DELTA AIRLINES

Dear Ms. M[redacted]   Please see our response to complaint #[redacted] for J[redacted] that was received by us on July 27, 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 Enrollment and Eligibility department to have the member’s concerns reviewed. We were advised that the member’s employer submitted the coverage request for [redacted]s and his wife on June 28, 2016, and requested that the coverage’s effective date be May 01, 2016. Since we did not receive the request until the end of June that is why there was a delay in receiving ID cards; which were mailed to the member on July 08, 2016. We did confirm that the employer requested the plan be terminated effective July 31, 2016.   If the member and his wife had services rendered within that timeframe the policy was effective they can have their providers submit claims for consideration under the plan. The member is also able to request an itemized bill and bill the insurance directly if any payments were made out of pocket.   Unfortunately, Aetna is only an administrator of the plan and has no control over the plan, when it is created and/or terminated, and what the premium is that is being billed to the member. The member will need to contact the Human Resource department of the employer and request the refund of the premiums and discuss why he and his wife were enrolled without their permission. We do not have access at Aetna to any of this information to assist the member any further.   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,   Ashley W. Complaint and Appeals Consultant Executive Resolution Team

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

department to have the member’s concerns reviewed. We were advised that the member was not terminated for nonpayment; she was terminated for no longer being eligible by the [redacted] Exchange. The member would have received several letters from the [redacted] prior to the member’s termination. Aetna has no control over the policies that are created under the [redacted] Exchange; we are strictly administrators of the member’s plan. Aetna has no control over a member’s termination.
The member was drafted two months in error for November’s premium due to a system error. A refund was issued on November 06, 2015, for the $174.35 that was withdrawn in error. The member’s plan was terminated correctly per information received from the Marketplace. If the member is wishing to dispute the termination she will need to contact the [redacted] to inquire why her plan was terminated. I sincerely 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] 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.
I sincerely apologize that we originally reviewed the first request incorrectly. Our executive team will make an exception if the member wishes and reopen the open and waive the timely filing so we can have the services reviewed based upon wrong information given. We already have the request in writing from the first appeal request, which is required by the employer, so if the member wishes to pursue this exception please have her send an email to my attention to the email address below and we will start an appeal immediately.
We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Mrs. [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 June 27, 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 for clarification on why the claim was processed correctly according to the member’s benefits. We were advised that the physician billed a routine physical procedure code, which falls under the routine office visit benefits. The claim was paid at 100% for the office visit.   The bloodwork was billed as an outpatient diagnostic lab by a different provider who performed the tests. Based on how the claim was billed to Aetna, it falls under the benefit of participating lab benefits. Page five of the member’s Schedule of Benefits shows that the member’s in-network, outpatient diagnostic lab is covered at 100% after Calendar Year deductible was met. The member’s deductible had not been met so the member’s responsibility correctly applied to the deductible.   We assure you that it is not our intent to mislead or misrepresent any benefit that may or may not be available under the member’s health plan. I understand the member’s concerns and recognize this is not the outcome that was desired. However, we must make coverage decisions in accordance with the member’s plan. The member does have the right to appeal the claims if the member still disagrees with our decision. Please send the appeal request to: Appeals Resolution Team [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]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 am waiting to see if the payment has been applied to the account at the proper provider. I contacted Forward Dental New Berlin on Friday 2/12/16 and spoke to Jessica---who said they are working with Aetna. Until the payment is actually posted, I do not consider the matter resolved--as the money has not been posted to the account. If Aetna would have paid Forward Dental New Berlin instead of Forward Dental Appleton---we would not continue to be having this issue. It appears they could clearly deny the claim to the proper provider when it first came in, but they can't seem to pay the proper provider when trying to correct the claim they initially denied.
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 Pharmacy department...

to have the member’s concerns reviewed. We were advised
by our Aetna Rx Home Delivery department that on August 21, 2014, the member’s
physician called in three new prescriptions for the member. The order diverted
to a member outreach to obtain a payment method for the order. On August 26,
2014, a call was made to the member to obtain a payment method for the order;
the member was not available and a message was left. On September 03, 2014, the
member had not returned the call and the order was released and charged to the
credit card on file, which had been used for a previous order. The order
shipped the same day via [redacted].
On September 04, 2014, the member contacted Customer Care
regarding the order to advise that the order was charged to her credit card
without her approval. The member requested to have the credit card removed from
her account and a note added stating not to fill orders until she calls to
request them. The note was added to the account per the member’s request and on
September 20, 2014, the credit card charge was refunded in the amount of
$160.00. Due to this refund, the member then owed the charges incurred for the
August 21, 2014, prescriptions.
On December 30, 2014, the member contacted Customer Care and
requested to have a prescription refilled. A request was sent to the pharmacy
to fill the prescription and the order diverted for a member outreach to obtain
a method of payment. On December 31, 2014, and January 02, 2015, outreaches
were made to the member to obtain a payment method. The member returned the
call to the account receivable team on January 05, 2015, and provided a method
of payment for the order. She was also advised that the order would be released
as a courtesy and she is responsible for the past due balance of $160.00. The
member requested to speak to a supervisor and was transferred to a supervisor.
The member advised the supervisor that she called to cancel the August
prescription order and was assured that the order would be cancelled. The supervisor
said that she would have the call reviewed to verify if the member was told the
order would be cancelled and would call her back.
The supervisor called the member back on January 08, 2015,
to advise her of the call review results but the member was not available and a
message was left. The call review confirmed that the member was advised that
the order could not be cancelled but that a return label could be sent to
return the prescription and the member stated not to worry about sending the
return label, that she would dispute the charge with her bank.
We did not hear back from the member and on April 24, 2015,
a new prescription was received via fax from the physician. The order diverted
to the account receivable team for a member outreach to obtain a payment method
for the order and to resolve the outstanding balance of $160.00. Three separate
outreaches were made to the member on May 01, 2015, May 07, 2015, and May 08,
2015 and messages were left.
On August 21, 2015, the member requested two prescriptions
via the Aetna website. The order diverted for a member outreach because the
outstanding balance had to be resolved prior to the order being shipped. An
outreach was made to the member to obtain payment for the past due balance on
August 25, 2015 and a message was left for the member to call back. As a second
courtesy to the member, the prescriptions were released on August 26, 2015,
without member contact for the outstanding balance. The orders shipped the same
day and were charged to the credit card on file.
On March 02, 2016, a prescription was received
electronically from the physician and on March 03, 2016, the prescription was diverted
for a member outreach because of the $160 past due on the file. On March 07,
2016, an outreach was made to the member to obtain a method of payment for the
prescription order and a message was left for the member to call back. The
member called Customer Care back the same day regarding the balance and declined
to pay the outstanding balance of $160.00. She was transferred to the account
receivable department to assist with the payment. The member again declined to
pay the balance and requested that the prescription order be released. The
member stated that she would call back regarding the past due balance.
As a last and final courtesy for the member, the balance of
$160.00 has been written off due to the situation. The prescription has been
release and the $75.00 copay has been charged to the credit card on file. Due
to the previous chargebacks to the credit card going forward the member will be
required to send money orders for any future prescriptions.
We take customer complaints very seriously and appreciate
you taking the time to contact us and giving us the opportunity to address Ms.
Keith’s concerns. If you have any additional questions regarding this
particular matter, please contact the Executive Resolution Team at [redacted].
Thank you,
Ashley S.
Complaint and Appeal Consultant
Executive Resolution Team

Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted] and find that this resolution is satisfactory to me.
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 Claims department to have a...

complete review of the member’s 2015 claims. We were advised that there were four claims on file for 2015, and only one date of service required reprocessing. This claim has been finalized and paid any additional money to the provider. All other claims were processed correctly, and were all processed in network.
Please accept my apology for the delay in processing your claim correctly. 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.  
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

[redacted]   Please see our response to complaint #[redacted] for [redacted] that was received by us on March 21, 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 reached out to our Disability department to have the claimant’s concerns reviewed. We were advised that our Disability department initially called the wrong doctor’s office on January 10, 2017, and January 13, 2017. We then were informed [redacted]r was being treated at another Medical Center in Cincinnati and we made several attempts to obtain the information necessary to review the case. We faxed requests on January 18th, 19th, 27th, 30th, February 01st and March 06, 2017. We have obtained the information needed to complete the disability claim review and it has been approved. The claimant will receive a letter from the Disability department with the claim details. We sincerely apologize for any inconvenience this has caused the claimant.   We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address [redacted]r’s concerns.  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

Revdex.com:
I have reviewed the response made by the business in reference to complaint [redacted]4, and find that this resolution is satisfactory to me.
Sincerely,
[redacted]

Hello, Thank you for your inquiry, regarding complaint # [redacted] for [redacted]. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you. Upon the receipt of the complaint, we contacted our Customer Service department to review your concerns. We have requested that all non-required letters and correspondence be stopped from both the medical and prescription portions of [redacted] policy. The member will continue to receive any pertinent correspondence for his current prescription and medical coverage. In regards to the request of having 3 months of premiums waived, we would need to receive proof of denial of access to medical or prescriptions coverage in order to justify premium waiver. That premium waiver would require home office exception. We apologize for any frustrations and difficulties the member has experienced with this matter. 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 s[redacted].   Thank you, Tanika K. 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 your complaint, we contacted our Claims department and confirmed that we have...

not received a claim from [redacted]. We contacted the provider’s office and confirmed the member’s health coverage. We also verified that the location is participating with the member’s plan. The provider will resubmit the claim to Aetna. Once we receive the claim, we will process and send an explanation of benefit to the member. 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] 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 reviewed our records which indicated that Ms....

[redacted] currently has an appeal open, received the same day as the Revdex.com complaint was received. Please allow this complaint to be reviewed under the appeal which requires clinical review. The case number for your records is [redacted] and has a due date of July 18, 2015. The member can expect a letter to be mailed to her home address with the decision of the appeal.
We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Ms. [redacted]’ concerns. If you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted].
 
Thank you,
[redacted]
Complaint and Appeal Consultant
Executive Resolution Team

Hello,
Thank you for your inquiry, regarding complaint #[redacted] for [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 see what information was needed...

to process the dental claims for Ms. [redacted]. We were advised that since these claims were foreign claims which did not have procedure codes on the claims, we reached out to verify the services that were rendered. This is not meant as harassment but is necessary to review foreign claims.
The member’s plan pays for services on what is called a “seat date”, meaning the date that services were actually completed. (i/e – a crown can be prepped and molded but the patient may come back on another day to have the crown “seated” or completed, most offices do not have the technology to prep and seat on the same day). Since there were numerous procedures completed on the same day our Claims department needed to verify some information from both Ms. [redacted] and the doctor who completed the work. At this moment the only thing we have yet to receive is the requested information from the doctor who completed the work. Once this is received we will be able to review the claims.
I apologize for the inconvenience this issue has caused. 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

Dear [redacted]: Please see our response to complaint # [redacted] for [redacted] that was received by us on January 11, 2018. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you. Upon receipt of the complaint, we contacted our...

Dental department to address the member’s concerns. We reviewed the member’s current [redacted] Dental benefits effective July 01, 2017. We found that they are based on a list of dental procedures determined and agreed upon by your employer. Unfortunately, it does not include orthodontic treatment as an expense eligible for reimbursement. The member’s prior [redacted] Dental plan effective from November 1, 2016 through June 30, 2017 had coverage for orthodontic coverage. The member changed the plan during mid treatment, which means it changed the coverage. We determined that the claim was processed correctly, according to the information we received, and no benefits are available for this service. 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, 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 out to our Dental department to verify...

the member’s benefits and claim history. Our records indicate that the member is enrolled in a Dental Maintenance Organization (DMO) plan. When enrolled in this plan the member is required to pick a primary care dentist (PCD) within the network for himself and his family to be assigned to. To receive in-network benefits, you must have your services performed or arranged by your selected PCD. If your PCD cannot perform a service, he or she will give you a referral to an in-network specialist to perform the services. When the member goes out of the network for the DMO plan, they are required to pay a $100 deductible before the plan will pay at a set fee scheduled amount for services rendered.
The claim on file is processed correctly and no additional payments will be made towards the services. Your dental plan allows for pediatric specialist referrals to age six with a written referral form from your PCD. Our records show that your son's referral was provided by his orthodontist who is invalid; this has to come from the PCD. Furthermore, your child is over the pediatric referral age limit and requires a special authorization on file to be seen when over the age of six.
The flyer information that you have is correct but that is only if the services are done by the in-network assigned PCD or a referred oral surgeon, then the uncomplicated extractions are covered at 100% with no cost to you. But since this was done by an out-of-network dentist, the fee schedule amount that is allowed is $27.00 a tooth and applies to the member’s annual $100.00 deductible.
Our records also indicate that we have not received any calls from the member to discuss the benefits, only internet inquires. There also were not any calls prior to services being rendered to verify coverage and benefits by either the member or the provider.
We assure you that it is not our intent to mislead or misrepresent any benefit that may or may not be available under your health plan. 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 are not able to cancel the policy or issue any premium refunds for the plan without permission from the employer. The member must contact his HR department to request this be done.
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: 10619073
I am rejecting this response because:Per conversation with [redacted] at Aetna yesterday, Aetna has
agreed to compensate me $26.46 for losses related to my health savings account
due to Aetna’s and [redacted] negligence. 
This is absolutely unacceptable.  I
would estimate that the loss in value alone of my health savings account would
likely exceed $500.  Furthermore, I
expect compensation for the time I have wasted dealing with Aetna regarding
this matter.  I will continue my efforts
at resolution through all available avenues. 
Sincerely,
[redacted]

Thank you for your inquiry received on 07/14/15 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. Upon receipt of your complaint, we contacted Aetna’s Pharmacy Management department (APM) and confirmed that the issue with her out of pocket maximum has been resolved.  We have refunded the member for claims that were billed under her Part D coverage instead of Part B coverage in error.  A reimbursement check in the amount of $1121.82 was issued on July 10, 2015. All of her Part B medication claims for July processed with a $0.00 copay applied.
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 reviewed the call history to verify if the provider...

was able to confirm the member’s coverage and benefits. On July 14, 2015, Dr. [redacted] office called to verify the member’s coverage and the office was advised that this plan is handled by an Aetna affiliate called Strategic Resource Company (SRC) who is able to discuss the eligibility and benefits. The provider was given the phone number to call but our records indicate that the provider never called the SRC. The provider will be able to check the member’s benefits by calling [redacted] and choosing option 2.
We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Ms. [redacted] concerns. If you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted]
 
Thank you,
[redacted]
Complaint and Appeal Consultant
Executive Resolution Team

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]