincerely, Michael H SrComplaint and Appeal Analyst Executive Resolution Team
Dear [redacted] ***: Please see our response to complaint # [redacted] for [redacted] that was received by us on December 6, Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with youUpon receipt of the member’s policy information, it was found that this member’s plan is administered through [redacted] , an Aetna company We reached out to the [redacted] area to assist with our investigationIt was found that the precertification for the procedures involved had been initiated as a routine or screening procedure, but after the clinical information was reviewed the precertification was approved for the diagnostic procedureHowever, when the claims were submitted they were billed as routine Also, the benefit for these procedures when done as routine in nature does not begin until the age of The resolution of this issue would require that the providers of the services submit corrected claims as diagnostic The Member Advocacy department of [redacted] has been involved and will be contacting the providers of the services Once full resolution is obtained, additional outreach will be made to [redacted] We regret any frustration or inconvenience this situation has caused We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address [redacted] s concerns If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] Regards, Chris BComplaints and Appeals Consultant Executive Resolution Team
Complaint: [redacted] I am rejecting this response because: Sincerely, [redacted] I called them because I wanted to go to a local facility to have the ultrasound done they told me that facility was out of networkI asked them where can I go that is in network they gave me the information I provided in the complaint they confirmed to me that that’s what they told me the address and the phone number I went to that location per their instructions which were was out of my way but I had it down there because that’s where they told me to goThen they’re claiming the facility they sent me to was out of networkI would like an independent party To review the recording because they will not let anybody else listen to it that should solve the problemThey will not give me access to the recording of me and the representative In the two appeals I made they never said that they told me it was out of network in that conversation they are flat out lying I have a feeling this is a common practice there and they have procedures to cover this up I have a feeling this is a common practice there and they have procedures to cover this up If independent party can review the conversation I will happily except their findingsThe representative did read to me Word for Word what I was told and agreed with me that I was told to go to that facility by address and phone number as they are in networkWhy won’t they let anybody else listen to the recording that will solve the whole matter
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 the Billing department to verify if the member was due a refund for overpaid premiums after she was no longer employed with the prevoius employerWe were able to verify that the member is due a refund as the premium was overpaidThe City of [redacted] is aware of the situation and they are currently working on refunding the member as quickly as possibleSince the City of [redacted] creates these deductions, please contact them for any questions about the amount of refund that is due and when they expect to have this refund to the member We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Ms [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
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 confirmed that both dates of service were processed correctly The claims are being allowed at the in-network benefit but the member is responsible for a deductible prior to the claims paying at 80% when billed as outpatient hospital visitsThe member would have been responsible for a specialist copay only if she was seen at a doctor’s officeI understand your concerns and recognize this is not the outcome you desiredHowever, we must make coverage decisions in accordance with your plan of 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] LaShonda C Complaint and Appeal Consultant Executive Resolution Team
Hello, Thank you for your inquiry, regarding complaint# [redacted] for Robert C [redacted] 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 for claim reviewWe determined that the services should allow up to the 80th percentile of Fair Health for emergent servicesThe emergency claims for date of service: July 30, have been reprocessedThe member and provider will receive an explanation of benefits within 7-daysThe claim for date of service August 27, was determined that it processed correctlyThe member’s plan states that follcare is not considered an emergency or urgent condition and is not covered as part of any emergency or urgent care visitWe 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 MrC [redacted] concernsIf you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] LaShonda CComplaint and Appeal Consultant Executive Resolution Team Tell us why here
Thank you for your rejection notice received on 07/17/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 Plan Sponsor Liaison contact for assistance, and were advised that our records show coverage for the period 05/24/through 07/04/15, which will be refundedThe refund amount of $will be included on this Friday’s (07/24/15) paycheck and no additional deductions have been taken We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Ms [redacted] concerns If you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted]
Complaint: [redacted] I am rejecting this response because: This is not entirely resolving my problem with Aetna I am still being harassed by AETNA RX home delivery for a balance of $ My tier exception should have been applied to this order according to different associates spoken to in the last few months Since a mistake was made in applying a prescription against my deductible when it should not have been, this problem needs to be fixed as well According to the different representatives I spoke to, I paid more than I should have for my prescription back in January because of the tier exception which backdates to January the first of this year The response from Aetna does not explain what the reimbursement consists of Am I receiving a reimbursement for paying too much for the medication back in January? Or, am I receiving one for the emergency medication I had to purchase from a local pharmacy back in January because your company was negligent and left me without medication? I am tired of being harassed by these letters I am so tired and stressed from this mess, I cannot take it anymore! Your company does not even understand or care how much stress and anguish you have caused me since December This entire mess needs to be fixed, not just part of the problem but the whole! Lastly, I want to make sure that the person that responded to this complaint from Aetna understands that I am a female! I am not [redacted] ***I am [redacted] That really shows me how much Aetna cares about their customers' complaints when they cannot even address the customer by their appropriate gender Sincerely, [redacted] ***