DELTA AIRLINES

Hello,
Please see our response regarding complaint #[redacted] for [redacted] that was received by us on July 15, 2015.
Upon receipt of your complaint, we contacted our Eligibility department and confirmed that the cancelation has taken effect within the normal timeframe. This member’s coverage...

is in arrears and she requested the cancellation on June 30, 2015. The member has to allow time for the request to transmit to CVS Health which occurred July 1, 2015. The deduction taken July 10, 2015, paid for coverage through July 4, 2015, which is one pay cycle beyond the cancellation date and falls within the normal time frame. 
We apologize for any inconvenience this has caused the member. However, a refund is not due based on the coverage guidelines.
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]
 
 
[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.
Upon receipt of the rejection we immediately asked for another review of his health savings account to determine if the loss of $26.46 that was correctly compensated. We were advised that this amount is correct and that is all Mr. [redacted] is owed at this time. We have communicated to the member that we have reimbursed him for the gain lost as a result of the missing payments only to his account. The missing payments have been posted to his account.
I apologize for the frustrations and difficulties you encountered while attempting to resolve this issue and regret that this matter required your time in order to facilitate a resolution. Unfortunately, we are unable to honor your request for compensation. We do appreciate your patience during the time involved in researching and resolving your issue.
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

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 Premium Accounting...

department to have the member’s concerns addressed. We were advised there was a system error that was causing the incorrect premium rate to be reflected on the invoices. It was confirmed that we have updated the member’s premium, in all of our systems, to reflect the non-smoker premium.
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]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

Dear [redacted]    Please see our response to complaint #[redacted] for [redacted] that was received by us on November 30, 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 member’s complaint we reached out to our Consumer Business department to have the member’s concerns reviewed. Based on review of the bill the member received, we confirmed it was generated in error. The $15.87 was written off and the member is currently showing a $0.00 balance.   I apologize for the frustration this situation has caused the member. Aetna’s goal is to provide prompt, accurate responses to inquiries from our constituents.  We regret that this matter required additional follow up from the member in order to facilitate resolution.  This is not indicative of Aetna’s standards and we appreciate the member’s patience during the time involved in researching and resolving his issue.    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,   Kim B. Complaint and Appeals 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]

Complaint: [redacted]
I am rejecting this response. This has happened again just today. Aetna rejected my claim from the same provider siting the reason of "no diagnosis code" on the claim. The diagnosis code is clearly provided on the claim.  They do this every time! I can provide documents and claim numbers as I have copies of the submitted claim.
Sincerely,
[redacted]

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

the complaint reviewed as priority. Our records indicate that the original appeal was received on August 18, 2015, and was being handled as an expedited appeal request. We were requesting a power of attorney from the member’s son; due to [redacted] guidelines we must obtain this to discuss any appeal information. On August 19, 2015, we received a request from the member’s doctor to complete a peer to peer. The member’s medical records were reviewed again by a medical director who overturned the appeal on August 20, 2015, and allowed the member to be transferred to the rehabilitation center.
Please accept my apologies for the difficulties the member has encountered with Aetna. I’m sorry that our representatives were not able to assist the member when his son or he called. Our goal is to provide quality service and satisfaction to our members, and I sincerely regret that the member did not receive the service he should rightfully expect and deserve. His concerns have been forwarded to our management team for improvement opportunities. I hope that going forward we will be able to regain the member’s confidence in us.
We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address [redacted]. 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

Dear Ms. [redacted],
Please see our response to complaint #[redacted] for [redacted] that was received by us on July 15, 2015.
We contacted our Medicare department and asked them to review Mr. [redacted] concerns. They advised that the claim submitted by Dr. [redacted] for March 25, 2015, was...

processed correctly. Dr. [redacted] billed the claim with a nonparticipating tax identification number (TIN), which does not accept the Aetna Medicare PPO plan. Dr. [redacted] is participating under a different TIN than the one used on the claim. However, we cannot tell providers how to bill their claims. The Medicare department sent Mr. [redacted] a letter on August 04, 2015, which includes a detailed explanation of their review and his next steps.
 
I apologize for any difficulties this situation has caused Mr. [redacted].  We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Mr. [redacted] concerns.  If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted]
Regards,
[redacted]
Executive Resolution Team

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  Billing department to determine how the member was enrolled with Autopay. Based on our review, it indicates that the member enrolled her information on April 26, 2015 at 04:39pm. Aetna did not set up this member's Autopay. We did receive the $100.00 payment on July 9, 2015. It was applied to the member's May invoice because it was short paid since her premium due for May was $411.68. Unfortunately, we can not refund the payment.   We apologize for the inconvenience however the member would need to contact the Marketplace to dispute the loss of APTC which increased her premium rates.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

Thank you for your rejection notice received on 07/21/15 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 Claims department, and...

were advised that we have have received one claim for the Emergency Room services which were provided by Dr. [redacted] on 06/11/14, and was paid on 07/04/14, in the amount of $114.04, with the member’s copayment responsibility of $30.00, under payment ID# [redacted]. Any remaining balance is a write-off for the provider and should not bill the member. To date, we have not received a claim from the Hospital/Facility for the Emergency Room services. Therefore, if the facility is participating they would need to resubmit the claim(s) with proof of timely filing to Aetna for consideration.
 
Aetna
Attention: Claims
P.O. BOX [redacted]
[redacted]
 
We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Mr. [redacted] 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 08/06/15 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.
 
The member’s concerns are currently being...

reviewed under appeal numbers [redacted] and [redacted]. The member's will receive a resolution letter with an explanation under separate cover.
 
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 rejection notice received on 06/05/15 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.
 
As previously advised, we reviewed our records to verify if the member called prior to services being rendered to confirm if his Primary Care Physician (PCP) was participating and/or selected as his PCP. The only call on file was pulled, prior to services being rendered, from 12/13/2013, and listened to. The member requested information on how his policy would cover his routine checkups. He stated that he could not locate the provider online as in network and stated he was told by the provider office that he could submit a claim form and the receipt to be considered for reimbursement. The Customer Service Representative (CSR) advised the member that he did not have out-of-network benefits and was required to see only participating providers in order to be covered. The CSR verified for the member that [redacted], MD was a nonparticipating provider, and again reiterated that he must go an in-network (participating) provider to be covered. Therefore, our original determination is correct.
 
We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Mr. [redacted]’ concerns.  If you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted]

Thank you for your inquiry received on 05/12/15 regarding complaint #[redacted] for Anna Knight.  Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.
 
We reached out to Aetna’s Pharmacy Management department...

(APM) for assistance, and were advised that the prior authorization entered to cover these medications under the Part B benefit was incorrectly set up and was not calculating the Part B accumulators.  The prior authorizations have been updated and corrected. This should not happen in the future for these medications.  Also, the claims already filled are being reversed and reprocessed.   We apologize for any inconvenience this has caused the member.
 
 
We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Ms. [redacted] concerns.  If you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted]

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 had someone reach out to Ms. [redacted] to speak with her about having a case manager assigned to her issue. Ms. [redacted] and the Aetna representative spoke in length about this issue and although she does not qualify for a case manager at this time since the surgery has already taken place but we were able to get to the bottom of all the issues Ms. [redacted] was encountering.
We have worked with [redacted] extensively on this issue and we have had all of Ms. [redacted] claims adjusted correctly under Part B of her plan. [redacted] has also corrected their system so that this error will not continue in the future and the medication will process under Part B of the plan.
Please accept my sincere apology for the delay in processing your claims correctly, and that it required multiple attempts on your part to resolve your issue. Unfortunately, in some instances, procedural 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.
Please also accept my apologies for the difficulties you have encountered with Aetna. I’m sorry that our representatives were not able to assist you on your numerous calls. Our goal is to provide quality service and satisfaction to our members, and I sincerely regret that you did not receive the service you should rightfully expect and deserve. Your concerns have been forwarded to our management team for improvement opportunities. I hope that going forward we will be able to regain your confidence in us.
We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Ms. [redacted] concerns. If you have any additional questions regarding this particular matter, please do not hesitate to contact the Executive Resolution Team at [redacted]
 
Thank you,
[redacted]
Complaint and Appeal Consultant
Executive Resolution Team

Thank you for your inquiry received on 07/08/2015 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 Dental department for...

assistance, and had the member’s file reviewed.  The Dental department did not locate any phone calls to customer service from the dental provider’s office or the member prior to the services being rendered.  However, there were several inquiries via the automated Aetna Voice Advantage (AVA) system, but no details as to what was discussed or inquired on.  The Dental department called the National Dental provider number to inquire and confirm through the AVA on the coverage information of code [redacted], and heard that this service was not covered under the members plan.  This is what the dental provider’s office would have heard if they had inquired via the AVA.  The AVA for members does not give information for this code.  The member would have been transferred to a live Customer Service representative in order to get this information.  To date, there is no record of a call from the member prior to the services being rendered. Additionally, there is no predetermination request on file that would have advised both the member and provider that the services was not covered. Therefore, the member was not misquoted nor given an estimate for the services in question.
 
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]

My advocate was told by [redacted] on 5/20/15 that she is no longer handling my case and that she would have an Aetna rep get back to her; however, as of 6/1/15, no one has gotten back to her.
The list is long on passing the buck. It goes back to before the work was done and has a long list of misinformation by Aetna representatives.
 
Complaint: [redacted]
I am rejecting this response because:
Sincerely,
[redacted]

Hello, Thank you for your inquiry, regarding complaint # [redacted] for [redacted]. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you. Upon receipt of the complaint, we contacted our Pharmacy department to address the member’s...

reimbursement request. We found that the member owed a balance for a prescription [redacted] filled on 01/20/16. The member disputed the charges with her credit card company and the card did a charge back to the account for 220.00 on 02/19/2016. On 02/24/2016 her card was charged again because it was the default card on file. The member disputed the charges with her bank again on 03/08/2016 and card did a charge back to her account on 03/08/2016. We have reviewed the member’s file and determined that some of her medications were applied to the plan deductible in error. We have reprocessed the claims. Once completed, a payment will be mailed to the member within 7-10 business. 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

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 sincerely apologize the effective date was a typo in the
previous response. The policy is effective for everyone on the policy effective
January 01, 2016, and shows as active in all of our systems.
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

Thank you for your inquiry received on 05/12/2015 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 the Health Savings Account...

department ([redacted]) for assistance, and found that the two missing contributions have now been reprocessed.  Due to the member shutting off the payroll deposits, they are set to refund into the member’s paycheck for today, Friday 05/22/2015, verses being resent to his [redacted]. An Aetna Client Advocate has been in touch with the member advising him of this information and will continue to be in contact directly with the member until completed. 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] concerns.  If you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at [email protected].

Dear [redacted]:   Please see our response to complaint #[redacted] for [redacted] that was received by us on January 24, 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 member’s complaint, we reached out to our Dental department to address the member’s concerns. As of July 1, 2017, the member enrolled in a new Dental [redacted] plan which no longer had orthodontic coverage. The member’s prior Dental [redacted] plan effective November 1, 2016 through June 30, 2017 had coverage for orthodontic treatment. The member changed plans in the middle of orthodontic treatment, which makes him responsible for the rest of the services. We confirmed that the claim was processed correctly based on the member’s new Dental plan.   The Summary of Benefits (SOB) for the member’s prior Dental [redacted] plan does not mention how we pay the provider because that is the contract between Aetna and the provider. We paid all of the claims up until the member changed dental plans and orthodontic treatment was no longer covered. The plan documents are always available online through the member’s Aetna [redacted] account. The member could have verified that his new plan did not cover orthodontics.   In the SPD section titled, “What The [redacted] Dental Plan Does Not Cover” it states:   “Not every dental care service or supply is covered by the plan, even if prescribed, recommended, or approved by your physician or dentist. The plan covers only those services and supplies that are medically necessary and included in the What the Plan Covers section. Charges made for the following are not covered except to the extent listed under the What the Plan Covers section or by amendment attached to this Booklet-Certificate. In addition, some services are specifically limited or excluded. This section describes expenses that are not covered or subject to special limitations.   …Dental implants, braces, mouth guards, and other devices to protect, replace or reposition teeth and removal of implants.   …Orthodontic treatment except as covered in the What the Plan Covers section.”   While we understand the member’s concerns and recognize this is not the resolution he 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 [redacted]’s concerns. If there are any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted]   Sincerely,   Kim B. Complaint and Appeals Consultant Executive Resolution Team