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  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 visits. The member would have been responsible for a specialist copay only if she was seen at a doctor’s office. I understand your concerns and recognize this is not the outcome you desired. However, 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] 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

Dear Ms. [redacted]:   Please see our response to complaint #[redacted] for [redacted] that was received by us on August 02, 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 member’s date of service reviewed. We were advised that the claim was originally billed with a modifier and then was corrected to show no modifier. We have confirmed with the provider’s office that a modifier was not supposed to be billed with the claim so we were able to have this corrected and finalized for the member and the provider.   The new claim ID for the member’s records is [redacted] with a responsibility of $129.90 that applied toward the member’s deductible. The corrected explanation of benefits (EOB) will be available to both the member and the provider within 48 hours. Once the provider EOB is available we will contact the office to clarify what the member’s out of pocket responsibility should be for this date of service.   Please accept my apology for the delay in processing the claim correctly, and that it required multiple attempts on the member’s part to resolve the issue. Our goal is to provide accurate and reliable information when the member needs it and to immediately resolve issues when they do occur. Clearly, in this case, we fell short of that goal. We regret that the member’s experience with Aetna was less than satisfactory and hope that we can better assist the member in the future.   We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Ms. Xiao’s 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 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 to our
Eligibility department and also reached out to [redacted] to
confirm the coordination of benefits information (COB). We confirmed that the
policy was active through the employer until May 01, 2015, when the member went
to a [redacted] plan. I have listed below when each plan was primary and secondary:
February 09, 2015 through April 30, 2015-- [redacted] primary,
Aetna secondary
May 01, 2015 through August 15, 2015-- Aetna was primary
because [redacted] became the [redacted] plan
August 16, 2015, through October 31, 2015-- [redacted] is primary
because Aetna became the [redacted] policy, so it reverts back to [redacted] primary
The claims in question were after August 16, 2015, therefor
would need to be billed directly to [redacted] to be paid as primary before Aetna is
able to review as the secondary payer. 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] 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 Roy Freese. 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 request a review of the member’s policy on file. We
were advised by the member's employer, [redacted], to terminate the
policy. The member would need to follow up with their Human Resources
department regarding this issue, as Aetna is only an administrator of the plan
and does not control termination requests. I apologize for the inconvenience
and difficulty this situation 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 [email protected].
 
Thank you,
Ashley S.
Complaint and Appeal Consultant
Executive Resolution Team

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 $220.  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]

Thank you for your inquiry received on 05/26/15 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 our Individual plan department for...

assistance, and were advised that they have credited the member’s account $35.00 to cover the fee.  However, we will not refund that as the account is still active.  The June draft will take $267.93 instead of the normal $302.93.  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].

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 reviewed. We were advised
that the policy will be re-opening with the effective date of January 01, 2016.
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 account. Then the member could call back to make a
payment for February and March. The 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 number. Please have the member
reference case number [redacted] when calling to make his binder payment. Once the
payment is processed and posted in the account the welcome packet and the
member ID card will be sent to the member within 7-10 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 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

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 Enrollment and Eligibility...

department to have the member’s concerns addressed. We were advised that this member changed plan options in 2016. The member changed from the CDHP plan, enrollment code EP1, to the Aetna Direct plan, enrollment code [redacted]
The FEHBP brochure states in section 5: “If you terminate your participation in this Plan, any remaining Medical Fund balance will be forfeited.” If the member would have stayed in the same plan, the funds would rollover from year to year, but due to the plan change the member forfeited the funds in the 2015 account.
We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Mr. Freedman’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

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.
please note - although the monies I paid out of pocket have been reimbursed, it took several weeks to do so. Also, please advise Aetna to check their records. Yes, my son is shown to have been added but due to a 'glitch' in their system it was not being shown properly, therefore causing the doctors office to charge me as if I had no insurance coverage. I was told this by multiple representatives upon calling Aetna. I hope this will not happen again, as this has caused unnecessary stress
Sincerely,
E[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 [redacted]...

department. Our [redacted] department attempted to reach the member
on April 05, 2016, to find out more information regarding the complaint.
Unfortunately, our [redacted] department has yet to hear back from the member
about the details surrounding this complaint. Once we receive more information
and details about this complaint, whether it is related to benefits, customer
service etc. we will be able to research further. Please have the member
contact our [redacted] department if they wish to pursue the complaint further.
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 reviewed all of Aetna’s records from this...

member’s previous complaints and appeals, and our responses which addressed in full detail all of the member’s concerns.
During the period in question, the member had coverage under two policies, one with [redacted] and one with Aetna Life Insurance Company (Aetna). However, the pharmacies were only aware of the individual policy with [redacted] and were not aware that [redacted] had an additional small group policy with Aetna. This resulted in numerous claims not being submitted to Aetna and the member being responsible for out-of-pocket expenses. Some of these claims were processed and then denied for various reasons, such as being filled to soon or pre-certification required.
Our records indicate that Aetna appropriately addressed each concern [redacted] presented to Aetna and the [redacted] (**I) over the past few years.
Aetna did not attempt to intimidate, threaten, delay or deceive [redacted], nor did it attempt to discourage submission of claims. In fact, where Aetna made reference to its legal department or compliance area reviewing the matter, we were only indicating that they were providing a higher level review of [redacted]’s issues to determine if Aetna had appropriately handled his claims. It was not Aetna’s intention to infer that [redacted] was being investigated, only that Aetna’s handling of his claims and concerns was being investigated. If the member has a specific claim or concern at this time that has not been addressed previously we would be more than happy to assist. Otherwise we consider this matter closed.
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 [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 Claims department to verify...

if the services rendered by Dr. [redacted] on August 21, 2014, were paid. We verified that the claim was reprocessed and paid to the provider as an EFT payment on March 25, 2015. The new member Explanation of Benefits (EOB) was mailed the member’s home address on March 25, 2015, reflecting this payment of the claim.
Please accept my apology for the delay in processing your claim correctly, and that it required multiple attempts on your part to resolve your issue. 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,
[redacted]
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 you. Upon receipt of your complaint, we contacted our Claims department for claim review. We...

determined that the services should allow up to the 80th percentile of Fair Health for emergent services. The emergency claims for date of service: July 30, 2015 have been reprocessed. The member and provider will receive an explanation of benefits within 7-10 days. The claim for date of service August 27, 2015 was determined that it processed correctly. The member’s plan states that follow-up care is not considered an emergency or urgent condition and is not covered as part of any emergency or urgent care visit. 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 Mr. C[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   Tell us why here...

Thank you for your inquiry, regarding complaint # [redacted] received on 08/24/15 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 Vision department and verified the spelling of the member’s name. A card was mailed to the member on the 8/21/15. The [redacted] system can confirm when a card was sent but cannot provide an image of the card from that mailing. Since [redacted] cannot verify the image of the card mailed out with [redacted] included, we decided to reissue a second card.  You should receive within 7-10 days.
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]. Thank you,
LaShonda C.
Executive Resolution Team

Dear [redacted]: Please see our response to complaint #[redacted] for [redacted] that was received by us on March 15, 2018.  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 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 B. Complaints and Appeals 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. I must add however that I called [redacted] today and they stated that a payment for $655.98 was made on May 25th and not earlier as Aetna said. The provider also told me that a payment is still pending and Aetna's payment is about $20 short but I will not be responsible for this as I already paid my coinsurance in 2015. Overall, I think I will no longer be billed because I am only responsible for the coinsurance. 
Sincerely,
[redacted]

From: [redacted] Sent: Thursday, May 05, 2016 9:12 PMTo: [email protected]: My Complaint v. Aetna Insurance Co. No. [redacted] Thank you for finally getting someone at Aetna Insurance Company to respond. Despite the information provided in my complaint,...

Aetna claimed it needed more.  I provided it.Then Aetna next said that it needed a signed Authorization from my client in order to communicate with me.  I provided it.An authorization is not necessary, as I am the attorney for the beneficiary under an Aetna Life Insurance Co.  I have been requesting payment from Aetna since February 2015.   All documentation has been provided to Aetna (birth certificate of the beneficiary, who is the son of the decedent, the death certificate, and other documents verifying the familial relationship).   According to one Aetna representative, Aetna completed its review in October 2015.  However, Aetna never paid the benefits.  I have been making numerous telephone calls to Aetna for the past year.  I have been promised return telephone calls, but no return calls are EVER made.  Then on March 21, 2016, I received an email from an Aetna adjuster, Angela P[redacted], who is handling this matter, stating that payment would be made.  She asked "where to send the check" and I provided the mailing address.  However, no payment was made.  I sent a follow up email requesting the status to Ms. P[redacted], but she ignored my inquiry.   After I filed a complaint with you, I did receive a request for more information and an Authorization as stated above.  I provided the Authorization, even though I am counsel for the beneficiary and I have provided Aetna with all of my client's documents.   I expected a response from Aetna, but there has been none.  I find it unconscionable for Aetna to withhold the payment of benefits when its policy states, in black and white, that payment will be made "within 10 days" upon proof.   If Aetna completed its review in October 2015, payment should have been made then.  Instead Aetna waited five (5) months to even communicate its acceptance of the obligation to pay, and even further, Aetna has still refused to make its payment to the beneficiary.  The failure of Aetna to respond to my inquiries, and its neglectful handling of my client's claim, is simply outrageous.   I hope that there is a remedy, not only for my client, one that will penalize Aetna for its sub-standard business practice.  Aetna should pay my client the policy amount, plus attorney's fees and costs, and damages.   If not, I will be filing a claim for bad faith.   Thank you,[redacted]

Thank you for your inquiry received on 06/16/15 regarding complaint #[redacted] for member: [redacted].
You may reference Aetna Case number [redacted], with a due date of 06/30/15.
If you have any additional questions regarding this particular matter, please contact the Executive Resolution...

Team at [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 contacted our Customer Service department to review your...

concerns. We have confirmed that the name change was completed on May 4, 2016. A new medical id card was sent by mail on May 5, 2016. We have also reviewed your claim history and found that there are no claim denials due to this error. We apologize for the inconvenience this has caused you. 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, LaShonda C. Complaint and Appeal Consultant Executive Resolution Team