DELTA AIRLINES

[redacted]   Please see our response to complaint #[redacted] for [redacted] that was received by us on August 31, 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 Pharmacy department to have the member’s concerns reviewed. We were advised that on August 29, 2016 the member’s pharmacy submitted the prescription and it rejected due to his age. A pre-certification was required by the plan and on August 31, 2016, the pre-certification request was received and approved the same day for a one year period for both strengths.   An override was entered effective for a one year period: August 31, 2016, through August 31, 2017, and it included both strengths of the medication. On August 31, 2016, the pharmacy submitted two claims, one for each medication strength. Both were paid and the member is being charged the generic $15 copay per strength dispensed, which is correct - a copay per dispense is the contracted benefit. Our Social Media Resolution Team contacted the member on September 01, 2016, to notify of him directly of the resolution.   Aetna takes seriously the responsibility to ensure that pharmaceuticals are dispensed timely and accurately, realizing that a member’s health and well-being can be dependent on their medication.  We strive to provide the highest level of service and satisfaction for our members, and I sincerely regret that the member did not receive the service he should rightfully expect and deserve.   We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Mr. [redacted].  If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted]   Sincerely,   [redacted] Complaint and Appeals Consultant Executive Resolution Team

From: [redacted]m] Sent: Tuesday, June 28, 2016 4:15 PMTo: [redacted]Subject: Aetna Executive Team- Regarding Complaint #[redacted]Hey Madelyn, I was able to get a resolution for this case. I believe this is another one that we did not get the first notification...

on. Can you reopen this case so I can put my resolution comments in it? I just don’t want it to go unresolved or affect the rating. If you are not able to reopen the case below is my resolution to the member: Dear Ms. [redacted]Please see our response to complaint #[redacted] for Angelique A[redacted] that was received by us on June 18, 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 Billing and Enrollment department to have the member’s concerns addressed. We were advised that the member’s plan was effective June 01, 2016, and they are covered by the Aetna Leap Specialty with a monthly premium due of $812.86. The policy premium of $812.86 is correct, as the primary policy holder listed himself as a smoker and the dependent a non-smoker. Currently the policy is active and paid through June 30, 2016. The original policy quote of $767.45 was based on both members being non-smokers but when the application was processed, the primary listed himself as a smoker; causing the premium to go up to $812.86. If this incorrect, please contact us immediately. We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Mrs. Allen’s concerns.  If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at s[redacted]Sincerely,Ashley W.Complaint and Appeals ConsultantExecutive Resolution Team

Complaint: [redacted]
I am rejecting this response because:Aetna is completely falsifying their statement.  I did call to get my member ID and Aetna COULD NOT provide it to me. I was advised to proceed to urgent care and submit my claim for reimbursement.  I did exactly what I was supposed to do and Aetna did not.  I did not go for an office visit( the office is not open on Saturdays or Sunday's) which is when I went.....a Saturday. Urgent care hours are from 10am - 2 pm on Saturday. To the other point, if it was processed correctly than why was I told repeatedly that my check was in the mail??? I paid over $10,000 in premium payments and used the insurance twice - the first time I paid in full out of pocket and the 2nd time Aetna admittedly filed claim incorrectly but did rectify that situation.  They are completely incompetent (in my experience) and wondering if they are doing this to me out of discrimination.
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 the prior authorization request and the...

appeal request. According to our records our pre-certification department was contacted by the provider on September 14, 2015, and the medical records were received by [redacted] on September 22, 2015. Our medical director reviewed the pre-certification request on September 22, 2015 and a determination was made that same day. We mailed a letter to both the member and the provider advising of the resolution on September 22, 2015, and we verified that the address on file for the member was the address the letter was mailed to.

The appeal request was made on November 27, 2015 by the provider on the member’s behalf. The first page of the appeal request included the pre-certification denial letter dated September 22, 2015, and at the top of the page the provider wrote received on September 30, 2015. The provider’s office was waited almost a month to request the first level appeal. The appeal was closed on December 07, 2015, in a timely manner and a resolution letter was mailed to the facility on the same day.
The member was advised of the resolution by a representative of [redacted] on December 10, 2015, and she also emailed the resolution letter. 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 and our medical necessity guidelines. The member and/or the provider can request another level of appeal by contacting our customer service department or sending a request in writing within 60 calendar days.
Concerning the customer service you experienced, our goal is to provide exceptional service to our customers, and immediately resolve issues when they do occur. I sincerely apologize for the frustrations and difficulties you experienced and that we did not provide the level of service that you rightfully expect and deserve. These actions are not consistent with [redacted]’s service standards and we appreciate you notifying us of your experience. We have addressed your customer service concerns directly with the representatives and supervisors who were involved.

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].com.
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.
Aetna does set the overall price to the government; however, it is the responsibility of the government to decide the portion that they will pay and what the member will pay. This is listed in every brochure, under the “Rates” section. Aetna does not collect premium or eligibility directly from individual members and is not able to refund any premium amounts.
We make every attempt to alert members of premium increases, along with notifying members of their choice to change into the correct enrollment code based on the address that we have on file.
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] 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 to have...

the member’s concerns reviewed. We were advised by the [redacted] department, that The Annual Notice of Change (ANOC) and Explanation of Coverage (EOC) The Centers for [redacted] & [redacted] require us to send a combined ANOC and EOC mailing each year. The ANOC describes the changes to the members plan for the upcoming plan year. The EOC is the actual contract that provides the members plan benefits and guidelines. All of our booklets and mailings are approved by [redacted] and are written according to [redacted] guidelines.
We reviewed the members ANOC/EOC and found the following: Page 54 states: Hospice
The member may receive care from any [redacted]-certified hospice program. The member is eligible for the hospice benefit when their doctor and the hospice medical director have given the member a terminal prognosis certifying that the member is terminally ill and has 6 months or less to live if the members illness runs its normal course. The member's hospice doctor can be a network provider or an out-of-network provider.
Covered services include:
- Drugs for symptom control and pain relief
- Short-term respite care
- Home care
For hospice services and for services that are covered by [redacted] Part A or B and are related to the members terminal prognosis: Original [redacted] (rather than our plan) will pay for hospice services and any Part A and Part B services related to the terminal prognosis. While the member is in the hospice program, their hospice provider will bill Original [redacted] for the services that Original [redacted] pays for.
For services that are covered by [redacted] Part A or B and are not related to the terminal prognosis: If the member needs non-emergency, non-urgently needed services that are covered under [redacted] Part A or B and that are not related to the terminal prognosis, the cost for these services depends on whether the member uses a provider in our plan’s network:
-If the member obtains the covered services from a network provider, the member will only pay the plan cost-sharing amount for in-network services
-If the member obtains the covered services from an out-of-network provider, the member will pay the cost-sharing under Fee-for-Service [redacted] (Original [redacted])
When a member enrolls in a [redacted]-certified hospice program, their hospice services and their Part A and Part B services related to their terminal condition are paid for by Original [redacted], not Aetna [redacted] Select Plan (HMO).
Hospice consultations are included as part of Inpatient hospital care. Physician service cost sharing may apply for outpatient consultations.
Aetna Compassionate Care Program This program offers case management and services to members and their families who are managing the complex and emotional issues involved in advanced illnesses. A nurse case manager by the name of Sue L. will be in contact with you.
We strive to provide the best customer service experience possible and we expect that in all of our departments. We have reviewed your concerns and verified the calls made into our Member Services. We forwarded the issue to the representative’s direct supervisor for education and/or re-training.
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

Complaint: [redacted]
I am rejecting this response because: The issue was not them sending me back my money. The problem was I never gave them the right to take money from my check in the first place. All I did was look at the web site to see what it would cost me if I was to chose another health plane other than the one I already had. When I saw that the amount was extremely too high I clicked out of the whole web site. Not one time did I click onto any thing to accept or agree or want any thing. So why and how did Aetna get the right and permission to start taking money from my check in the first place????.  I want others to know that if they too just look at Aetna's web site they too may be a victim of money theft from their pay check. This is not over and they will be hearing from me more later.  
Sincerely,
[redacted]

Thank you for your inquiry received on 05/11/2015 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 coinsurance. Under the terms of the member’s plan, Out-of-Network Laboratory services are covered at 50%, after the deductible is satisfied. The member has a $5,000.00 individual Out-of-Network deductible responsibility and the deductible has not been satisfied for 2015.  
 
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]

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 claim completed. The claim was finalized on July 29, 2015 under claim ID [redacted] and was paid to the member on July 30, 2015.
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. 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 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 Mrs. [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] 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 information that was provided to the member. Our records indicate that the member advised the customer service representative that this procedure would take place in the provider’s own facility, with the doctor’s name and procedure code. Based upon that description the general benefits were provided to the member.
Information provided through member services is not a guarantee of benefits under the plan. The claim that was submitted to Aetna did not list the services rendered as being taken place in the office setting, instead in an ambulatory surgical center as outpatient surgery. Due to the way the claim was billed it triggered the deductible instead of an office visit copay. The claims in question were processed correctly in accordance to your plan benefits.
I realize that understanding your benefits can be challenging. It is our goal to be there for you when you need us, and I apologize that the assistance you received from our customer service representatives did not meet your needs.

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,
Ashley S.
Complaint and Appeal Consultant
Executive Resolution Team

Thank you for your inquiry received on 07/06/15 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 made several attempts to reach out to Mr. [redacted] for additional information...

and were unable to get ahold of him via email or telephone. Voicemail messages were left with contact phone number for him to call us back so we can assist him. To date, Mr. [redacted] has not returned the phone calls or email. Furthermore, the Pharmacy department reviewed Mr. [redacted] file, and found no denials on file for any medications to date.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].

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 thank you all very much for quickly responding and the courteous follow up call from Aetna's Complaint Dept.
Sincerely,
[redacted]

Complaint: [redacted]
I am rejecting this response because: there are still claims (approx 6) that are still listed as "not approved". I will need proof that ALL claims have been accepted and there EOB via postal mail. I need this proof because Aetna can very easily change the status on their website; which I have personally seen those changes. Aetna between the dates of Feb 9 through Oct 31, 2015 was the only health insurance that was active. 
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.
We requested a copy of the letter to confirm the information
the member is requesting. We 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 requested. We requested records for any services
rendered from August 20, 2015 through September 19, 2015. Once the records are
received we will be able to review the claims on file for any benefits
available under the plan. If the provider has not received this letter, they
can contact our Provider Service Center and have the letter regenerated. They
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] 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 have the calls pulled related to...

the pregnancy coverage prior to services being rendered. The records indicate only general pregnancy benefits were provided during the call from the member. The claims in question were processed correctly in accordance to the member’s plan benefits.
When the child is born and is added to the policy as an individual, the facility is able to bill separately for both mom and child for any charges related to the pregnancy. The submitted charges were sent for both the mom and child; which triggered the individual copays. 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.
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

Complaint: [redacted]
I am rejecting this response because: AETNA ignored the already verified TIN by [redacted] in July. AETNA has made no effort to contact HER. She is in charge of physician contracts.
Sincerely,
[redacted] First name SPELLING correction

Thank you for your inquiry, regarding complaint #[redacted] for Joan H[redacted]. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you. We contacted our Life coverage department to address the complainant concerns regarding a policy for [redacted]...

[redacted].  On May 10, 2016 we received the claims information and an Assignment of Benefits to [redacted]l Funeral Home. We allow up to 30-45 business days for claim processing. The claim was approved for payment and a check was issued in the amount of $3062.94 on July 06, 2016.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

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 back out to our Aetna’s Individual Plans and Eligibility department to have our records again and we have confirmed we do not have the copies of the money orders. We sent an email to the member on August 12, 2015, requesting the member to send in copies of the money orders for our records but we have not heard back from the member as of today. I sincerely apologize for any inconvenience this has caused for the member.
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]
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 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