Business Profile

Insurance Companies

Aetna Inc.

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Complaints

This profile includes complaints for Aetna Inc.'s headquarters and its corporate-owned locations. To view all corporate locations, see

Customer Complaints Summary

1,334 total complaints in the last 3 years.
467 complaints closed in the last 12 months.

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The complaint text that is displayed might not represent all complaints filed with BBB. Some consumers may elect to not publish the details of their complaints, some complaints may not meet BBB's standards for publication, or BBB may display a portion of complaints when a high volume is received for a particular business.

Initial Complaint
Date:07/10/2025
Type:Delivery Issues
Status:
ResolvedMore info
Complaint statuses
Resolved:
The complainant verified the issue was resolved to their satisfaction.
Unresolved:
The business responded to the dispute but failed to make a good faith effort to resolve it.
Answered:
The business addressed the issues within the complaint, but the consumer either a) did not accept the response, OR b) did not notify BBB as to their satisfaction.
Unanswered:
The business failed to respond to the dispute.
Unpursuable:
BBB is unable to locate the business.
Aetna sent a prescription to the wrong address and I am trying to seek a credit for my next prescriptin. Phalyn from corporate has elected to ghost me with limited information and other colleagues trying to help. I’ve filed a state complaint as well.

Phalyn does not answer calls at ###-###-####
Business Response
Date: 07/17/2025
**** *** ******* **********

Please see our
response to complaint #******** for **** ***** that was received us on July 10, 2025.
Our Executive Resolution Team researched the concerns, and I would like to
share the results of the review with you.

Upon
receipt of the complaint, we immediately reached out internally to further
research the consumer’s concerns. The member had a
prescription that was sent to the incorrect mailing address due to an old
Caremark profile that was selected and the address had an active range set to
April 11, 2122. This caused the systems to auto select as the preferred address
to ship to and, unfortunately, was not corrected prior to shipment. The member
cost share was $1.94.

On May
09, 2025, the dates on the alternate address were corrected to end on April
11, 2022, and the default primary address for this member was updated so going
forward any prescriptions for this account will ship to the correct primary
address. A reshipment was sent to the member, who confirmed receipt on May 12,
2025.

Typically,
a letter is then mailed to the member to sign and return confirming that they
did not receive the original shipment of medication so that a credit can be
applied to the account. Due to the escalation, the pharmacy team allowed a
one-time courtesy and did not require the letter be signed and returned. The credit
of $1.94 was applied to the reshipment order in place of payment method to
cover the cost so the member was not charged twice.

We take customer complaints
very seriously and appreciate you taking the time to contact us and giving us
the opportunity to address ****’s concerns.

Sincerely,

Phalyn C. |Analyst, Executive Resolution
Executive Resolution Team

Customer Answer
Date: 07/17/2025

Better Business Bureau:

I have reviewed the response made by the business in reference to complaint ID ********, and find that this resolution is satisfactory to me.

Sincerely,

**** *****
Initial Complaint
Date:07/08/2025
Type:Sales and Advertising Issues
Status:
AnsweredMore info
Complaint statuses
Resolved:
The complainant verified the issue was resolved to their satisfaction.
Unresolved:
The business responded to the dispute but failed to make a good faith effort to resolve it.
Answered:
The business addressed the issues within the complaint, but the consumer either a) did not accept the response, OR b) did not notify BBB as to their satisfaction.
Unanswered:
The business failed to respond to the dispute.
Unpursuable:
BBB is unable to locate the business.
I have repeatedly informed this company I am not interested in obtaining insurance through them. I have repeatedly informed this company that I have insurance. I have repeatedly asked this company not to call me. They have called me four times this morning. They called me twice last week. They called me twice a week before I don’t know how to make them stop calling me.
Business Response
Date: 07/08/2025
**** *** ******* **********

Please see our response
to complaint #******** for ****** **** that was received by us on July 08, 2025. Our Executive Resolution Team
researched your concerns, and I would like to share the results of the review
with you.

Upon
receipt of your request, we immediately added Ms. ****’s information to our Do
Not Contact List.

We
take customer complaints very seriously and appreciate you taking the time to
contact us and giving us the opportunity to address Ms.
****’s concerns. If there are any additional questions regarding
this particular matter, please contact the Executive Resolution Team at *******************************.

Sincerely,

Marshell H.
Analyst, Executive Resolution
Executive
Resolution Team
Initial Complaint
Date:07/07/2025
Type:Sales and Advertising Issues
Status:
ResolvedMore info
Complaint statuses
Resolved:
The complainant verified the issue was resolved to their satisfaction.
Unresolved:
The business responded to the dispute but failed to make a good faith effort to resolve it.
Answered:
The business addressed the issues within the complaint, but the consumer either a) did not accept the response, OR b) did not notify BBB as to their satisfaction.
Unanswered:
The business failed to respond to the dispute.
Unpursuable:
BBB is unable to locate the business.
My health insurance carrier, Aetna CVS Health, offers a $100 gift card in exchange for a “Healthy Home Health” visit provided by ******* ******. My husband and I did this in 2023 and 2024 and with one exception (the subject of this letter), we did receive the $100 **** gift card as promised.

Unfortunately, the gift card arising from my last Healthy Home Visit on December 17, 2024 initially arrived in the mail with $0 balance. I first called to inquire about the $0 balance in January 2025 and was told it could take up to a month to upload the benefit (even though my husband’s card had arrived at the same time with $100 balance).

To make a long story short, I have been calling Aetna since January at least once monthly with no remedy. I am told that my case would be escalated and the balance will be adjusted. There is now, weirdly, a $17 balance on my card. And Aetna acknowledges all of this since, when the $17 first appeared, I questioned if there had been a fraudulent $83 spend. They said “No, only the $17 was credited from $0.” I have also tried calling ******* ******, but they punt the ball to CVS’s responsibility. The last two times I have called, I am promised that a supervisor would be receiving my case and would be getting back to me within two business days. I have neither received those calls nor the $100 balance. At this point, I have no other recourse than to file an official consumer complaint with the ***, Better Business Bureau and to Aetna executives.
Customer Answer
Date: 07/09/2025
This case has been satisfactorily resolved by Aetna. Please withdraw my complaint, thank you. ******** ******
Initial Complaint
Date:07/02/2025
Type:Product Issues
Status:
AnsweredMore info
Complaint statuses
Resolved:
The complainant verified the issue was resolved to their satisfaction.
Unresolved:
The business responded to the dispute but failed to make a good faith effort to resolve it.
Answered:
The business addressed the issues within the complaint, but the consumer either a) did not accept the response, OR b) did not notify BBB as to their satisfaction.
Unanswered:
The business failed to respond to the dispute.
Unpursuable:
BBB is unable to locate the business.
I am a private speech-language pathologist with ********** ******** ***. I went through the credentialing process for in-network status with Aetna Insurance Company before I provided any services for a client. Aetna has ever since insisted on paying me as an out-of-network provider and finally for 2025 claims, has refused to pay me for services rendered to this client. I have called multiple times to straighten this out, have been told that it will be taken care of, and it has NOT been resolved. On 06/06/2025, I was informed by phone that my contract had been approved as of 01/05/2024 and that Aetna did not load it properly; that my claims were being escalated, and that I should resubmit the claims after 7 to 10 days. I informed the agent, Brie, that I would not be resubmitting the claim, as it was not my problem, but Aetna's. I was given Call Reference #***************. I called again on 06/09/2025 and spoke with Jon C in Credentialing, who said my info would be uploaded to an Onboarding Specialist. I told him that the info was supposed to already be wherever Aetna needed to send it. He gave me Call Reference # ********* -- I was told later that this is an ** Escalation. Having heard nothing, I called Aetna Provider Services on 06/24/2025, and was told that the problem was that I was not an Aetna provider AT ALL! This was the first time that I had been told THAT information, and that that was NOT what I had previously been told. It is apparent that Aetna is being disingenuous, as they have previously paid me for working with this client. As a private provider, I do not have a staff to keep interacting with these people. I have spent hours on the phone with different Aetna agents, and they are still refusing to pay! I have had enough of their shenanigans!
Business Response
Date: 07/08/2025
**** *** ******* **********

Please see our response
to complaint #******** for ******* ********* that was received by us on July 03, 2025. Our Executive Resolution Team
researched your concerns, and I would like to share the results of the review
with you.

Upon
receipt of your request, we immediately reached out internally to have Ms.
*********’s concerns reviewed. Based on the review it has been confirmed that the
provider is out of network with Aetna. Our network team has confirmed a
mistake was made and the provider was not credentialed before having a contract
executed in 2023. An email was sent to the provider explaining that the contract
was voided, and a new contract was required since the credentialing process was
not completed. A credentialing case was opened, and a new contact was sent to
the provider in December of 2023, the provider never signed the contract. The credentialing
application was approved in April of 2024 and multiple emails were sent to
provider asking them to sign the new contract, but the provider would not sign
it. Ms. ********* cannot be loaded as in-network provider without a signed
contract. In October of 2024, the provider was sent another contract, which
went unsigned. The provider
were sent emails and had calls with provider services that explained that they
needed to sign the contract, but they would not. There is nothing more that
can be done at this time since the provider has not cooperated with all past
attempts when they were given instructions on how to rectify their in-network
status.

We
take customer complaints very seriously and appreciate you taking the time to
contact us and giving us the opportunity to address Ms.
*********’s concerns. If there are any additional questions
regarding this particular matter, please contact the Executive Resolution Team
at *******************************.

Sincerely,

Marshell H.
Analyst, Executive Resolution
Executive
Resolution Team
Initial Complaint
Date:06/30/2025
Type:Customer Service Issues
Status:
AnsweredMore info
Complaint statuses
Resolved:
The complainant verified the issue was resolved to their satisfaction.
Unresolved:
The business responded to the dispute but failed to make a good faith effort to resolve it.
Answered:
The business addressed the issues within the complaint, but the consumer either a) did not accept the response, OR b) did not notify BBB as to their satisfaction.
Unanswered:
The business failed to respond to the dispute.
Unpursuable:
BBB is unable to locate the business.
Hi -- I'm a former employee of ******* who was insured with Aetna. I'm reaching out because I need paperwork/documentation from Aetna that states the end date of my insurance with them. This is important for me to submit to my husband's insurance so my 15 month old daughter and I can be insured by then. I've reached out to Aetna now 5x and keep getting passed on other people in customer support without a resolution. I need this asap so I don't miss the deadline for my daughter and I to be insured on the other policy. Can I please receive this information?
Business Response
Date: 07/03/2025
**** *** ******* *********:

Please see our response
to complaint #******** for ******* ****** that was received by us on June 30, 2025. Our Executive Resolution Team
researched your concerns, and I would like to share the results of the review
with you.

Upon
receipt of your request, we immediately reached out internally to have Ms. ******’s
concerns reviewed. Based on the review it has been confirmed that ******* has
specific instructions concerning coverage verification letters. Specifically, this
information is distributed by their benefit service center (******* People
Services). Unfortunately, Aetna is not able to supply this letter. The member will
need to contact ******* People Services at ###-###-#### to request the “Coverage
Verification Form.”

We
take customer complaints very seriously and appreciate you taking the time to
contact us and giving us the opportunity to address Ms. ******’s concerns. If there are any additional questions
regarding this particular matter, please contact the Executive Resolution Team
at *******************************.

Sincerely,

Marshell H.
Analyst, Executive Resolution
Executive
Resolution Team
Initial Complaint
Date:06/30/2025
Type:Billing Issues
Status:
ResolvedMore info
Complaint statuses
Resolved:
The complainant verified the issue was resolved to their satisfaction.
Unresolved:
The business responded to the dispute but failed to make a good faith effort to resolve it.
Answered:
The business addressed the issues within the complaint, but the consumer either a) did not accept the response, OR b) did not notify BBB as to their satisfaction.
Unanswered:
The business failed to respond to the dispute.
Unpursuable:
BBB is unable to locate the business.
I reached out to Aetna to ask a representative how much my physical therapy would cost me. Aetna told me it would be a $45 copay per visit.

After finishing treatment and paying the $45 at every appointment, I am being left with a bill for $151.09. Aetna has denied my appeals without addressing the fact that I was misinformed about the cost of my treatment.
Business Response
Date: 07/09/2025
**** ******* **********
Please see our
response to complaint # ******** for ******* **** that was received by us on
June 30, 2025. Our Executive Resolution Team researched the concerns, and I
would like to share the results of the review with you.
Upon
receipt of your request, we immediately reached out internally to further
research the concerns. After
further review it
was determined that the member’s physical therapy benefits are covered at 100
percent no deductible after a $45.00 copay. An evaluation code billed by the
provider does not apply the copay of $45.00 but is subjected to the deductible.
For the date of service March 25, 2025, the provider billed an evaluation code
which processed correctly per the plan benefits, the other physical therapy
codes on the claim were processed correctly with the $45.00 copay. On the call
made to member services the member was misquoted and was not educated on the
evaluation code being subjected to the deductible. Although the member had not
met the deductible at the time of service due to the misquote provided to the
member the claim was sent back for reprocessing to waive the $106.09 evaluation
charge. The member now is only responsible for the $45.00 copay. A new claim
number was generated, and a new explanation of benefits will be sent to the
member once the claim has finalized.
We take customer
complaints very seriously and appreciate you taking the time to contact us and
giving us the opportunity to address *** ****** concerns. If there are any
additional questions regarding this particular matter, please contact the
Executive Resolution Team at *******************************.
Sincerely,
ShaCarra B.
Executive Analyst,
Executive Resolution Team

Business Response
Date: 07/09/2025
**** ******* **********
Please see our
response to complaint # ******** for ******* **** that was received by us on
June 30, 2025. Our Executive Resolution Team researched the concerns, and I
would like to share the results of the review with you.
Upon
receipt of your request, we immediately reached out internally to further
research the concerns. After
further review it
was determined that the member’s physical therapy benefits are covered at 100
percent no deductible after a $45.00 copay. An evaluation code billed by the
provider does not apply the copay of $45.00 but is subjected to the deductible.
For the date of service March 25, 2025, the provider billed an evaluation code
which processed correctly per the plan benefits, the other physical therapy
codes on the claim were processed correctly with the $45.00 copay. On the call
made to member services the member was misquoted and was not educated on the
evaluation code being subjected to the deductible. Although the member had not
met the deductible at the time of service due to the misquote provided to the
member the claim was sent back for reprocessing to waive the $106.09 evaluation
charge. The member now is only responsible for the $45.00 copay. A new claim
number was generated, and a new explanation of benefits will be sent to the
member once the claim has finalized.
We take customer
complaints very seriously and appreciate you taking the time to contact us and
giving us the opportunity to address *** ****** concerns. If there are any
additional questions regarding this particular matter, please contact the
Executive Resolution Team at *******************************.
Sincerely,
ShaCarra B.
Executive Analyst,
Executive Resolution Team

Customer Answer
Date: 07/09/2025

Better Business Bureau:

I have reviewed the response made by the business in reference to complaint ID ********.
I appreciate the acknowledgement of the misquote and the waiving of that amount. I do wish that this could have been resolved earlier in my appeal process, but assuming the bill is adjusted as promised I now find that this resolution is satisfactory to me.

Sincerely,

******* ****
Customer Answer
Date: 07/09/2025

Better Business Bureau:

I have reviewed the response made by the business in reference to complaint ID ********.
I appreciate the acknowledgement of the misquote and the waiving of that amount. I do wish that this could have been resolved earlier in my appeal process, but assuming the bill is adjusted as promised I now find that this resolution is satisfactory to me.

Sincerely,

******* ****
Initial Complaint
Date:06/30/2025
Type:Billing Issues
Status:
ResolvedMore info
Complaint statuses
Resolved:
The complainant verified the issue was resolved to their satisfaction.
Unresolved:
The business responded to the dispute but failed to make a good faith effort to resolve it.
Answered:
The business addressed the issues within the complaint, but the consumer either a) did not accept the response, OR b) did not notify BBB as to their satisfaction.
Unanswered:
The business failed to respond to the dispute.
Unpursuable:
BBB is unable to locate the business.
After multiple scare tactics of the health industry, I finally agreed to have a MRI done. I had previously had one done in which I had copies via disk and print that was provided, but I guess it was of no use since my insurance policy couldn’t be billed again. I was also referred to an ultrasound “guru” specialist who confirmed there were no concerns yet the physician insisted on an MRI. I finally had the test done after being scared into it and after it was done I was never contacted with the results. I called the physicians office twice to get the results and never received a call back. Once they were able to bill my insurance there was no sense of urgency anymore. I contacted my insurance company to assist and received no help. I disputed the claim which was denied. I followed the instructions on the back of the document to submit a second appeal via postal mail which Aetna now states they cannot find. I’ve contacted Aetna on multiple occasions asking for assistance and next steps. I’m told I’m on the call back list. It’s been 3 weeks and I have no call back yet and my mail is still misplaced on their end.
Business Response
Date: 07/10/2025
**** *** ******* **********

Please see our response to complaint
#******** for *****
****** that was received by us on June 30, 2025. Our Executive
Resolution Team researched your concerns, and I would like to share the results
of the review with you.

Upon
receipt of your request, we immediately reached out internally to have Ms.
******’s concerns reviewed. It has been confirmed that an Aetna Health
Advocate has scheduled a call with Ms. ****** for July 11, 2025, to discuss the
MRI claim from the date of service January 03, 2025.

We take customer complaints very
seriously and appreciate you taking the time to contact us and giving us the
opportunity to address Ms. ******’s concerns.
If there are any additional questions regarding this particular matter, please
contact the Executive Resolution Team at *******************************.

Sincerely,

Marshell H.
Analyst, Executive Resolution
Executive
Resolution Team
Customer Answer
Date: 07/11/2025

Complaint: ********

I am rejecting this response because I’m still waiting to hear back. There has been no resolution as of yet.

Sincerely,

*****
Customer Answer
Date: 07/11/2025
I’m writing in regards to the above mentioned complaint, can you please send back to me for closing? I’d like to close it as resolved.
Initial Complaint
Date:06/23/2025
Type:Service or Repair Issues
Status:
ResolvedMore info
Complaint statuses
Resolved:
The complainant verified the issue was resolved to their satisfaction.
Unresolved:
The business responded to the dispute but failed to make a good faith effort to resolve it.
Answered:
The business addressed the issues within the complaint, but the consumer either a) did not accept the response, OR b) did not notify BBB as to their satisfaction.
Unanswered:
The business failed to respond to the dispute.
Unpursuable:
BBB is unable to locate the business.
Aetna representatives did an override to pick up a 90 day supply of my prescription. After, seeing my doctor, getting the prescription sent to the pharmacy they told me to go to and countless time on the phone I was never able to get the prescription. The pharmacy even ran the prescription on Friday, June 13 and it was approved. The pharmacy placed the order for the medication. The next week when I went to pick it up it would not run through again. Then Aetna said no, we don’t approve. It is unethical to approve a medication and have the patient(me) do everything asked of me only to deny it.
Customer Answer
Date: 06/25/2025
Hello. I was able to pick up the medication today. I’m not sure if it’s related to my complaint, as I have not heard from Aetna, but I did want to update you and let you know it’s been resolved as far as I’m concerned. I do hope that Aetna doesn’t do this to myself or other members again. Thank you for your help with this.
Initial Complaint
Date:06/20/2025
Type:Billing Issues
Status:
AnsweredMore info
Complaint statuses
Resolved:
The complainant verified the issue was resolved to their satisfaction.
Unresolved:
The business responded to the dispute but failed to make a good faith effort to resolve it.
Answered:
The business addressed the issues within the complaint, but the consumer either a) did not accept the response, OR b) did not notify BBB as to their satisfaction.
Unanswered:
The business failed to respond to the dispute.
Unpursuable:
BBB is unable to locate the business.
Hello, I am respectfully requesting the BBB to help me recover an Aetna ** incorrectly processed claim . Attached you will find screenshot of my in-network specialist benefit . ****** co-pay that covers all medically necessary treatment including consult diagnostics and treatment I was referred to the ******** *** ********* ***** by Aetna customer service for in network care. *** gave me an appointment with ** ****** ******** on May 15th. At that time I made them check to make sure he was in network with my specific plan and I was told he was by Kim in billing. I paid my $20 at the time of visit.
3 weeks later I received a bill from ******** *** ********* for an additional $80, which I have paid on credit card.
Upon reviewing my explanation of benefits with Aetna. The claim is processed is in network, however out of network benefits are what was applied and reflected
Aetna processed " in-network "specialist visit as $43.66
This is not my plan benefit. See the screenshot of page 70 that clearly outlines a flat $20 copay that includes all treatment and diagnostics medically necessary.
Further I was charged 100% for each CPT code outside of the office visit at a Medicare negotiated price which is precisely how out of network benefits are processed. The trouble is the claim is stamped in network but the benefit is out of network so this particular problem needs to be manually overridden. I hope you can help me because I have had such a difficult time with Aetna . I seek the $80 refund from either Aetna or ******** *** ********* wants the claim is reprocessed correctly thank you!
Business Response
Date: 06/23/2025
**** *** ******* **********

Please see our response to follow-up on complaint #******** for *** **** **** that was received by us on June 20, 2025. Our Executive Resolution Team researched the concerns, and I would like to share the results of the review with you.

Upon receipt of the complaint, we immediately reviewed *** ****’s account. We have confirmed in the member’s account, she is enrolled into an Aetna Medicare Value (HMO-POS) plan with an effective date of January 1, 2025, and the plan is active.

As a member of our Aetna Medicare Value (HMO-POS) plan, the member must use network providers. This plan does not have out-of-network benefits, if the member receives unauthorized care from an out of network provider, we may deny coverage and they will be responsible for the entire cost.

We confirmed the provider, *** ****** ********, and the facility, ******** *** ********* is in-network with the member's Aetna Medicare Value (HMO-POS) plan. We reviewed the claim ********* for date of service May 15, 2025, from ******** *** *********, listing the rendering service provider as *** ****** ********, **. The billing procedure codes submitted on claim ********* are as follows:

Code 99204; shows a billed amount of $380, the plan paid $117.62, and the member responsibility is $43.66.

Note: CPT procedure code ***** represents an office or other outpatient visit for a new patient, involving a medically appropriate history and/or examination, and a moderate level of medical decision-making. It's a code used for new patient visits where the provider needs to thoroughly assess the patient's condition and develop a management plan.

Code ******; shows a billed amount of $85, the plan paid $0, and the member responsibility is $29.90.

Note: CPT procedure code ***** represents scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; optic nerve. This code is used for ophthalmological procedures involving computerized imaging of the optic nerve in the posterior segment of the eye, including interpretation and reporting.

Code *****; shows a billed amount of $65, the plan paid $0, and the member responsibility is $26.44.

Note: CPT procedure code *****-Gonioscopy. This is used for diagnosing and monitoring glaucoma, a condition that can damage the optic nerve due to increased intraocular pressure.

The total billed amount on claim ********* is $530. The plan paid the provider $117.62, and the member responsibility is $100.

The claim may appear as split charges, however the member would be responsible for the higher copay when two or more services are applied to a claim. This information can be found in the Evidence of Coverage plan booklet, on page 43, which states:

If a member receives services from an outpatient facility and gets more than one covered service during the single visit: the highest single copay for all services received is applied.

The plan’s benefit for outpatient diagnostic tests and therapeutic services and supplies has a $0-$100 copay for each Medicare covered diagnostic procedure and test.

The $0 copay is for services provided by a member’s primary care physician in their office.
The $100 copay is for services performed by a provider other than the member’s primary care physician.

We have confirmed the claim ********* shows, in addition to an office visit with *** ****** ********, MD; the provider billed for computerized ophthalmic diagnostic imaging. This claim is processing in-network under her outpatient diagnostic tests plan benefit. Her cost-share for diagnostic testing is $100.00 for services performed by a provider other than her primary care physician.

Please know, if our members disagree with their cost applied on a claim, they have the right to file an appeal. The only way to overturn a decision made by the plan, is to utilize the appeal process. Appeals can be submitted either in writing or on our website, www.aetnamedicare.com. Our members have 60 days from the date on their explanation of benefits statement to file an appeal, this timeframe can be extended if the member provides a valid explanation for the delay.

Our appeal turnaround timeframe to be completed is as follows:
30 days for a pre-service appeal, meaning for services not yet rendered.
60 days for a post-service appeal, meaning for services already rendered.

We have confirmed the plan received an appeal from the member on June 10, 2025. The appeal is filed under appeal case number A2516160770 regarding the member’s cost-share amount applied on claim EQ37NNXB2. The due date for the appeal to be completed by is August 9, 2025. Our appeals department will notify the member directly with the outcome of this appeal.

The member will receive a detailed Medicare Resolution Letter within 7-10 business days with this response, from us, as well.

We take customer complaints very seriously and appreciate you taking the time to contact us and giving us the opportunity to address *** **** ****’s concerns.

Sincerely,
Marilyn G.
Analyst, Medicare Enterprise Resolution
Customer Answer
Date: 06/24/2025

Complaint: ********

I am rejecting this response because:
Aetna processed a flat $20 specialist visit benefits, listed on page 70. Any reasonable person who was going to a specialist would not know about page 43 or page 64. That's because that is not a specialist visit. That is an outpatient diagnostic procedure. A specialist visit on page 70 includes all diagnostics . It is a flat $20 copay there is no reference on page 70 that says there are any conditions where you will be referred to page 64 or 43. Even so Aetna's explanation that they are using $100 diagnostic test copay does not correlate with my explanation of benefits. I am amazed that they are willing to admit this to the better Business. They told me and the better Business bureau to pay no mind to the explanation of benefits that clearly show I am being charged cost sharing for each individual procedure. Meaning the physician unbundled three codes. That's different than $100 diagnostic fee. Aetna Medicare is allowed this position to unbundle my office visit into three separate procedures. If he did not submit proper modifiers like a 59 along with documentation explaining ..like to know if ncci edit is being followed in their claims processing and if their claims processor is aware that these are unbundled codes and if they're following correct Medicare protocol . Their explanation is inapplicable to this situation. Or else they need to produce $100 diagnostic copay in the explanation of benefits. Would like this explanation to go to my appeal in their department because the appeal is based on out of network. Because Grover Robinson is listed out of network in their database. So I don't know how they could process it in that work. I spent weeks trying to unravel multiple discrepancies with Aetna's database, that lists this doctor is out of network which would result in cost sharing but they say that there is no out of network benefit so that means it has to be the unbundling of the codes and should have been caught by their claims processors because the majority of Medicare Advantage plans do not allow physicians to unbundle at all. But they're denying this is what it is even though my explanation of benefits says that's what it is. I just can't believe that they're responding with pay no attention to the explanation of benefits it really doesn't mean what it says. It means what we say it means which is page 64 an outpatient blah blah blah . Page 64 is not mentioned anywhere in a specialist visit comprehensive benefits section on page 70. Nowhere on page 70 does it say if you receive a diagnostic test not be covered under these benefits you will have to refer to page 64. Page 70 is quite clear that it covers medically necessary care that includes diagnostics . It doesn't say what they're saying. 64 is when you have multiple services. Generally that means if I saw orthopedics and an eye doctor in the same day that's multiple services. It doesn't say multiple procedures. But they're using it to mean that and then they're applying it to an explanation of benefits that doesn't reflect even what they're saying it does. They have successfully twisted every explanation of benefit that is in their book to mean something so abstract that no logic could possibly follow it.

Sincerely,

**** ****
Customer Answer
Date: 06/24/2025
Yes I accidentally clicked on something in my email and it unregistered me from receiving future notices about this complaint

I why would I even be allowed to do such a thing,m
Nowow does my complaint could be closed and I won't be able to complain I??
I clicked on the hyperlink in the message you sent me and it took me to a page that said click here in a red box and I did and then it said that I'm no longer signed up for correspondence
Can this be fixed???
Initial Complaint
Date:06/19/2025
Type:Product Issues
Status:
AnsweredMore info
Complaint statuses
Resolved:
The complainant verified the issue was resolved to their satisfaction.
Unresolved:
The business responded to the dispute but failed to make a good faith effort to resolve it.
Answered:
The business addressed the issues within the complaint, but the consumer either a) did not accept the response, OR b) did not notify BBB as to their satisfaction.
Unanswered:
The business failed to respond to the dispute.
Unpursuable:
BBB is unable to locate the business.
I am a contracted mental health provider. In October of 2024, Aetna changed my rates without any notification. I contacted them immediately, and they reissued a new contract at my previous rates in November 2024. It took them 2 months to finally start reprocessing the claims and reimbursing me the correct amount for the claims they processed incorrectly in October. While waiting for those claims to be corrected, they began to downcode my office procedures and insist on documentation. I provided all the documentation for the requested clai*** They also purposely separated my office code ***** from the psychotherapy add-on code *****, noting (Your claim has been divided to expedite handling. You will receive a separate notice for the other services reported. (***) ) Then when they finally paid the office code they denied the add-on code stating it can not be processed without the apporpriate office code. We have called and requested that they reprocess them, only for them to deny the request again. We have spent numerous hours on the phone and sending emails with no resolution. They currently owe me $1,898.61. I am requesting that, in addition to the simple interest on the unpaid claim amount at a rate of 10 percent per year. This interest accrues starting 30 days after the claim is processed, according to the prompt pay regulations of the *** ****** Division of Insurance.
Customer Answer
Date: 06/24/2025
Since this is Patient related issues, due to HIPPA Regulation we can not provide the patients name, DOB, policy # etc. I will include the exact Claim # and amount due for each claim. Aetna is able to pull the needed information using the claim #.
1) claim *********** was finally paid on 3/15/2025 but you only paid the office code ***** with Remark noted *** Your claim has been separated to expedite handling. You will receive a separate notice for the other services reported. (***) and *** The late claim interest/penalty charge is required by state regulations. A late claim interest/penalty charge has been applied and is included in the payment The ***** add on code has not been paid and gets denied everytime we resubmit or ask you to reprocess it. Stating code-*** We didn't allow this service, but the member doesn't owe this amount. We haven't received or allowed a claim for the primary service. [***]. Your company is the one that separated the primary code ***** from the add on code *****- You owe $92.58, which is the allowed amount for this code PLUS interest from original date of receipt of original claim 10/31/2024
2) claim *********** is still unpaid- Reason code *** Your claim has been separated to expedite handling. You will receive a separate notice for the other services reported. (***)
Remark *** We received the medical chart. It didn't have the right information, so we denied this charge. Resubmit the claim with the correct medical chart. The member doesn't owe this amount. ***. These records were submitted and your company verified receipt. You again have denied the claim for code ***** *** Your claim has been separated to expedite handling. You will receive a separate notice for the other services reported. (***)
Remark *** We didn't allow this service, but the member doesn't owe this amount. We haven't received or allowed a claim for the primary service. [***] Not even considering the ***** which was submitted with the ***** on the original claim date 12/24/2024. You Owe us $133.53 for the ***** and $92.58 for the ***** for a total amount due of $226.11 PLUS instrest from original claim date 12/24/2024.
3) claim *********** was finally paid on 4/8/2025 but this time you paid the add on code ***** and did not pay the office code ***** and notes Remark *** Your claim has been separated to expedite handling. You will receive a separate notice for the other services reported. (***) Status *** Processed according to contract provisions (Contract refers to provisions that exist between the Health Plan and a Provider of Health Care Services) Which is completely inaccurate. You cannot process and pay an add on code ***** without the E/M office code as the primary code. When we resubmitted and asked you to reprocess this claim for the ***** you returned a denial remark Remark *** Your claim has been separated to expedite handling. You will receive a separate notice for the other services reported. (***) Remark *** We denied this service. We asked you for the member's medical chart, but we didn't receive it. The member doesn't owe this amount at this time. [***] We faxed and sent all requested records numerous times through ********. Your company confirmed receipt then only paid the add on code, which again makes no sense. For this Claim you owe us $133.53 PLUS interest original date of receipt of original claim 03/11/2025
Total Due for just 1 patient is $452.22 NOT counting interest due. I will include the other patients claim # below but I am not going to continue to do their job for them. We have emailed them numerous times with this information and they are fully aware of the amount they owe.
Patient #2 Claim # ********** (DOS 10/30/2024) # *********** # *********** (DOS 12/30/2024) # *********** #*********** (DOS 2/4/2025) # *********** # *********** (DOS 3/4/2025)
Patient #3 Claim # *********** #*********** (DOS 12/30/2024) ************ (DOS 2/4/2025) # *********** #*********** (DOS 3/4/2025)
So that we are clear DOS is short for Date of Service. That was the date the patient was seen. Each Claim # indicates the payline that has not been paid. If I included two claim numbers with one DOS then you did not pay both the office code or the add on code for psychotherapy. If only 1 claim # was included that means you paid one line of service but failed to pay the other. Hopefully this will help your corporate office to pull the documentation regarding this complaint.
Please let me know if any further information is needed.
Sincerely,
*** ***** ****** *****
Business Response
Date: 07/01/2025
**** ******* **********

Please see our response
to complaint # ******** for *** ***** ****** that was
received by us on June 19, 2025. 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 internally to further research the provider’s concerns. We
confirmed that a project request was submitted to review *** ******** claims as
well as to prevent these issues from occurring again. Please know, one of our
client advocates, Tiffani, sent *** ****** an email on June 27, 2025, stating the
project has been completed. Tiffani provided *** ****** with a copy of the
completed spreadsheet which included the project
payment information along with any comments. Also, a summary was added which
outlined the results of the project. Furthermore, Tiffani reminded the provider
that they should continue to utilize their Explanation of Benefits (EOBs) as
the formal notification of claim financial details. In addition, the provider’s call
history was reviewed, and the necessary feedback has been provided. Should ***
****** have any questions or concerns regarding her claim project, she may
contact provider services at ###-###-####.
We take customer complaints very
seriously and appreciate you taking the time to contact us and giving us the
opportunity to address *** ******** concerns. If there are any additional
questions regarding this particular matter, please contact the Executive
Resolution Team at *******************************.
Sincerely,

Shay
G.
Analyst,
Executive Resolution
Executive
Resolution Team

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