DELTA AIRLINES

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]

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

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

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 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

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

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: I did not complain about correspondence regarding policy options, as this dishonest "response" claims. I complained about the advertising junk mail they refuse to stop harassing me with, and I am prepared to Take further action if forced, and if they continue in their refusal to cease and desist. 
[redacted]

Dear Ms. [redacted]:   Please see our response to complaint #[redacted] for [redacted] that was received by us on November 10, 2017.  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 member’s file to have the member’s concerns addressed. I requested that a Supervisor who handles this member’s account through the employer contact her directly to attempt to resolve. At this time we discovered that the doctor that referred her son referred them to [redacted]. The member went to the center in [redacted] and the sign read [redacted] and also [redacted]. It appears that the services were actually performed by [redacted] which does the billing through [redacted] Hospital. The member understands that we quoted her the correct rate for [redacted] and that the issue lies with the bill that was received from [redacted] Hospital not [redacted].   The member asked to the Supervisor to contact [redacted] to clarify the billing and to follow up with her on the findings. We did advise the member that in order for us to make any changes to this billing we would have to have a corrected bill from [redacted]. The Supervisor spoke to a representative at [redacted]. She advised that if an [redacted] provider refers the patient to them it is then billed as an [redacted] provider [redacted] Hospital. If a non [redacted] provider refers the patient to them it is billed by [redacted]. The representative also advised there are signs within the facility to warn the patients. However, she was going to escalate the issue to her manager and will follow up with the Supervisor the week of November 27, 2017. The Supervisor followed up with [redacted] and shared the above information with her and advised her we would follow up with her the same week after talking to the facility. We will continue to work directly with this member in an attempt to resolve this to the member’s satisfaction.      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].   Sincerely,   Ashley W. Complaint and Appeals Consultant Executive Resolution Team

Complaint: [redacted]
I am rejecting this response because:I dont have the cards in hand.  Once I receive the cards, I will review them to ensure they have the correct information and I will be in touch.I will not close the case until 100% certain the cards are correc**Revdex.com, can you fix my name on your website?Thanks
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 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 06/30/2015 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 Aetna’s Eligibility department...

for assistance, and the member was on a low deductible plan from 04/01/2013 to 03/25/2015. Then, transferred to a [redacted] plan effective 03/22/2014, until 03/25/2015, and was on the correct plan. The member was only on the high deductible plan from 04/01/2015 to 04/30/2015.  There is only one outstanding claim for both Mr. and Mrs. [redacted], which have been sent for reconsideration. A new Explanation of Benefit (EOB) will be mailed under separate cover 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 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

Thank you for your inquiry received on 06/01/2015 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 Aetna’s Pharmacy Management department (APM) for assistance, and were advised that the member tried to obtain a refill of [redacted] on 05/27/2015 at Public Pharmacy, and the claim was denied as being too early to refill. The member had filled a 60 day supply of [redacted] at Public Pharmacy last on 04/19/2015.The plan has a 75% utilization requirement. Therefore, a refill is not available on a 60 day supply until after 45 days has passed from the previous fill. In this case, the member would not have been eligible for a refill until on or after 06/03/2015. The member had enough medication to last through the termination date. The member’s termination date was 05/31/2015.
 
Additionally on 05/29/2015, the member contacted APM’s Customer Care and requested that he be provided with an early refill for vacation. The request was denied. The member was traveling domestically to an area where there are participating pharmacies. The 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 defective. Aetna’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]

Thank you for your inquiry received on 06/01/2015 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 Aetna’s Pharmacy Management...

department (APM) for assistance, and our records indicate the member’s effective date of coverage is 01/26/2015. If the member purchased medications prior to that date before her employment started, then there was no active coverage and the medications are not eligible for reimbursement.     
 
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] 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 correct. We verified that our previous response was correct regarding the coverage for codes [redacted] and [redacted]. We mailed a check to the member on October 08, 2014 for $1,227.80 for code [redacted]. 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 $210.00 will not be allowed. We have had this reviewed under appeal case [redacted], where a medical director agreed with this determination. When a code is incidental the charge for the service ([redacted]) is not payable because it is considered part of another procedure ([redacted]) performed on the same date and is included in that payment of [redacted].
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 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]
 
Thank you,
[redacted]
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]

Revdex.com res sent 05/15/17 @ 05:12pmDear [redacted]: Please see our response to complaint #[redacted] for [redacted] that was received by us on May 09, 2017. 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 Overpayment department to address the member’s concerns. We have confirmed that all pended overpayments have been stopped. We are no longer pursuing funds from your providers, since the member was active during the date of services. We also verified that all claims where money was recouped from the provider’s, have been reprocessed and  payments reissued. Please allow time for payments to be processed and posted by each 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 there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] Sincerely, LaShonda C.Complaint and Appeals Consultant Executive Resolution Team

Complaint: [redacted]
I should get a full refund.  It's obvious your online billing system is filled with glitches.  It's not my fault that your system was unable to process my request.  It is downright criminal that you would erroneously bill me with your inefficient system and have the audacity to refuse to give me a refund.
Sincerely,
[redacted]