DELTA AIRLINES

Hello,
Thank you for your inquiry, regarding complaint #[redacted] for [redacted] Arevalo. 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 went back through all the member’s claims for 2014 and created a PDF spreadsheet that breaks down all the claim information for the member’s records. As previously stated the majority of the claims for the member fall under “early intervention” and the state of [redacted] require that we pay for these services in full. The deductible was not met for the 2014 year, as the member’s financial responsibilities only had $215.60 applied to that deductible.  The claims have now been reprocessed and are finalized in Aetna’s system. Again we sincerely apologize for any confusion or inconvenience this has caused the member. The member can either call member services to discuss any questions that he may have or you can log online to your Aetna Navigator account and view your corrected explanation of benefits.
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

I do not accept the response made by the business to resolve this complaint I did in fact send them copies of the money orders they stated they did not receive.

Dear [redacted]: Please see our response to complaint #[redacted] for [redacted] that was received by us on December 6, 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 policy...

information, it was found that this member’s plan is administered through [redacted], an Aetna company.  We reached out to the [redacted] area to assist with our investigation. It was found that the precertification for the procedures involved had been initiated as a routine or screening procedure, but after the clinical information was reviewed the precertification was approved for the diagnostic procedure. However, when the claims were submitted they were billed as routine.  Also, the benefit for these procedures when done as routine in nature does not begin until the age of 50.  The resolution of this issue would require that the providers of the services submit corrected claims as diagnostic.  The Member Advocacy department of [redacted] has been involved and will be contacting the providers of the services.  Once full resolution is obtained, additional outreach will be made to [redacted].  We regret any frustration or inconvenience this situation has caused.  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

Thank you for your inquiry received on 05/14/2015 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 Plan Sponsor Services for...

assistance, and were advised the plan sponsor [redacted] approved the termination of the plan, as Mr. [redacted] did not want the coverage. The refund check has been approved and it was mailed on Friday May 15, 2015 to 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 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 contacted our Benefits department to determine the...

member’s fertility coverage. We confirmed the benefits for IVF at 100% up to a $15,000 maximum per year and no more than 3 cycles per lifetime. The services are subject to medical necessity guidelines. The fertility drugs are covered by [redacted]. Our records show that the member was provided coverage details on 06/22/16 by our customer service team. 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

Complaint: [redacted]
I am rejecting this response because:I need to hear what they believe I still owe. I was also turned in to a collection agency due to the error in processing. I need to have these problems addressed. I thank them (and the Revdex.com) for their help in continuing to find resolution to this matter. 
Sincerely,
[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 the Claims department to...

verify if the claim was processed correctly according to the member’s benefits. We were advised that according to the benefits for hospital emergency room services the claim was processed correctly. Hospital emergency room services are covered 85% after the deductible is met. The level of care was not a factor when considering the amount the member owes, it is strictly based upon the 15% due of the contracted rate of the provider’s billed charges.
We also had the calls pulled prior to the member purchasing the breast pump to see if incorrect information was provided to the member. The member was advised that a breast pump would only be covered under the plan if it was medically necessary, meaning there has to be an issue with feeding before it will be covered. She was advised that a letter would have to be submitted by the provider stating the reason for medical necessity and the customer service representative (CSR) again reiterated that it must be medically necessary. We also listened to the calls after the purchase of the breast pump and again the member was advised that it would only be covered under the plan if medically necessary. The member requested what would qualify as medically necessary and the CSR provided an example of if the child was born with a cleft palate or if the mother was discharged prior to the baby being discharged. The member stated she understood the benefits on both calls. I empathize with your situation and regret that our decision could not be more favorable.
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 [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 has not completed all of the stipulations requested in my original Revdex.com complaint on 5/12/15 and Aetna has yet to complete the tasks that they promised in their original response on 5/27/15.  Specifically, Aetna has not reversed, reprocessed or paid the claims for Part B medications that I received between January and May 2015.  I am still being billed by [redacted] Pharmacy for these medications for over $700.  Luckily, [redacted] Pharmacy is being very understanding about my situation and has not turned me over to a collection agency yet.  I do not know why it has taken Aetna so long to pay these previous claims.  Because Aetna has not reprocessed my claims, I still do not know which medical claims count toward my annual out-of-pocket maximum of $400.  The explanation of benefits for claims in January lists several companies and dollar amounts that I should pay.  However, I already paid $373.94 to [redacted] Pharmacy for medications I received in mid January under the assumption that this money would count toward my $400 out-of-pocket maximum.  This money still isn't counting toward my out-of-pocket maximum for Aetna.  In early June, a representative from Aetna told me that they may not count any of the money I've already paid to [redacted] toward my out-of-pocket maximum because it was too time consuming for Aetna to reprocess the non-medication related claims.  Therefore, they wanted to inconvenience me further by having me pay $400 to other businesses for my out-of-pocket maximum and wait for a refund from [redacted] Pharmacy once Aetna pays them in full.  At this point, several other businesses believe I owe them money.  One business, [redacted], is charging me late fees ($15 per month) and all are ready to send me to collection agencies over the bills.  I don't want to pay anyone before I know for sure who I need to pay and I certainly don't think I should be responsible for paying late fees when it was Aetna's fault for failing to process the claims correctly.  Also, if I do have to pay $400 to businesses other than [redacted] Pharmacy I have to come up with an extra $400 out of my fixed income budget until I am eventually reimbursed.  This is yet another example of the horrendous customer service at Aetna.  They are more concerned about their own inconvenience and bottom line than their customer's inconvenience and ability to pay.  
With this said, Aetna has made some progress toward correcting my situation after my first rejection of their business response on June 1, 2015.  I believe that Aetna covered my June 2015 Part B medications at 100% (I haven't received my EOB yet).  Aetna did set up a case manager for me, but as an R.N., his job was to lend medical advice and assistance and he couldn't help with any issues related to my Revdex.com complaint.  More valuably, Aetna finally provided me with a contact person and a direct phone number for me and my daughter-in-law to call to check on Aetna's progress on this Revdex.com claim.  [redacted] ext [redacted] has called my daughter-in-law at regular intervals to keep us informed about the progress toward resolving their issues with my Part B medication coverage.  [redacted] originally said that it would take a month to reprocess the claims but then said she would put in a request to have Aetna expedite it.  [redacted] left a message recently that Aetna did not expedite the reprocessing of the claims as she hoped.  It is good that someone at Aetna is keeping me in the loop, however, I would be even happier if they reprocessed and paid not just the Part B medication claims from January to May, 2015, but all claims relating to my out-of-pocket maximum.   I would appreciate it if a representative from Aetna would speak to [redacted] to inform them about Aetna's errors in processing my out-of-pocket maximum and ask that late fee be dropped.  If [redacted] does not drop their fees, I believe that Aetna should pay them for me.  I believe Aetna has inconvenienced me enough by putting me through a 7 month (and counting) ordeal just to have them pay my medical claims according to Medicare and my insurance plan.  I do not want the added inconvenience of having to pay other businesses and then get my money reimbursed from [redacted] Pharmacy whenever Aetna gets around to paying the previous claims.  For these reasons, I refuse to close the complaint with Revdex.com until Aetna reprocesses all my claims related to Part B medications as well as my other medical claims related to my out-of-pocket maximum and pays all my prior Part B claims in full according to my insurance plan.
Sincerely,
[redacted]

Dear [redacted] Please see our response to complaint #[redacted] fo[redacted] that was received by us on October 14, 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...

Credentialing department to address the provider’s concerns.  We confirmed that our office has contacted this provider. A contract has been sent and we will work directly with his office once we received the signed copy.   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]
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] I am still disappointed that my coverage was changed from what I had under [redacted].  I was told by the person who called me that it was the same, but when I protested that I had had [redacted] surgery in the past I did not pay a $600 co-pay.  When he researched it he admitted I was right.  I was happy they resolved the medication compensation and he told me there had been an error in calculating my other co-pay and that it would be adjusted.  I am still waiting to hear about that.  I appreciate that they contacted me and made an effort to address my complaint.

Thank you for your inquiry received on 05/05/2015 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 found the claim was originally processed incorrectly. The amount of $182.04 has been added back into the member’s Aetna Healthfund. 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 [redacted]

Thank you for your rejection notice received on 09/14/15 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 apologize for the inconvenience and difficulty this situation has caused you. Aetna strives to provide the highest level of service, quality, and satisfaction, and to continually improve our processes.  We regret that your experience was not a positive one. We 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.
Upon further review, all claims on file have been processed and finalized timely within 10-15 business days of receipt. If the member sees an out-of-network provider, the payment of the claim is going to be based upon a reasonable and customary rate, not determine by Aetna, and will pay the percentage of the allowable.
If there is a specific date of service in question that the member feels was not processed correctly or disagrees with the payment, the member may file an appeal in writing to:
Aetna- CRT Member Appeals [redacted]
The request should include:
Name, Aetna ID, date of birth, claim information (including date of service, billed amount, provider name), and your contact information.
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].

Dear
[redacted]
Please
see our response to complaint #[redacted]
for [redacted] that was received by us on March 01, 2016.
During our review, we reached out to
our Billing and Enrollment department to address [redacted] concerns. It was
determined that the member had a policy...

that became effective for the month of January
2016 with a premium of $254.16; the policy was termed as of January 30, 2016. A
new policy became effective for this member as of February 01, 2016 and has
been effective since, this policy has a premium of $295.14 and is the policy
the member elected to have active.
A total of three payments were received
from the member, one for $254.16, another one for $295.14 and another one for
$295.14. The member was reimbursed to her MasterCard on February 12, 2016 for $254.16
+ $295.14= $549.30. The other premium payment of $295.14 was applied to the
current policy paying the month of February. 
In order for the member to be current in the premium payments, [redacted] would need to provide payment for January ($254.16) + March ($295.14).
I
apologize for any difficulties or confusion this may have caused [redacted]. 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 [email protected].
Regards,
Julian
C[redacted]
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 Claims department to have...

the member’s claim history from February 2015 through October 2015 reviewed. We have confirmed that all the member’s claims have been processed and paid to the provider for the 2015 calendar year.
I apologize for the frustrations and difficulties you have experienced while attempting to obtain payment for your claims, and we regret that your customer service experience was not consistent with Aetna’s service standards. Our goal is to pay claims timely and accurately, and to promptly resolve issues when they do occur. I am sorry that this matter required additional follow ups from you in order to facilitate a resolution. We have addressed your customer service concerns directly with the representatives who handled your calls.
We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Ms. Martin’s concerns. If you have any additional questions regarding this particular matter, please contact the [redacted]
Thank you,
[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 complaint, we contacted our Eligibility department to verify if
the member should have [redacted] coverage with Aetna. We confirmed that the
member’s employer changed health insurance carriers to [redacted] in
2015.  We have no record of receiving any [redacted] information for medical coverage.  However
for 2016, this member has medical coverage with another employer: [redacted]
Her member ID is [redacted]. The member ID card has been mailed. Please
allow 7-10 business days. She can register for Aetna Navigator with the new ID number to get
a temporary ID card.
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[redacted]                                         ...⇄ Complaint and Appeal Consultant Executive Resolution Team

Complaint: [redacted]
I am rejecting this response because:they make false claims:1. the diagnosis codes were there at the first submission...All the forms and receipts were the same (the same receipt) every week. However, they chose to randomly deny claims and have me re-submit them.2. They paid what they claim to be "usual and customary provider rate". This is a lie. I have quotes from several providers of the same service, and all of them came up with higher quotes that the one I went with eventually. 
Sincerely,
[redacted]

Complaint: [redacted]
I am rejecting this response because: I was Never contacted by Aetna regarding changing my code except when I first enrolled back in 2012. I was told to change the enrollment code from Ep1 to 221. Thereafter,  Aetna took it amongst themselves to change my code to JS1 a code that doesn't exist anywhere on aetnas website or brochure. My premium was raised by Aetna not my human resources office. This is ridiculous and robbery.  I would like my plan changed back and all overpayment returned to me.  I never signed nor agreed to change my plan to JS1. I was informed by Aetna that they were changing my plan without my permission.  I plan to take legal action an continue to report these unethical practices until it is rectified. 
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 our records to verify if Mr. [redacted]...

called prior to services being rendered to confirm if his primary care physician (PCP) was participating. We had the only call on file pulled, prior to services being rendered, from December 13, 2013, and had it listened to. Mr. [redacted] requested information on how his policy would cover his routine checkup with his provider. He stated that he could not locate the provider online as in network and that the office stated he could submit a claim form and the receipt to be considered for reimbursement. The customer service representative (CSR) advised Mr. [redacted] that he did not carry out of network benefits and would be required to be seen by a participating provider to be able to be covered. The CSR asked for the doctor’s name and said that she would verify if the provider was participating with his plan. Mr. [redacted] advised the doctor was [redacted], and the CSR confirmed the doctor was not participating with his plan. The CSR again reiterated that he must go in network to be covered for a checkup visit.
We are not able to retro a PCP on file to cover a claim. It is the member’s responsibility to verify that everything on file is correct prior to being seen by the physician. Due to the information provided our original determination was correct in denying the date of service April 28, 2014. 
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

Thank you for your rejection notice received on 07/17/15 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 Plan Sponsor Liaison contact for assistance, and were advised that our records show coverage for the period 05/24/15 through 07/04/15, which will be refunded. The refund amount of $109.62 will be included on this Friday’s (07/24/15) paycheck and no additional deductions have been taken.
 
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 contacted our Disability department and confirmed that his...

request for Short Term Disability was denied due to insufficient clinical information. His case manager called him on 04/11/16 to advise of this denial however there was no answer and no voicemail available. A letter was sent to [redacted] to explain the denial and provide his appeal rights. We contacted [redacted] on 04/18/16 to discuss his complaint. He understands what is needed to support disability and the lack of supporting information. We have advised him that we will determine if we can offer a peer to peer review even though the claim is denied or if he must file an appeal. We will contact him tomorrow, to advice of the next steps. He expressed appreciation with the call. We apologize for any difficulties and inconvenience this has caused the member. We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address [redacted]’s 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