Hello, Thank you for your inquiry, regarding complaint # [redacted] for [redacted] ***Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you Upon receipt of the complaint we immediately reached out to our Claims department to have the member’s claims reviewedWe were advised that the services rendered require medical records to be submitted by the providerAt this time we have yet to receive the medical records requested from the provider so we are unable to process the claimOnce they are received we will be able to process the claims for any benefits available under the plan Our goal is to provide accurate and reliable information when you need it and to immediately resolve issues when they do occurPlease 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 reoccurringYour concerns have been forwarded to our management team for improvement opportunities We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address [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 you We sincerely apologize the effective date was a typo in the previous responseThe policy is effective for everyone on the policy effective January 01, 2016, and shows as active in all of our systems 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
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 Eligibility department to verify the member’s termination dateWe confirmed it should reflect terminated on June 30, 2015, not May 11, We are having our eligibility department update the termination date to reflect June 30, We also had our Claims department adjust any claims that were affected by the incorrect termination date on fileBoth dates of services on May 29, 2015, were sent for reprocessing and have been paid to the providerThe new claim IDs for the member’s records are: [redacted] - paid $and [redacted] - paid $ Please accept my apology for the incorrect termination date on file which led to a delay in processing your claims correctly, and that it required multiple attempts on your part to resolve your issueUnfortunately, in some instances, procedural errors do occurWhen they do, we take them very seriously and do our best to understand how and why the errors occurred and determine what we can do to prevent a recurrenceWe continually use feedback like yours to improve our service and prevent issues from reoccurring We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Mr***’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
Thank you for your rejection notice received on 07/21/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 Claims department, and were advised that we have have received one claim for the Emergency Room services which were provided by Dr [redacted] on 06/11/14, and was paid on 07/04/14, in the amount of $114.04, with the member’s copayment responsibility of $30.00, under payment ID# [redacted] Any remaining balance is a write-off for the provider and should not bill the memberTo date, we have not received a claim from the Hospital/Facility for the Emergency Room servicesTherefore, if the facility is participating they would need to resubmit the claim(s) with proof of timely filing to Aetna for consideration Aetna Attention: Claims P.OBOX [redacted] 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 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 January 31, 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 and Customer Service department to have the member’s concerns reviewedWe were advised that the claim was submitted electronically to Aetna with the incorrect member information and our system processed the claim without the logic of the member’s demographic information not matchingUnfortunately, this is a learning curve for Aetna and we are working to have our system distinguish this information going forward to try to prevent this type of situation occurring for our membersOur records indicate that we have corrected this claim and zeroed out this claim under [redacted] ***’s policy and have processed the claim under the correct member at AetnaThe provider has also been educated on the issue and to be sure the correct information is submitted to Aetna for their patients Concerning the customer service the member experienced, our goal is to provide exceptional service to our customers, and immediately resolve issues when they do occur I sincerely apologize for the difficulties the member experienced and that we did not provide the level of service that the member rightfully expects and deservesThese actions are not consistent with Aetna’s service standards and we appreciate the member for notifying us of the experienceI would like to assure the member that we have taken the appropriate actions to address the service issues the member experienced I apologize for the frustrations and difficulties the member encountered while attempting to resolve this issue and regret that this matter required much of your time in order to facilitate a resolutionWe do appreciate the member’s patience during the time involved in researching and resolving the issue We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address [redacted] concerns If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] Sincerely, Ashley WComplaint and Appeals Consultant Executive Resolution Team
Complaint: [redacted] I am rejecting this response because: I want it to be noted I have not received any such phone calls as I would have jumped at the chance to speak with someone other than "let me pass it on to my supervisor and someone will get back to you"I have been waiting for a call back from a supervisor since my initial call in DecemberIt wasn't until these contacts through the Revdex.com that I now have two correspondence emailsNo responses from my initial complaints through customer service, no phone calls since filing this complaintI have requested to hear the recorded calls and to no availI clearly understand now the individual co pays for mom and baby as it has FINALLY been explained to meHad this information been presented to me a year ago when I was initially inquiring on my expected fees there would not be any disputesIt's this simple: "I'm pregnantWhat are my expected fees if I deliver at hospital A as I'm trying to decide between my (employer) hospital and this other and I do not want any surprise bills?" "$You have no deductible, which some people have, so you are only going to pay $500." Twice this happened with no mention of a second copay for baby from either repWhen a member calls, twice, to make sure they have accurate information and the rep verifies benefit/copay amounts, on two separate occasions, I think it's fair to believe the presented information is accurate when what it stated are identical responsesThere was no room for error or misinterpretation in my questioning or answers receivedAt this point in time, I will be proceeding through small claimsThank you, Revdex.com, for providing me the channel to have dialogue with someone higher up Sincerely, [redacted]
Revdex.com: I have reviewed the response made by the business in reference to complaint ID [redacted] and find that this resolution is satisfactory to me Sincerely, [redacted] ***
Hello, Thank you for your inquiry, regarding complaint # [redacted] for [redacted] Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you Upon receipt of the complaint we immediately reached out to have the call pulled to verify the benefits that were provided to the member prior to services being renderedWe confirmed that the customer service representative (CSR) quoted that the procedure would be covered when you have a medical condition that covers/warrants the servicesAt the time the member had not been seen by the provider so was unable to provide the CSR with the diagnosis code to completely verify the coverage under the plan When the claims were submitted to Aetna they were denied as not covered based upon the diagnosis that was sent to usAs a one-time exception, we have reprocessed the claims for the two dates in October of to allow services rendered Please allow 7-business days for your provider to receive any payment made on the claims Going forward if the member wishes to seek these services the member or provider must call our pre-certification department to request a review be completed for coverage under the plan or the member could be responsible for any billed expenses Please accept my apology that we did not provide the level of service that you rightfully expect and deserve, and my assurance that your concerns are getting the highest level of attention at 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 the complaint, we contacted our Pharmacy department to address the member’s reimbursement requestWe found that the member owed a balance for a prescription [redacted] filled on 01/20/The member disputed the charges with her credit card company and the card did a charge back to the account for on 02/19/On 02/24/her card was charged again because it was the default card on fileThe member disputed the charges with her bank again on 03/08/and card did a charge back to her account on 03/08/We have reviewed the member’s file and determined that some of her medications were applied to the plan deductible in errorWe have reprocessed the claimsOnce completed, a payment will be mailed to the member within 7-businessWe 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 CComplaint and Appeal Consultant Executive Resolution Team
Revdex.com: I have reviewed the response made by the business in reference to complaint ID [redacted] , and find that this resolution is satisfactory to me Sincerely, [redacted]
Dear [redacted] ***: Please see our response to complaint # [redacted] for [redacted] that was received by us on May 25, Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you We had all the calls on file, prior to services being rendered reviewed, back to August of to confirm the information provided to the memberThere was a call on November 06, 2017, where the member was inquiring about [redacted] The representative advised the member that this place would be out-of-network for his planThe member asked what providers would be considered in-network and the representative advised the following: o [redacted] *** The member then also asked to verify if a provider was participating, [redacted] with [redacted] , [redacted] The representative advised this particular provider does not participate with your plan; therefore, he is out-of-network for your planThe member then asked to check his primary care physician to see if he was in-network, [redacted] with [redacted] ***, zip ***The representative advised this provider was also out-of-network for the plan The member got upset and said he would have to change six of his providers and it wasn’t worth it to have to do all of that for this insuranceThe member also asked for costs of out-of-network providersThe representative went over the out-of-network deductible and coinsurance rates, as well as the out-of-network benefits We are not able to release call recordings without a court affidavitOur calls are recorded for training and quality purposes onlyThey will not be released to a member or an independent company to be reviewed We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address [redacted] concerns If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] Sincerely, Ashley 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 the complaint we immediately reached out to the Eligibility and Billing department for the member’s employer to verify why there was an increase in premiumsWe were advised that this member has the [redacted] planAetna does send out notifications each year of the benefit changes and ratesFederal members have a choice; it is a passive enrollment, meaning if they do nothing, they will stay in the same planThis letter is sent to all members and is mandatory from Office of Personnel Management (OPM)The member needs to refer to her Human Resources department in regards to the premium amounts, as Aetna has no control in the premium rate changes, Aetna is strictly an administrator in the plan benefits This member has been receiving this letter each October since she has been a member with AetnaThe address that we have on file is [redacted] ***, [redacted] , **, *** Also, the member is still in the old enrollment codeWe continue to send her letters to switch her enrollment code to the correct one for her areaI have attached a copy of this year’s letter that has already went out to members We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Ms [redacted] ’s concerns If you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] Thank you, Ashley S Complaint and Appeal Consultant Executive Resolution Team
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 requested a copy of the letter to confirm the information the member is requestingWe were able to verify the medical records request was mailed on September 14, 2015, to address: [redacted] Records were sent to the main office address on file instead of to the individual doctors since the member was seen by more than one doctor in the date range records were requestedWe requested records for any services rendered from August 20, through September 19, Once the records are received we will be able to review the claims on file for any benefits available under the planIf the provider has not received this letter, they can contact our Provider Service Center and have the letter regeneratedThey can reference document control number: [redacted] when calling for a copy of the letter 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
Thank you for your inquiry received on 07/08/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 Dental department for assistance, and had the member’s file reviewed The Dental department did not locate any phone calls to customer service from the dental provider’s office or the member prior to the services being rendered However, there were several inquiries via the automated Aetna Voice Advantage (AVA) system, but no details as to what was discussed or inquired on The Dental department called the National Dental provider number to inquire and confirm through the AVA on the coverage information of code ***, and heard that this service was not covered under the members plan This is what the dental provider’s office would have heard if they had inquired via the AVA The AVA for members does not give information for this code The member would have been transferred to a live Customer Service representative in order to get this information To date, there is no record of a call from the member prior to the services being renderedAdditionally, there is no predetermination request on file that would have advised both the member and provider that the services was not coveredTherefore, the member was not misquoted nor given an estimate for the services in question 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]
During our review, we reached out to our Enrollment department to address [redacted] ’ [redacted] concernsHowever, [redacted] ’s information was not found in our system which required [redacted] to be contacted.An outbound call was placed to [redacted] by our Enrollment department so we could address *** [redacted] concernsHowever, there was no answer from [redacted] , so a detailed voicemail was left including the nature of the call and a direct call back number ###-###-####This way [redacted] may call our Enrollment department directly so her concerns may be addressed.I apologize for any difficulties or confusion this may have caused [redacted] We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address [redacted] ’s concerns If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] Regards,Julian C***Executive Resolution Team
Hello, Thank you for your inquiry, regarding complaint # [redacted] for [redacted] ***Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you Upon receipt of the complaint we immediately reached out to our Claims department to have the member’s claims reviewedWe were advised that the services rendered require medical records to be submitted by the providerAt this time we have yet to receive the medical records requested from the provider so we are unable to process the claimOnce they are received we will be able to process the claims for any benefits available under the plan Our goal is to provide accurate and reliable information when you need it and to immediately resolve issues when they do occurPlease 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 reoccurringYour concerns have been forwarded to our management team for improvement opportunities We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address [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 you We sincerely apologize the effective date was a typo in the previous responseThe policy is effective for everyone on the policy effective January 01, 2016, and shows as active in all of our systems 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
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 Eligibility department to verify the member’s termination dateWe confirmed it should reflect terminated on June 30, 2015, not May 11, We are having our eligibility department update the termination date to reflect June 30, We also had our Claims department adjust any claims that were affected by the incorrect termination date on fileBoth dates of services on May 29, 2015, were sent for reprocessing and have been paid to the providerThe new claim IDs for the member’s records are: [redacted] - paid $and [redacted] - paid $ Please accept my apology for the incorrect termination date on file which led to a delay in processing your claims correctly, and that it required multiple attempts on your part to resolve your issueUnfortunately, in some instances, procedural errors do occurWhen they do, we take them very seriously and do our best to understand how and why the errors occurred and determine what we can do to prevent a recurrenceWe continually use feedback like yours to improve our service and prevent issues from reoccurring We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Mr***’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
Thank you for your rejection notice received on 07/21/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 Claims department, and were advised that we have have received one claim for the Emergency Room services which were provided by Dr [redacted] on 06/11/14, and was paid on 07/04/14, in the amount of $114.04, with the member’s copayment responsibility of $30.00, under payment ID# [redacted] Any remaining balance is a write-off for the provider and should not bill the memberTo date, we have not received a claim from the Hospital/Facility for the Emergency Room servicesTherefore, if the facility is participating they would need to resubmit the claim(s) with proof of timely filing to Aetna for consideration Aetna Attention: Claims P.OBOX [redacted] 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 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 January 31, 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 and Customer Service department to have the member’s concerns reviewedWe were advised that the claim was submitted electronically to Aetna with the incorrect member information and our system processed the claim without the logic of the member’s demographic information not matchingUnfortunately, this is a learning curve for Aetna and we are working to have our system distinguish this information going forward to try to prevent this type of situation occurring for our membersOur records indicate that we have corrected this claim and zeroed out this claim under [redacted] ***’s policy and have processed the claim under the correct member at AetnaThe provider has also been educated on the issue and to be sure the correct information is submitted to Aetna for their patients Concerning the customer service the member experienced, our goal is to provide exceptional service to our customers, and immediately resolve issues when they do occur I sincerely apologize for the difficulties the member experienced and that we did not provide the level of service that the member rightfully expects and deservesThese actions are not consistent with Aetna’s service standards and we appreciate the member for notifying us of the experienceI would like to assure the member that we have taken the appropriate actions to address the service issues the member experienced I apologize for the frustrations and difficulties the member encountered while attempting to resolve this issue and regret that this matter required much of your time in order to facilitate a resolutionWe do appreciate the member’s patience during the time involved in researching and resolving the issue We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address [redacted] concerns If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] Sincerely, Ashley WComplaint and Appeals Consultant Executive Resolution Team
Complaint: [redacted] I am rejecting this response because: The doctor's office still has NOT been paid Sincerely, [redacted]
Complaint: [redacted] I am rejecting this response because: I want it to be noted I have not received any such phone calls as I would have jumped at the chance to speak with someone other than "let me pass it on to my supervisor and someone will get back to you"I have been waiting for a call back from a supervisor since my initial call in DecemberIt wasn't until these contacts through the Revdex.com that I now have two correspondence emailsNo responses from my initial complaints through customer service, no phone calls since filing this complaintI have requested to hear the recorded calls and to no availI clearly understand now the individual co pays for mom and baby as it has FINALLY been explained to meHad this information been presented to me a year ago when I was initially inquiring on my expected fees there would not be any disputesIt's this simple: "I'm pregnantWhat are my expected fees if I deliver at hospital A as I'm trying to decide between my (employer) hospital and this other and I do not want any surprise bills?" "$You have no deductible, which some people have, so you are only going to pay $500." Twice this happened with no mention of a second copay for baby from either repWhen a member calls, twice, to make sure they have accurate information and the rep verifies benefit/copay amounts, on two separate occasions, I think it's fair to believe the presented information is accurate when what it stated are identical responsesThere was no room for error or misinterpretation in my questioning or answers receivedAt this point in time, I will be proceeding through small claimsThank you, Revdex.com, for providing me the channel to have dialogue with someone higher up Sincerely, [redacted]
Revdex.com: I have reviewed the response made by the business in reference to complaint ID [redacted] and find that this resolution is satisfactory to me Sincerely, [redacted] ***
Hello, Thank you for your inquiry, regarding complaint # [redacted] for [redacted] Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you Upon receipt of the complaint we immediately reached out to have the call pulled to verify the benefits that were provided to the member prior to services being renderedWe confirmed that the customer service representative (CSR) quoted that the procedure would be covered when you have a medical condition that covers/warrants the servicesAt the time the member had not been seen by the provider so was unable to provide the CSR with the diagnosis code to completely verify the coverage under the plan When the claims were submitted to Aetna they were denied as not covered based upon the diagnosis that was sent to usAs a one-time exception, we have reprocessed the claims for the two dates in October of to allow services rendered Please allow 7-business days for your provider to receive any payment made on the claims Going forward if the member wishes to seek these services the member or provider must call our pre-certification department to request a review be completed for coverage under the plan or the member could be responsible for any billed expenses Please accept my apology that we did not provide the level of service that you rightfully expect and deserve, and my assurance that your concerns are getting the highest level of attention at 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 the complaint, we contacted our Pharmacy department to address the member’s reimbursement requestWe found that the member owed a balance for a prescription [redacted] filled on 01/20/The member disputed the charges with her credit card company and the card did a charge back to the account for on 02/19/On 02/24/her card was charged again because it was the default card on fileThe member disputed the charges with her bank again on 03/08/and card did a charge back to her account on 03/08/We have reviewed the member’s file and determined that some of her medications were applied to the plan deductible in errorWe have reprocessed the claimsOnce completed, a payment will be mailed to the member within 7-businessWe 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 CComplaint and Appeal Consultant Executive Resolution Team
Revdex.com: I have reviewed the response made by the business in reference to complaint ID [redacted] , and find that this resolution is satisfactory to me Sincerely, [redacted]
Dear [redacted] ***: Please see our response to complaint # [redacted] for [redacted] that was received by us on May 25, Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you We had all the calls on file, prior to services being rendered reviewed, back to August of to confirm the information provided to the memberThere was a call on November 06, 2017, where the member was inquiring about [redacted] The representative advised the member that this place would be out-of-network for his planThe member asked what providers would be considered in-network and the representative advised the following: o [redacted] *** The member then also asked to verify if a provider was participating, [redacted] with [redacted] , [redacted] The representative advised this particular provider does not participate with your plan; therefore, he is out-of-network for your planThe member then asked to check his primary care physician to see if he was in-network, [redacted] with [redacted] ***, zip ***The representative advised this provider was also out-of-network for the plan The member got upset and said he would have to change six of his providers and it wasn’t worth it to have to do all of that for this insuranceThe member also asked for costs of out-of-network providersThe representative went over the out-of-network deductible and coinsurance rates, as well as the out-of-network benefits We are not able to release call recordings without a court affidavitOur calls are recorded for training and quality purposes onlyThey will not be released to a member or an independent company to be reviewed We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address [redacted] concerns If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] Sincerely, Ashley 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 the complaint we immediately reached out to the Eligibility and Billing department for the member’s employer to verify why there was an increase in premiumsWe were advised that this member has the [redacted] planAetna does send out notifications each year of the benefit changes and ratesFederal members have a choice; it is a passive enrollment, meaning if they do nothing, they will stay in the same planThis letter is sent to all members and is mandatory from Office of Personnel Management (OPM)The member needs to refer to her Human Resources department in regards to the premium amounts, as Aetna has no control in the premium rate changes, Aetna is strictly an administrator in the plan benefits This member has been receiving this letter each October since she has been a member with AetnaThe address that we have on file is [redacted] ***, [redacted] , **, *** Also, the member is still in the old enrollment codeWe continue to send her letters to switch her enrollment code to the correct one for her areaI have attached a copy of this year’s letter that has already went out to members We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Ms [redacted] ’s concerns If you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] Thank you, Ashley S Complaint and Appeal Consultant Executive Resolution Team
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 requested a copy of the letter to confirm the information the member is requestingWe were able to verify the medical records request was mailed on September 14, 2015, to address: [redacted] Records were sent to the main office address on file instead of to the individual doctors since the member was seen by more than one doctor in the date range records were requestedWe requested records for any services rendered from August 20, through September 19, Once the records are received we will be able to review the claims on file for any benefits available under the planIf the provider has not received this letter, they can contact our Provider Service Center and have the letter regeneratedThey can reference document control number: [redacted] when calling for a copy of the letter 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
Thank you for your inquiry received on 07/08/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 Dental department for assistance, and had the member’s file reviewed The Dental department did not locate any phone calls to customer service from the dental provider’s office or the member prior to the services being rendered However, there were several inquiries via the automated Aetna Voice Advantage (AVA) system, but no details as to what was discussed or inquired on The Dental department called the National Dental provider number to inquire and confirm through the AVA on the coverage information of code ***, and heard that this service was not covered under the members plan This is what the dental provider’s office would have heard if they had inquired via the AVA The AVA for members does not give information for this code The member would have been transferred to a live Customer Service representative in order to get this information To date, there is no record of a call from the member prior to the services being renderedAdditionally, there is no predetermination request on file that would have advised both the member and provider that the services was not coveredTherefore, the member was not misquoted nor given an estimate for the services in question 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]
During our review, we reached out to our Enrollment department to address [redacted] ’ [redacted] concernsHowever, [redacted] ’s information was not found in our system which required [redacted] to be contacted.An outbound call was placed to [redacted] by our Enrollment department so we could address *** [redacted] concernsHowever, there was no answer from [redacted] , so a detailed voicemail was left including the nature of the call and a direct call back number ###-###-####This way [redacted] may call our Enrollment department directly so her concerns may be addressed.I apologize for any difficulties or confusion this may have caused [redacted] We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address [redacted] ’s concerns If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] Regards,Julian C***Executive Resolution Team