DELTA AIRLINES

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 regarding the claims from June...

18, 2014. We confirmed the coordination of benefits for this member’s plan. The claims have been reprocessed for both health plans and payment will be made to Dr. [redacted] within 7 – 10 days. We apologize for the inconvenience this has caused.  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, [redacted] Executive Resolution Team[redacted]Complaints and Appeals ConsultantExecutive Resolution Team[redacted]

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 Disability...

department to have the member’s concerns addressed. We were
advised that the claim was finalized on February 17, 2016, and the case manager reached
out to him the same day to advise of the claim decision.
Aetna strives to provide the highest level of service, quality,
and satisfaction, and to continually improve our processes. I want you to know
that we appreciate your feedback because it gives us the opportunity to listen
to our customers and make any improvements to our processes and the service we
provide. Your opinion is valued at Aetna, and I trust that you will not
hesitate to contact us when you need assistance.
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 you have any additional questions regarding this
particular matter, please contact the Executive Resolution Team at [redacted]
Thank you,
Ashley S.
Complaint and Appeal Consultant
Executive Resolution Team

Hello,
Thank you for your inquiry, regarding complaint #[redacted] for [redacted] Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.
Upon receipt of the complaint we immediately reached out to have the call pulled to verify the...

benefits that were provided to the member prior to services being rendered. We confirmed that the customer service representative (CSR) quoted that the procedure would be covered when you have a medical condition that covers/warrants the services. At 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 us. As a one-time exception, we have reprocessed the claims for the two dates in October of 2015 to allow services rendered.
Please allow 7-10 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 Aetna. I would also like to thank you for sharing your experience with us. It 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] 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

Complaint: [redacted]
I am rejecting this response because: I have contacted my HR Department and they said that Aetna sets there premium price. 
Sincerely,
[redacted]

Tell us why here...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 to review the...

member’s concerns.  We found that the lab charges billed from [redacted] were processed correctly. The charges billed were not a part of the preventative services and applied according to the medial benefit.  The benefit states that for diagnostic services billed at a participating lab, 100% is allowed after a $5000.00 deductible is met. The member is responsible for $64.44.We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Mr.  Karran ‘s concerns. If you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] Thank you, LaShonda C.Complaint and Appeal Consultant Executive Resolution Team

Complaint: [redacted]
I am rejecting this response because: Your advertising and marketing of this plan is misleading and deceptive.
Sincerely,
[redacted]

Thank you for your inquiry received on 08/21/15 regarding complaint #[redacted] for [redacted].  Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.
 
We reached out to the Flexible Spending Account...

(FSA) department, and were able to find the system error with the processing of the member’s claims.  All claims have since been reprocessed correctly as of 08/20/15, and a check was issued on 08/20/15. We apologize for any inconvenience this may have caused the member.
  
We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address **. [redacted]’s concerns.  If you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted].

Hello,
Thank you for your inquiry, regarding complaint #[redacted]
for [redacted]. Our Executive Resolution Team researched your concerns, and
I would like to share the results of the review with you.
Upon receipt of the compliant we immediately reached out to
[redacted]...

to confirm the children were not active under the
policy. We were able to confirm the children were never active on any other
plan, making Aetna the primary payer for the claims on file.
After confirming that Aetna is
the primary payer, we immediately reached out to our Claims department to have
all the claims reprocessed and paid as primary to the providers. Please allow
7-10 business days for the providers to receive the payments as well as the
corrected explanation of benefits. Please accept my apology for the delay in
processing the claims correctly, and that it required
multiple attempts on the member’s part to resolve the issue. Unfortunately,
in some instances, errors do occur. When they do, we take them very seriously
and do our best to understand how and why the errors occurred and determine
what we can do to prevent a recurrence.  We
continually use feedback like the member’s to improve our service and prevent issues
from reoccurring.
Our goal is to provide
exceptional service to our customers, and immediately resolve issues when they
do occur. These actions are not consistent with Aetna’s service standards and
we appreciate you notifying us of the member’s experience. I would like to
assure you that we have taken the appropriate actions to address the service
issues the member experienced.
We take customer complaints very seriously and appreciate
you taking the time to contact us and giving us the opportunity to address Dr.
Jain’s concerns. If 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 your complaint, we contacted our Claims department...

and
confirmed that the claim was reprocessed correctly based on our review. The
member is responsible for 10% coinsurance based on the plan benefits. The
claim was reconsidered for an additional payment of $112.70. The customer
service representative did not consider the plan benefit which allows 90% of
the allowed charges. The member’s portion was 10% of this amount so no
additional payment is due for this claim. 
We apologize for any difficulties and 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 [redacted] concerns.
If 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

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]

Complaint: [redacted]
I am rejecting this response because Aetna should make good on its representation to my wife and reimburse us the remaining $11.27 which Aetna acknowledged was attributable to customer service representation error. :
Sincerely,
[redacted]

Dear Ms. [redacted]
*Please see our response to complaint #[redacted] for [redacted] that was received by us on June 22, 2016. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you. Upon receipt of the complaint we...

immediately reached out to our Claims department to have the date of service reviewed. We were advised that the provider submitted a corrected claim on March 28, 2016, which was processed correctly per the plan benefits. The benefit for these services rendered, when completed by an out of network provider, is to cover any lab work at 60% after the deductible is met. At the time of service the member’s deductible had not been met, so it correctly applied the member’s responsibility to the deductible, for the services that were rendered.  While we understand the concerns and recognize this is not the resolution the member sought, our decision remains unchanged. Our actions are solely guided by the plan guidelines in order to administer fairly and equitably to all participants. The member does a second level of appeal if he wishes to pursue another review of the claim.  We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Mr. Gibbins’ concerns.  If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] Sincerely, Ashley W.Complaint and Appeals ConsultantExecutive 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]

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] received on 09/23/15 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 Provider Network...

department and confirmed that this provider is contracted with Aetna. [redacted] applied for credentialing in [redacted] on 11/06/14. The provider was credentialed and approved on 12/26/14. A contract was not sent to this provider until 02/26/15. The provider countersigned on 03/02/15. Based on our review, we will approve the contract as of 01/01/15 to cover the multiple rejected claims on file. We will submit a claims project to reprocess the claims. We have contacted this provider to confirm our findings. We will also terminate the [redacted] service location once we confirm with the provider.
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, LaShonda 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 your inquiry, we contacted our
Billing department regarding this member's complaint. We have confirmed that the employer, specifically The Office of Personnel Management, changes
the premiums each year on their website. For 2015, general information was
released on 9/29/15 and can be found at the link: [redacted] .
The premiums are also notated in every plan brochure, available on
line. The federal government has a “Green Initiative”, and does not distribute
brochures. The
eligibility I currently show continues to be enrollment code JS1 for single
coverage [redacted] which indicates the member should still be paying the $105.17
premium. We cannot change the member’s plan or refund any monies paid toward
her premium. Ultimately, she must resolve her intent with her payroll
department as stated previously. 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, 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 October 7, 2016. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you. Upon receipt of the complaint, we contacted our Claims department to address the member’s concerns. We verified that all claims have been reviewed and reprocessed to show the correct rate. We also confirmed that the provider’s contracted rate is $65 for HMO products. The $80 rate is for non-HMO products.  We apologize for the inconvenience in regards to the delay in processing the member’s claim. We have provided feedback to improve service and to prevent these issues from reoccurring. We appreciate the member’s comments and have submitted the recommendations to leadership for review. 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, [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.
We have worked with the member throughout the process to review
the surgery and provider performing the surgery. We have approved the surgery
as all criteria have been met and the member and provider have both been
informed of the approval. We are now in negotiations with both the facility and
the provider to come to an agreement for the payment of the surgery.
I will continue to be in touch with the member and the
provider’s office throughout the agreement until a decision is made and the
surgery date is set. I spoke with the member again today to reassure that I
will continue to follow this case up until the surgery.  
We take customer complaints very seriously and appreciate
you taking the time to contact us and giving us the opportunity to address Ms.
Head’s 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

Thank you for your inquiry received on 09/15/15 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 Individual Plan’s department, and...

the member is not due a refund.  According to the member’s record, the Marketplace stated he was not eligible for a tax credit for the month of January 2015, so he was billed the full premium of $239.83.  Aetna does not control or determine eligibility of tax credits for Marketplace members, and cannot make any changes without permission from the Marketplace.  A refund of $216.00 was processed in error on 01/23/2015, and sent back to the member’s credit card.  A plan change and premium change was received from the Marketplace on 01/12/2015, and was made effective 02/01/2015.  The February bill then produced the charge back of the $216.00 that was refunded in error and the new rate of $23.83.  If the member is disputing that he should have a tax credit for the month of January, then he needs to contact the Marketplace at ###-###-####.
Furthermore, the ebilling system was down previously, but the issue is now resolved and the member should now be able to access his account. We apologize for any inconvenience this may have caused the member.
 
We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address 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.
Upon receipt of the complaint we immediately reached out to our Claims department to verify...

if the claim was denied correctly. We were advised that the member was within the waiting period of 12 months to have any Type C Services dental work done and the claim was denied correctly.
As stated in the Benefit Plan Booklet-Certificate:
Your Effective Date of Coverage With respect to Type A and B Services, your coverage takes effect on the later of:
-- The date you are eligible for coverage; and
-- The date you return your completed enrollment information.
With respect to Type C Services, if you are then in an Eligible Class, will be the Effective Date of this Plan. Otherwise, your coverage takes effect after 12 months of continuous service under the Plan.
Type C Expenses: Major Restorative Care
...
Inlays/Onlays
...
Our records reflect your original effective date is October 1, 2014, with a 12 month waiting period. Since this criterion was not met, benefits are not eligible under the plan for the service performed June 3, 2015. Unfortunately, your claim was denied based on your plan's limitation on Type C dental work; therefore, we are unable to pay your claim.
Aetna does care about the safety and health of our members and I empathize with your situation. While we understand your concerns and recognize this is not the resolution you sought, our decision remains unchanged. Our actions are solely guided by the plan guidelines in order to administer fairly and equitably to all participants. We have attached the member's plan documents which explains the coverage waiting period.
We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Mr. [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