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My advocate was told by [redacted] on 5/20/that she is no longer handling my case and that she would have an Aetna rep get back to her; however, as of 6/1/15, no one has gotten back to her The list is long on passing the buckIt goes back to before the work was done and has a long list of misinformation by Aetna representatives Complaint: [redacted] I am rejecting this response because: 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 our Pharmacy Pre-Certification department to verify if we had received any forms from the doctor’s office for a pre-cert for a brand name medicationWe did not find any forms on file, so we faxed to the office the pre-cert form on May 22, to the number provided to usWe received a confirmed receipt for the form, please see below: Your fax was successfully sent to Dr*** Fax number: [redacted] Subject: Pre-Auth Form Status: (success) Completed: 1:42:PM, Friday, May 22, Sent pages: of Duration: 0:00: Please accept my apologies for the difficulties you have encountered with AetnaOur goal is to provide quality service and satisfaction to our members, and I sincerely regret that you did not receive the service you should rightfully expect and deserveYour concerns have been forwarded to our management team for improvement opportunitiesI hope that going forward we will be able to regain your confidence in us We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address 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

Complaint: [redacted] I am rejecting this response because:I need to hear what they believe I still oweI was also turned in to a collection agency due to the error in processingI need to have these problems addressedI thank them (and the Revdex.com) for their help in continuing to find resolution to this matter 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 reviewed our records to verify if Mr [redacted] called prior to services being rendered to confirm if his primary care physician (PCP) was participatingWe had the only call on file pulled, prior to services being rendered, from December 13, 2013, and had it listened toMr [redacted] requested information on how his policy would cover his routine checkup with his providerHe stated that he could not locate the provider online as in network and that the office stated he could submit a claim form and the receipt to be considered for reimbursementThe customer service representative (CSR) advised Mr [redacted] that he did not carry out of network benefits and would be required to be seen by a participating provider to be able to be coveredThe CSR asked for the doctor’s name and said that she would verify if the provider was participating with his planMr [redacted] advised the doctor was [redacted] ***, and the CSR confirmed the doctor was not participating with his planThe CSR again reiterated that he must go in network to be covered for a checkup visit We are not able to retro a PCP on file to cover a claimIt is the member’s responsibility to verify that everything on file is correct prior to being seen by the physicianDue to the information provided our original determination was correct in denying the date of service April 28, We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Mr [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

Thank you for your inquiry received on 05/18/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 [redacted] [redacted] (***) for assistance, and were advised that [redacted] is considered a maintenance medication, as it typically used daily to improve urinationWe have explained this member’s unique situation to the plan, and they have approved an override to bypass the maintenance choice requirement for the next refillsIf the member is still using the medication after more refills, we can revisit and review at that time 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]

Complaint: I am rejecting this response because:Per conversation with [redacted] at Aetna yesterday, Aetna has agreed to compensate me $for losses related to my health savings account due to Aetna’s and [redacted] negligence This is absolutely unacceptable I would estimate that the loss in value alone of my health savings account would likely exceed $ Furthermore, I expect compensation for the time I have wasted dealing with Aetna regarding this matter I will continue my efforts at resolution through all available avenues Sincerely, [redacted]

Thank you for your rejection notice received on 06/05/regarding complaint # [redacted] for [redacted] Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you As previously advised, we reviewed our records to verify if the member called prior to services being rendered to confirm if his Primary Care Physician (PCP) was participating and/or selected as his PCPThe only call on file was pulled, prior to services being rendered, from 12/13/2013, and listened toThe member requested information on how his policy would cover his routine checkupsHe stated that he could not locate the provider online as in network and stated he was told by the provider office that he could submit a claim form and the receipt to be considered for reimbursementThe Customer Service Representative (CSR) advised the member that he did not have out-of-network benefits and was required to see only participating providers in order to be coveredThe CSR verified for the member that [redacted] ***, MD was a nonparticipating provider, and again reiterated that he must go an in-network (participating) provider to be coveredTherefore, our original determination is correct 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]

Complaint: [redacted] I am rejecting this response because: I purchased prescriptions after my employment date of 1/26/including the flu vaccinationYou have not paid me for the prescriptions purchased in February and the flu shotI will continue to escalate this as now you have not paid for general annual blood tests in the amount of $90.I HAVER NEVER HAD HEALTH INSURANCE ISSUES PRIOR TO THESE MULTIPLE EXPERIENCES WITH AETNA Sincerely, [redacted] ***

Thank you for your inquiry received on 05/12/regarding complaint # [redacted] for Anna Knight 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 Pharmacy Management department (APM) for assistance, and were advised that the prior authorization entered to cover these medications under the Part B benefit was incorrectly set up and was not calculating the Part B accumulators The prior authorizations have been updated and correctedThis should not happen in the future for these medications Also, the claims already filled are being reversed and reprocessed We 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] concerns If you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted]

First it says my initial visit is covered which is not true I was charged a $copaySecond it says no limits but then in the next paragraph it states prenatal is limited toThey are contradicting themselvesUltrasounds are routine to prenatal how can they not be covered? Meanwhile I have an email from another Aetna rep stating my ultrasounds are covered 100% and I am only responsible for a $copay Complaint: [redacted] I am rejecting this response because: 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 reviewed our records which indicated that Ms [redacted] currently has an appeal open, received the same day as the Revdex.com complaint was receivedPlease allow this complaint to be reviewed under the appeal which requires clinical reviewThe case number for your records is [redacted] and has a due date of July 18, The member can expect a letter to be mailed to her home address with the decision of the appeal 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

Thank you for your inquiry received on 05/14/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 Life Insurance department for assistance, and were advised that the claim was processed and paid on 05/07/2015, in the amount of $under check number [redacted] to the estate of [redacted] and mailed to Mr [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] ’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 06/01/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 Pharmacy Management department (APM) for assistance, and were advised that the member tried to obtain a refill of [redacted] on 05/27/at Public Pharmacy, and the claim was denied as being too early to refillThe member had filled a day supply of [redacted] at Public Pharmacy last on 04/19/2015.The plan has a 75% utilization requirementTherefore, a refill is not available on a day supply until after days has passed from the previous fillIn this case, the member would not have been eligible for a refill until on or after 06/03/The member had enough medication to last through the termination dateThe member’s termination date was 05/31/ Additionally on 05/29/2015, the member contacted APM’s Customer Care and requested that he be provided with an early refill for vacationThe request was deniedThe member was traveling domestically to an area where there are participating pharmaciesThe plan will consider vacation supplies as a courtesy when the member is leaving the country and will not have access to a network of participating pharmacies The member then called a second time on 05/29/2015, and indicated that the medication was damaged or defectiveAetna’s standard is that replacement supplies for Lost/Stolen or Damaged Medications are excluded 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]

Complaint: [redacted] In response to Aetna: "he would be required to be seen by a participating provider to be able to be covered" and this is precicely what I didI verified with Dr [redacted] office that they were in networkAfter the office visit I never received any notification from Aetna stating that my claim had been deniedI only found out that there was a problem when [redacted] contacted me, almost SIX MONTHS LATER! Sincerely, [redacted]

Thank you for your inquiry received on 05/11/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 our Claims department for assistance, and were advised that the claim was processed correctly under the member’s out-of-network benefits for using a nonparticipating laboratory, and applied to their out-of-network deductible and coinsuranceUnder the terms of the member’s plan, Out-of-Network Laboratory services are covered at 50%, after the deductible is satisfiedThe member has a $5,individual Out-of-Network deductible responsibility and the deductible has not been satisfied for We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Mrs [redacted] 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 05/26/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 our Individual plan department for assistance, and were advised that they have credited the member’s account $to cover the fee However, we will not refund that as the account is still active The June draft will take $instead of the $ Also, please be advised, the member may cancel the Automatic EFT (Electronic Funds Transfer) at any time and opt for paper billing where we send an invoice each month 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]

Thank you for your inquiry received on 05/26/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 our Claims department and requested a claims audit to be done on Mr [redacted] daughter [redacted] claims for the year of An audit has been completed and the majority of the claims for her fall under “early intervention” and the state of [redacted] require that we pay for these services in fullMost of the member’s claims did have to be reprocessed because the system did not apply the charges correctlyTherefore, the deductible was indeed not been met for the year, as the member’s financial responsibilities only had $applied to that deductible The claims have now been reprocessed and correctedWe 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 Mr [redacted] ‘s concerns If you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted]

Hello, Thank you for your inquiry, regarding complaint # [redacted] for [redacted] ***Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you We show that this complaint was already reviewed and responded to under previous Revdex.com case [redacted] We had the complaint reviewed again to make sure the original determination was correctWe verified that our previous response was correct regarding the coverage for codes [redacted] and ***We mailed a check to the member on October 08, for $1,for code ***The procedure code [redacted] is not being denied at this point for medical necessity, the procedure is being considered incidental to code [redacted] so an additional payment of $will not be allowedWe have had this reviewed under appeal case [redacted] , where a medical director agreed with this determinationWhen a code is incidental the charge for the service (***) is not payable because it is considered part of another procedure (***) performed on the same date and is included in that payment of *** While we understand your concerns and recognize this is not the resolution you sought, our decision remains unchangedOur actions are solely guided by the plan guidelines in order to administer fairly and equitably to all participants We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Mr***’ 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

Complaint: [redacted] I am rejecting this response because: Supposedly the money was sentIf this is actually the case, then it will be acceptedI am taking all precautions since from day one, including submissions here, there have been inaccurate commitments Sincerely, [redacted]