DELTA AIRLINES

Complaint: [redacted]
I am rejecting this response because:
I have already filled out multiple forms for the prescriptions listed and have already sent in many copies of the receipts for the prescriptions, I'm sure if you asked the pharmacy department and Aetna Student Health for those they would be able to find them. I guess for the sake of repetition, because this seems to be something Aetna loves to have me do over and over, I'll attach them all again. I was absolutely covered by Aetna Student Health insurance for the months of July and August last year, I know that because I was actively rotating as a full time student at [redacted] during that time, and if you do not forfeit the health insurance with proof of your own, which I did not, then it is automatically added to the tuition. This is a serious error, and if in fact I was not covered during that time, I would like to be reimbursed for that time that I absolutely paid for, and you will need to discuss this error with my school.These mistakes in processing do not happen "sometimes." I received excellent service from Aetna until I actually needed the company to reimburse me for more than birth control pills. Suddenly, when diagnosed with mental health issues and actually needing to use the health insurance and not just giving the company my money, my claims are constantly rejected for ambiguous reasons or lost. My previous complaint with the Revdex.com concerned being reimbursed for out-of-network therapy coverage, for which every time the claim was rejected I was given a different reason each time for the rejection, and my therapist told me that in all the times she has had to fill out forms for reimbursement, she has never had to put down so much information. She has never had to give [redacted] codes or diagnoses for patient reimbursement, and this bothered her because she does not like to brand people with mental health diagnoses that could leave them stigmatized for the rest of their lives. When attempting to call customer service to discuss the forms to make sure she included all the right information for me to be reimbursed, she was hung up on. I don't bother calling the main customer service help line, because I have found those individuals to be lacking in knowledge about the health insurance and very rude, I stick to email now so that it leaves a paper trail. Luckily, specifically in the Student Health department, they are very nice and accommodating, however there seems to be a serious lack of communication between them and the pharmacy department. I would like to be reimbursed for all prescription claims in a timely manner. I do not need to be reminded once again as to what needs to be included in a prescription claim, I have been told this over and over because the customer service representatives feel the need to tell me this over and over without bothering to look at the claim forms I have attached with my complaints.I am very disappointed with the response I have received, 
Sincerely,
[redacted]

Compl[redacted]I choose to respectfully reject this response because one has to keep in mind this resolution comes after:·       Nine claims (nine opportunities).·       A minimum count of twenty customer service calls.·       Multiple fulfilled requests that EOBs be mailed to me due to not receiving EOBs at all and being incorrect online.·       Escalation to level 4 supervisor.·       Two appeals mailed with no response to date.All of which did not yield an efficient and timely resolution. However, ten months into this year, I am able to review claims on the portal and noting that perhaps multiple issues may be resolved.·       The online portal is updated (issue).·       The portal is currently reflecting the non-HMO provider reimbursement rate $65.00 (main issue).·       In this one instance, I have received affirming communication (issue) from Aetna (via Revdex.com).Though I am left to believe this is more than "procedural errors" and wonder about all the other clients and providers who may continue to experience such "procedural errors". My recommendations to Aetna:·       Adopt strategy to get it right, get it resolved, the first time.·       Provide real time portal updates, i.e. Claims processing and EOBs.·       Institute 24-72 hour issue to resolution response times (not 30 or 60 days as with appeals).·       Make accessible to obtain and provide correct updated information and documentation in real time.·       Use EMAIL between clients and client facing departments such as Appeals and Customer Service (work in the background so not to waste the client’s time on the phone).·       Streamline internal processes so that one person can take charge and produce results on any given customer issue.·       Most important - Always, always, always take care of the customer! Thank you for finally taking care of my issues and do know I appreciate it. I hope my comments do help improve customer experience. I just wish it did not have to go this far for resolution. Sincerely,[redacted]

Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted] and find that this resolution is satisfactory to me.
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 contacted Aetna Student Health (ASH) Claims department to review her claims. We confirmed that the member’s plan has a $250 annual deductible per plan year. The plan renewal date is based on the academic year, not a calendar year. The plan renews on September 01, 2015, therefore the member’s deductible is renewed as well. The visit on July 07, 2015, was for an urgent care visit (sick visit) and was applied to the 2014/2015 plan year deductible in the amount of $224.58. The visit on December 07, 2015, was also an office visit (sick visit) and was applied to the 2015/2016 plan year deductible in the amount of $218.30. The member would be responsible for these amounts because her deductible had not been met. We apologize for the inconvenience this has 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] concerns. If you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted] LaShonda C.Complaint and Appeals Consultant Executive Resolution Team

I did receive the advertised gift card 2 weeks after receiving the insurance packet.  I also received a second identical insurance packet from Aetna.  I would highly recommend that Aetna include the gift card in the insurance packet, or at least a note stating when it should arrive.  Otherwise customers are left with the impression that the card was forgotten.

Thank you for your inquiry received on 08/12/15 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 had the phone calls reviewed from the member,...

and the member called and said that she was going to see an allergist today (06/02/15), and wanted to see if [redacted] was covered.  The Customer Service Representative (CSR) asked for the first name and the member said that she was unsure, but had the telephone number.  The CSR clarified that the doctor was an allergist, and the member confirmed.  The CSR then provided the in-network benefits, but did advise the member that this would be for an “in-network” provider, as they were unable to confirm participation of [redacted] without the provider’s first name. 
 
Currently, the member’s concerns are being reviewed under appeal number [redacted]. The member 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 Ms. [redacted]’s 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 because: The claim presented was not for the procedure (9/11), it was for the consultation (dated 9/3).  The executive team has not responded back with any concerns or questions, and have not reached out to any of the providers as well.
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 our Eligibility department...

to have the member’s concerns reviewed. We confirmed that they reached out to the member’s university and the department was advised that the member submitted a waiver on December 31, 2015, but it was rejected as they were unable to verify – “Policy no longer active” – on this date the policy was not active as it was not effective until January 01, 2016. On January 08, 2015, the member contacted the university was able to verify the coverage and process the refund.

The university bills the student’s the insurance premium, the students do not pay Aetna directly. Per the university, they have processed the refund for the student the amount of the Spring insurance premium of $2,099.
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: Unfortunately, I have not received a full complete resolution. Ashley is correct, the doctor and myself has received approval for the requested procedures but the final piece has not been completed.  Following my conversation with Ashley yesterday, I spoke with the doctors office whom advised me that they had not received a follow-up from Aetna in a week regarding the negotiations. I do not want to be one of those cases that get to the finish line and the insurance company doesn't see there part to completion. This has been a very complicated process. I am hoping to receive an adequate resolution ASAP.
Sincerely,
[redacted]

Hello,
Thank you for your inquiry, regarding complaint #[redacted] for [redacted]. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.
Upon receipt of the complaint we immediately reviewed the member’s records to see what type...

of dental discount policy the member is enrolled in. We found that the member is enrolled in a Vital Savings plan purchased through http://www.[redacted].com. Aetna is strictly an administrator of this plan; Aetna does not control the enrollment or the billing.
All enrollments are handled through a Third Party Administrator ([redacted]) and the Billing is handled by the [redacted], not by Aetna. The participant makes the payments directly to the [redacted]; there is no pay roll deduction. Anyone requesting a refund of premiums or a cancellation of the plan must contact the [redacted] directly. You can call ###-###-#### or go online to the website listed above.
Please be aware that this plan is strictly a discount plan and is not insurance. There are no claim submissions of any kind and the member is responsible for paying the discounted price directly to the dentist. Aetna would have no way of verifying if the plan was not used by the member. Also any renewal information would come from the [redacted] directly to the member; Aetna is not responsible for any communications to 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].com.
Thank you,
Ashley S.
Complaint and Appeal Consultant
Executive Resolution Team

From: [redacted] [mailto:[redacted] Sent: Saturday, June 25, 2016 1:26 AMTo: [email protected]: Complaint #[redacted]To whom it may concern:I realize that my complaint is still being worked on, but today I just received a notice in the mail that Aetna sent me to collections for the amount I disputed and contacted you guys about.  I am so sick about it, and my anxiety is causing me a lot of pain. I am sick and really scared they are going to destroy my credit, which up until now has been very good.  I have never not paid a bill and always pay on time. I don't know what to do, mentally, I cannot handle dealing with Aetna anymore. I can't sleep, and my nerves are a mess. I don't know what I did to deserve this mess. It is almost the end of June now, and I have been trying to get this mess resolved for almost half a year now. Somebody please help me![redacted]

[redacted]   Please see our response to complaint #[redacted] for [redacted] that was received by us on August 31, 2016.  Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.   Upon receipt of the...

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

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

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

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

Hello,
Thank you for your inquiry, regarding complaint #[redacted] for [redacted]. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.
Upon receipt of the complaint we immediately reviewed the prior authorization request and the...

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

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

We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Mr. [redacted]’s concerns. If you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted].com.
Thank you,
Ashley S.
Complaint and Appeal Consultant
Executive Resolution Team

Hello,
Thank you for your inquiry, regarding complaint #[redacted] for [redacted]. Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.
Aetna does set the overall price to the government; however, it is the responsibility of the government to decide the portion that they will pay and what the member will pay. This is listed in every brochure, under the “Rates” section. Aetna does not collect premium or eligibility directly from individual members and is not able to refund any premium amounts.
We make every attempt to alert members of premium increases, along with notifying members of their choice to change into the correct enrollment code based on the address that we have on file.
We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Ms. [redacted]’s concerns. If you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted].
Thank you,
Ashley S.
Complaint and Appeal Consultant
Executive Resolution Team

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

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

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

Thank you for your inquiry received on 05/11/2015 regarding complaint #[redacted] for [redacted].  Our Executive Resolution Team researched your concerns, and I would like to share the results of the review with you.
 
We reached out to our Claims department for assistance,...

and were advised that the claim was processed correctly under the member’s out-of-network benefits for using a nonparticipating laboratory, and applied to their out-of-network deductible and coinsurance. Under the terms of the member’s plan, Out-of-Network Laboratory services are covered at 50%, after the deductible is satisfied. The member has a $5,000.00 individual Out-of-Network deductible responsibility and the deductible has not been satisfied for 2015.  
 
We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Mrs. [redacted] concerns.  If you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted]

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

member’s claim completed. The claim was finalized on July 29, 2015 under claim ID [redacted] and was paid to the member on July 30, 2015.
Please accept my apology for the delay in processing your claim correctly, and that it required multiple attempts on your part to resolve your issue. Unfortunately, in some instances, errors do occur. When they do, we take them very seriously and do our best to understand how and why the errors occurred and determine what we can do to prevent a recurrence.  We continually use feedback like yours to improve our service and prevent issues from reoccurring.
We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address Mrs. [redacted] concerns. If you have any additional questions regarding this particular matter, please contact the Executive Resolution Team at [redacted]
 
Thank you,
[redacted]
Complaint and Appeal Consultant
Executive Resolution Team