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

1,333 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:03/27/2025
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.
Subject: Urgent Fraudulent Account Dispute – Immediate Action Required

Dear Aetna Health,

I am writing to formally dispute an account fraudulently opened in my name. Yesterday, I received an email stating that I owe $125.01 under Account ID: **********, which led me to call the ****** ********* ***********. I never applied for or signed up for an Aetna insurance plan.

I have always been on my father’s ******* **** ***** *** **** ****** insurance due to my cognitive disabilities, and he ensured my continued coverage. It makes no sense for me to have any other insurance. Also, every time *** attempted to run my prescriptions through Aetna, I told them I had no knowledge of any Aetna policy.

An Aetna representative informed me that the person who fraudulently signed me up used the false name “**** *****” and a fake phone number, ###-###-####, which links back to Aetna. The fraudulent application listed *** * **** *** ********* ** *****, while my actual residence was *** * **** **. This raised suspicions that my ex-girlfriend, ****** ***** (birth name ******* ******* *************), or my former roommate, ******* *****, both of whom have legal issues, may have done this.

I have reported this fraud to:
• ***** ****** ********* ****** **** – Case # **********
• *** ******** ***** ********* ****** ***** – Report # ********************************
• ******* ***** ********** ***** – Report #***-***-**** • Better Business Bureau (BBB)
• ***** ******** ******** ********* ******
• Aetna Executive Team

I also learned that three fraudulent applications were submitted in my name. If I had signed up, I wouldn’t have reported it.

I demand Aetna cancel this fraudulent policy, remove all records from your system, and confirm I am not responsible for any charges. If this is not resolved, I will take legal action.

Sincerely,
******* * ******
###-###-####
********************
**** **** *** ************ ** *****
Business Response
Date: 04/01/2025
**** *** ******* **********

Please see our
response to complaint #******** for ***
******* ******that was received
us on March 27, 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. We confirmed that an
application was received on December 07, 2023, and coverage was active for the
entirety of 2024 with a $0.00 premium. Another application was received on
October 16, 2024, for 2025 coverage with a monthly premium of $41.67, which
resulted in a past due balance and notification to you via email.

The
*********** handles all concerns related to unauthorized enrollments. They
have created a case to escalate the concerns and will contact you directly
with the resolution. If the *********** deems the case to be an unauthorized
enrollment, your providers and pharmacies will need to rescind their claims
and rebill to the correct insurance. If the *********** declines the case as a
valid enrollment, you may appeal their decision directly with the ***********.
Any further questions or concerns regarding this enrollment should be directed
to the ***********.

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: 04/02/2025

Complaint: ********

I am rejecting this response because:

It isn’t my responsibilities to take care of this matter. If I have to I will hire an attorney I didn’t sign up for this fraudulent insurance you guys and market place should be talking not me! Or talk to agent **** ***** this is illegal what you and market place and agent **** ***** did all 3 of you guys should be sued in court! Talk to my dad about this ###-###-#### I am not filing anything out or doing anything else! I may even get the media involved if I have to!

Sincerely,

******* ******
Initial Complaint
Date:03/25/2025
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 went to a physical therapy appointment in early Jan 2025. Aetna denied my claim. I called CS and was assured that it would be covered. Once I filled out a manual
form with the supper bill. I did as I was told and had to call back numerous times before I could confirm it was received and being processed. This continued into February where I had to call, speak to a supervisor and was told my claim was denied. I explained that I was told by multiple reps it would be covered. The supervisor said he could see in the notes this was true. He told me physical therapy isn’t covered using the code submitted on the form and that there is no way of knowing in advanced if a medical service is covered or not. Darryl (supv) said he would submit a special claim that takes 12 days.
It’s now late March. I’ve called at least 6 times to be told the same thing. Darryl is the only person at the entire company who can assist with my claim. Each agent told me they left Darryl messages but he had never attempted to contact me.
I can not get treated by my doctor due to the outstanding balance and they are sending me to collections.
After months Darryl still can’t get reached. They had the audacity to tell me, in late March to resubmit the super bill and form again.
I literally feel sick every time I call because they have me going in circles. They are preventing me from continuing my treatment and my credit score is at risk.
This is the most incompetent, unethical and corrupt insurance experience I’ve ever had.
I’ve waisted literally hours and gotten no where.
Customer Answer
Date: 03/25/2025
I’d like to withdraw my complaint. Aetna is now trying to assist with my claim.
Initial Complaint
Date:03/24/2025
Type:Product 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 submitted a medical claim for $188.58 related to services received in ****** from 02/24/2025 to 02/27/2025. I p
aid in cash and uploaded a doctor-signed receipt with dates, prices, and an official stamp as proof of payment.
Despite multiple messages clarifying that:
• No credit card, bank statement, or wire transfer exists (since payment was in cash),
• I had already uploaded the stamped, signed receipt from the doctor, and
• The doctor reissued an updated version at his request,
Aetna repeatedly stated the documentation was either:
• Not received, or
• Not acceptable without a bank statement or wire transfer—even for a cash payment.
After continued back-and-forth, the receipt I provided was eventually acknowledged, and the claim was forwarde
d to processing. However, Aetna later reversed course, saying the document was still not acceptable, insisting ag
ain on a receipt or wire transfer proof—even though a wire transfer is not possible for cash.
Business Response
Date: 04/01/2025
**** *** **********

Please
see our response to complaint # ********
for ****** ***** that was received by us on March 24, 2025. Our Executive
Resolution Team researched the provider’s concerns, and I would like to share
the results of the review with you.

Upon receipt of the complaint, we reached
out internally to have the member’s concerns reviewed. We confirmed that the
member’s claim was processed correctly as billed. Unfortunately, the submitted
information does not prove that an actual payment was made to the provider.
Instead, the documents only show that the services were rendered and billed
which is why we continued to request a copy of the paid receipt. However, as a
one-time courtesy exception, we reprocessed the member’s claim on March 28, 2025,
at the in-network benefit level. Please know, the claim was allowed in full,
and the total amount was applied to the member’s deductible. Mr. ***** should
receive an Explanation of Benefits (EOB) within 7-10 business days.

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

Sincerely,

Herman M.
Analyst, Executive Resolution
Executive Resolution Team
Customer Answer
Date: 04/01/2025

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:03/20/2025
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.
BBB took a complaint over the phone. Below is the voice to text voicemail description

Hi, my name is ****** ****. My complaint number is *********. Last year I had Aetna Medicare and I had some dental work done and I had them up until January of this year and I went to a different insurance company. Aetna won't pay for the dental work that I had done while I still had them. So, I'm just wanting them to pay their part of the bill when I was on Aetna. I thank you, appreciate it, bye-bye.
Business Response
Date: 04/09/2025
**** *** ******* **********

Please see our response to follow-up on complaint
#******** for *** ***** ***** that was received by us on April 8, 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 the member’s account. We have confirmed in the member’s account, we
have confirmed *** ***** was enrolled into an Aetna Medicare Premier HMO-POS
plan with an effective date of July 1, 2024. The plan terminated on December
31, 2024, due to the member voluntarily disenrolling from the plan.

After our review of the member's claims on her
account, we do not show any dental claims have been submitted into the plan to
process for possible payment. During the review of the call history, ***
***** is referring to a dental provider, by the name of ******** ****** ****. We have
confirmed ******** ****** **** is in-network with the Aetna Medicare Premier HMO-POS plan. When our customer service
department reached out to the dental office on multiple calls, the dental
provider advised the bill she received is just a lingering bill until the
dentures are completed and that she doesn’t need to pay that bill. The dental office also explained
they do not bill for the dentures until they are fitted, and she takes them
home. They advised the dentures are not yet completed.

We have confirmed in the 2024 dental coverage does
cover prosthodontic and maxillofacial services, with an in-network $0 copay.
The 2024 an Aetna Medicare Premier HMO-POS plan has an annual benefit amount,
also known as an allowance. Covered services will be paid to the provider up to
the annual benefit amount (allowance). Members are responsible for any costs
over the benefit amount of $2,900 every year for covered preventive dental
services and comprehensive dental services combined. Members will not be
reimbursed for any costs over the annual benefit amount. We have confirmed *** ***** did not use any of her
2024 dental allowance amount of $2,900.
The dental network for the Aetna Total Choice
dental benefit is the Aetna Dental PPO network. Members save money when they
receive dental services from a provider in this network. And network providers
agree to bill us directly, so members you won’t need to pay up front and get
reimbursed. The member just needs to be sure to show their member ID card to
the provider at the time of service. Our members can find a provider in the
dental network, by visiting *************************** or call Member
Services. Please note: Members dental network is different than their medical
network. For medical they must use an in-network provider. For dental members
may receive services from a dental provider outside of the network that is
licensed in the US or US territories. If they receive services from a provider
that is not in the Aetna Dental PPO network, they may have higher costs. If
they choose an out-of-network provider and they are not willing to bill us
directly, members may have to pay upfront and submit a request for
reimbursement. For information on requesting reimbursement, visit ***************************.

If the member has received a bill from a dental
provider, she can submit the claim into the plan. Members may request us to pay
them back by sending us a request in writing. If a member sends a request in
writing, they can send their bill and documentation of any payment they have
made. It’s a good idea for members to make a copy of their bill and receipts
for their records. Members must submit their medical claims to us within 12
months of the date that they received the service or item. To make sure members
are giving us all the information we need to make a decision, they can fill out
our claim form to make their request for payment. When we receive the request
for payment, we will let the member know if we need any additional information
from them. Otherwise, we will consider their request and make a coverage
decision. If we decide that the medical care or drug is covered and the member
followed all the rules, we will pay for our share of the cost. If the member
has already paid for the service or drug, we will mail the reimbursement of our
share of the cost to the member. If a member has not paid for the service, we
will mail the payment directly to the provider. If we decide that the medical
care is not covered, or the member did not follow all the rules, we will not
pay for our share of the cost. We will send the member a letter explaining the
reasons why we are not sending the payment and their rights to appeal that
decision.

Please know, the member will receive our formal
detailed Medicare Resolution Letter, along with a medical claim form for her
convenience, within 7-10 business days with this response.

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 Executive Resolution
Customer Answer
Date: 04/09/2025
All I am asking is that Aetna pays their part..I have received 2 bills for the total bill..If they would like me to I can send them the bill..All I need is information sent to me where to send the bill. Thank you..
Business Response
Date: 04/15/2025

**** *** ******* **********

Please see our response to follow-up on the
rejection of complaint # *********** for *** ***** *****, which was received by us on April 9, 2025. After
receiving the complaint, we promptly conducted internal research.

Our Executive Resolution Team has finalized the
research, and I would like to share the results of the review with you.

We have confirmed in the member’s account, that
her concern relates to dental coverage for 2024. We found that the member was enrolled
in the Aetna Medicare Premier (HMO-POS) plan that was effective July 1, 2024,
and terminated on December 31, 2024.

We were unable to find any dental authorization or claims in
our records. If the member received dental services while enrolled in our plan,
she may submit a request for reimbursement. Claims will be processed based on
the plan benefits and covered services while the member was enrolled.

We have included the reimbursement form. According to the 2024,
Evidence of Coverage, the dental benefits are as follows:
Dental services:
In general, preventive dental services (such as cleanings,
routine dental exams, and dental x-rays) are not covered by Original
Medicare. However, Medicare currently pays for dental services in a limited
number of circumstances, specifically when that service is an integral part of
specific treatment of a beneficiary's primary medical condition. Some examples
include reconstruction of the jaw following fracture or injury, tooth
extractions done in preparation for radiation treatment for cancer involving
the jaw, or oral exams preceding kidney transplantation. In addition, we cover:

• Preventive dental services:
? Oral
exams $ 0 copay
? Cleanings $0 copay
? Fluoride treatments $0 copay
? Bitewing x-rays
$0 copay

• Comprehensive dental services:
? Non-routine
services $0 copay
?
Diagnostic services $0 copay
?
Restorative services $0 copay
? Endodontics $0
copay
? Periodontics
$0 copay
? Extractions
$0 copay
?Prosthodontic
and maxillofacial services $0 copay

What you must pay when you get
these services out-of-network:

Preventive dental services:
• 50%
coinsurance

Comprehensive dental services:
• 50%
coinsurance (See “Physician/Practitioner services,
including doctor’s office visits” for information about Medicare-covered dental services.)

For covered services: ADA
recognized dental services are covered excluding only cosmetic services, those
considered medical in nature, and administrative changes.

This plan has an annual benefit
amount, also known as an allowance. Covered services will be paid to the
provider up to the annual benefit amount (allowance). You will be responsible
for any costs over the benefit amount of $2,900 every year for covered preventive
dental services and comprehensive dental services combined. You will not be
reimbursed for any costs over the annual benefit amount.

The dental network for the Aetna
Total Choice dental benefit is the Aetna Dental PPO network. You save money
when you receive dental services from a provider in this network. And network
providers agree to bill us directly, so you will not need to pay up front and
get reimbursed. Just be sure to show your member ID card to the provider at the
time of service. To find a provider in the dental network, visit
*************************** or call Member Services. Please note: your dental
network is different than your medical network.

You may receive services from a
dental provider outside of the network that is licensed in the US or US
territories. If you receive services from a provider that is not in the Aetna
Dental PPO network, you may have higher costs. If you choose an out-of-network
provider and they are not willing to bill us directly, you may have to pay
upfront and submit a request for reimbursement.

For information on requesting
reimbursement, visit *************************** or see the Payment Requests
for Medical Coverage — Contact Information in Chapter 2 (Important phone
numbers and resources). Important: You have limited coverage for Medicare-covered
dental services with this plan. You are required to receive Medicare-covered
dental services from a network provider in the standard provider directory.
Visit AetnaMedicare.com/findprovider to find a provider for these services. You
may only get care from an out-of-network provider for non-Medicare
covered dental services. *Amounts you pay for preventive dental services do not
apply to your maximum out-of-pocket amount. *Amounts you pay
for comprehensive dental services do not apply to your maximum out-of-pocket
amount.

The member will receive the detailed Medicare response in
the mail within seven to ten business days.

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

Sincerely,
Jennifer
Analyst
Medicare Executive Resolutions
Initial Complaint
Date:03/20/2025
Type:Order 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.
ID **********

I had three claims denied by this health care provider due to an expiring pre-authorization that I was unaware of. The doctor continued to provide care due to the impression that this situation had been permanately resolved. It was not until multiple claims were denied that we discovered that a pre-authorization had expired and was in need of renewal. Aetna provided no communication regarding the expiration of this pre authorization, no email, no letter, no phone call, anything. Aetna set a financial trap and watched me fall into it. The pre authorization has been resolved but I am being told that because I knowingly sought care without coverage that the denied claims are unable to be back-dated with the pre authorization. Insurance providers should be communnicating with their clients to ensure that they have the relevant information and know when it is time to renew something. The original authorization was not done by me nor requested by me, additionally, the renewal was not done by me. These claims need to be covered and insurance companies should be more forthcoming with information to help clients seek affordable care. Aetna failed grossly in this matter and have presented me with an impossible financial burden.
Business Response
Date: 03/21/2025
**** ******* **********
Please see our
response to complaint # ******** for ****** ******* that was received by us on
March 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 your request, we immediately reached out internally to further
research the concerns. After
further review it was determined
that the member was made aware of the authorization expiration date on the original
authorization approval letter dated January 25, 2024, on that letter it states
the approval dates were from January 23, 2024, through January 23, 2025.
Notification is also sent to the initiating provider when an authorization is
expired. It is up to the initiating provider to submit the new authorization
request with the requested documents. I have attached the original authorization
approval letter. The new authorization has been approved for the following
dates: March 19, 2025, through March 19, 2026, this authorization is approved
for 52 visits. The member currently has an appeal on file under case number *************.
The appeal is currently still being reviewed and has a case closing date of
April 19, 2025, the member can get appeal status through member services or
wait on the decision which the member will be notified via standard mail
through a resolution letter.
We take customer
complaints very seriously and appreciate you taking the time to contact us and
giving us the opportunity to address Mr. *******’s 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: 03/21/2025
Authorization letter dated January 25, 2024
Customer Answer
Date: 03/21/2025

Complaint: ********

So the be clear, your defense to this egregious and malicious practice is that you sent me a letter over a year ago after it was originally approved? You provided no such communication at the point of expiration to, there was no effort whatsoever to ensure the covered person (me), was made aware that I was financially exposed and/or action was required. To state otherwise is a gross misrepresentation of the events and further evidence of the financial trap set up by Aetna. I am requesting the three claims be covered due to the gross mishandling of the situation by Aetna and their complete and blatant lack of effort to ensure I was made aware of any action required.

Sincerely,

****** *******
Business Response
Date: 04/02/2025
**** ******* **********

Please see our
response to complaint # ******** for ****** ******* that was
received by us on March 21, 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
member’s concerns. We confirmed that previously, the rendering provider was not
participating with the member’s plan. Therefore, an approved network deficiency
was required. We also confirmed that the provider is participating with the
member’s current plan. Thus, the authorization under reference number
************ has been canceled since a network deficiency request is no longer
required.

Mr. *******’s
claims for dates of service January 31, 2025, February 12, 2025, and March 11,
2025, are now eligible to be reprocessed at the in-network benefit level.
Please know, the claims were sent for haste reprocessing on April 2, 2025, and
can take up to 7 business days for completion. Once the claims have been
finalized, Mr. ******* should receive a new Explanation of Benefits (EOB) with
details regarding the estimated costs for his services.

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

Sincerely,

Brittany F.
Analyst,
Executive Resolution
Executive
Resolution Team
Initial Complaint
Date:03/20/2025
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.
In February of 2022 I received a letter from you outlining the adjustments to the standard fee schedule for Aetna. I have attached a copy of the correspondence I received. The letter advises the fee changes were to be effective beginning April 1, 2022. However, none of the claims I subsequently received were adjusted to the fees as outlined in the letter. I checked with other providers in the area to find they received the fee adjustments as promised. I have made attempts to contact your office by phone but was repeatedly disconnected or transferred with no one taking responsibility for making the updates.
I would like to request that the fees be updated, and my claims filed subsequent to April 1, 2022 be adjusted accordingly.

I have called multiple times and submitted letters and all have been ignored or denied.
I am attaching a copy of the letter you sent me stating you would be correcting my fee. I am also attaching an enlarged copy of the portion with the fees for the two services i submit as your original copy is in tiny print. However you should be able to either see the original letter from your records or enlarge the first letter attached.
Business Response
Date: 03/31/2025
**** ******* **********
Please see our response to complaint # ******** for **** ***** that was received by us on March 20, 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 James from our provider executive complaints team
emailed Ms. ***** directly on March 31, 2025, to clarify her concerns regarding
the letter about fee schedule increases. James explained that the change in
rates were for the Aetna Market Fee Schedule (AMFS), not the provider’s
specific contract. James also explained that his team cannot compare different
providers’ contractual agreements to Ms. *****’s because the signed agreement
with Aetna is referred to as contractual (carve out rates). This means that the
rates do not get adjusted unless a contractual update has occurred. If Ms.
***** bills for services that are not identified as a carve out in the contract
specifically, then the rate increase would apply from the current pricing of
the AMFS. Please know, our claims team
conducted a review of all the provider’s claims billed in the last 30 calendar
days and have identified that all claims are being reimbursed properly, as the
procedure codes were not a part of the rate changes, due to contract written specific rates.
If Ms. ***** would like to submit for a proposed rate
increase, she must submit
a written rate renegotiation or new contract request to our network team. This request should be submitted on the provider’s letterhead and
include the name of all providers involved, the proposed rates for each procedure
code, and rationale on how the proposed rate was calculated, along with the
billing provider’s demographics. This request can be sent to our mailing address of **** *** ******* ** **** ** ***** or it
can be faxed to ###-###-####. Once received, a Network Assistance Forum
(NAF) ticket will be submitted on the provider’s behalf. The standard
turnaround time is 10-14 business days for a decision. Should Ms. ***** have
any questions regarding this process, she may contact provider services at
###-###-####. Additionally, the provider’s communication history is being
reviewed and the necessary feedback will be provided.
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,

Brittany
F.
Analyst,
Executive Resolution
Executive
Resolution Team
Initial Complaint
Date:03/19/2025
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.
Was a member of the Silverscript SmartSaver PDP plan for 2023 and 2024. I was enrolled under Member ID: *********. My union reimburses me on an annual basis for my PDP payments. I am in need of the monthly proof of payments for both 2023 and 2024.
Business Response
Date: 03/21/2025
**** *** ******* **********

Please
see our response to follow-up on complaint #******** for *** ***** ****** that
was received by us on March 19, 2025. Our Executive Resolution Team researched
the concerns, and I would like to share the results of the review with you
below.

Upon
receipt of the complaint, we immediately reached out to our premium billing
department with the member’s request. Our premium billing department has
supplied us with a copy of her monthly proof of payments for both 2023, and
2024, as the member has requested. We have confirmed a copy has been mailed to
her and we have also attached a copy to this response for the members
convenience.

The
member will receive a detailed Medicare Resolution Letter within 7-10 business
days with this response.

We
take customer concerns 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 Executive Resolution
Customer Answer
Date: 03/24/2025

Complaint: ********

I am rejecting this response because:
My union just contacted me and advised me that before they reimburse me, they need something to prove what type of Aetna Silverscripts Medicare Prescription plan that I was enrolled in for 2024. It can be an annual benefits summary pertaining to me, a copy of an ID card or a letter. Please provide me with whatever is the easiest to obtain from your system. My Member ID was: *********

Sincerely,

***** ******
Business Response
Date: 04/04/2025
**** *** ******* **********

Please see our response to complaint # ******** for *** ***** ******, which we received on March 26, 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 concern, we immediately reviewed the member’s enrollment details. *** ****** was enrolled in the SilverScript SmartRx (PDP) effective, January 1, 2022. The plan was terminated on December 31, 2024. We have attached a copy of the member ID card.

The member will receive a written resolution letter within 7-10 business days. My contact information will be included in the letter. The member can feel free to contact the plan if you need any further documentation.

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,
Jasmine W.
Analyst
Medicare Enterprise Resolution
Initial Complaint
Date:03/18/2025
Type:Order 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 purchased health insurance through the ***********, using the filter to show plans where my Dr. is in network. I selected Aetna (one of the highest priced plans) because it listed my Dr. in network.
Now that I'm ready to make an appt, my doctor's office told me that they do not take *********** insurance.
I called Aetna who could see my Dr. is listed in network in my plan, they called my dr. to verify and confirmed back to me that it is correct that they are not in my network, and are listed incorrectly on both *********** and Aetna's site (mis-representation).
Their only solution is to do a pre-certification request where I have to gather the procedure codes and tax id info from my dr, to see if Aetna will approve for me to get a check up at in-network pricing.
Business Response
Date: 03/28/2025
**** ******* **********
Please see our
response to complaint # ******** for ********* ****** that was received by us
on March 18, 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 provider is listed as being participating with the member’s Silver S Aetna
Network plan. Further research was done to see if we have any claims on file
from the provider that processed as Out of Network (OON) incorrectly, after
researching no claims were found from this provider so as it stands no claims
were received or processed from this provider. If the provider has any
questions or concerns regarding participation status the provider can 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 *** ******’s concerns. If there are any
additional questions regarding this particular matter, please contact the Executive
Resolution Team at [email protected].
Sincerely,
ShaCarra B.
Executive Analyst,
Executive Resolution Team
Customer Answer
Date: 04/01/2025

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:03/18/2025
Type:Order 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 had a ********** *********** on 10/29/2023. I arrived in the ER a day before, unable to function, walk, or even stand on my own. The emergency surgery was to prevent further damage to the sciatic nerve. The claim was immediately denied following the surgery, with notes on both medical necessity and a coordination of benefits issue. I made dozens of phone calls to Aetna to sort this out - they told me that it was ALL caused by the *** issue which was effectively a clerical error on someone else's part, and no action was needed on my end. Each time, I was told it would be resolved within the week. A year filled with routine phone calls later, the issue was FINALLY resolved, after which I was immediately struck with the medical necessity denial AFTER my window to appeal had already lapsed due to the clerical issue. From the EOB letter:

"The requirements for coverage are:
(1) you have a new loss of spinal cord function as shown by any of the following: (a) you're unable
to control your urine or stool, (b) you have numbness in your buttocks or groin area, or (c) you
have another problem that suggests a nerve(s) is compressed; (2) you need hospital care to
control your pain; or (3) the cause of your condition can only be managed in the hospital. You
don’t meet any of these requirements."

However, I clearly met all requirements (besides incontinence) according to **I images, medical records and notes from the surgeon, including a personal letter addressing the denial. I spoke with the surgeon's office and found that they had attempted their own appeals but were also denied without review. Aetna told the surgeon's office that I had failed to send documents, but told me vice versa and that no action was needed during my dozens of phone calls. This leads one to believe that Aetna abused their position as a mediator to cause delays and confusion, to illegally deny appeals, knowing that financial disincentives (legal fees) would save them from accountability in civil court.
Business Response
Date: 03/26/2025
**** ******* **********
Please see our
response to complaint # ******** for **** ****** that was received by us on
March 18, 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 claim originally denied for Coordination of Benefits (***) issues, the
claim was then sent back for reprocessing. However, the claim denied for no authorization.
That denial is correct the provider billed observation, but it was over 24
hours, anything after 24 hours requires an authorization. The authorization
under ************ was denied on October 31, 2023, the member, provider, and
facility were notified of this denial on October 31, 2023, via standard mail.
On the denial letter it explains the appeals process for the member, as well as
the provider. The provider did a Peer to Peer (P2P) which was denied on
November 2, 2023, from this date the member and the provider could have
submitted an appeal. The appeal was not received until January 6, 2025, at that
time the appeal was denied correctly for timely filing. Unfortunately, we would
not be able to override this decision denial. No further reviews will be
conducted on this claim issue as the claim denied correctly, as well as the
appeal.
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: 03/26/2025

Complaint: ********

I am rejecting this response. The claim was wrongly denied to begin with, and every call I made to Aetna after the surgery was met with "coordination of benefits" as an explanation. I specifically asked about medical necessity, but was told that the coordination of benefits issue must clear first and that the medical necessity denial was likely an error resulting from the *** issue. This is the entire reason I did not send a medical necessity appeal within 180 days of the surgery. If this sounds wrong based on your internal documentation of events, just know that nothing was properly communicated to me despite my numerous phone calls to gather information and did the issue in the months following the surgery.
I have proceeded with external appeals through the **** ********** ** ***, as well as the ***** ********** ** *********, as I could not get a consistent answer from Aetna on how to proceed with this.
The appeals from my provider were rejected on the grounds of a clerical issue, according to the provider. ***** **** ********* was informed that I had failed to provide documents, but no documents were ever requested of me, including during my dozens of calls to Aetna in an effort to resolve the denial.
The prior authorization denial was wrong (possibly due to some accident, or maybe an intentional violation of policy), and the appeal denials were issued without review of the facts due to Aetna's errors and/or abuse of their position as a mediator. Aetna is transparently wrongly denying claims to secure extra profit by violating the law, knowing that legal action may be more expensive than paying the surgery bill. If they will admit this in writing, I will accept their response on BBB, but I expect that one of my external review requests will be successful.
The medical necessity denial is objectively wrong, comically so when seeing it spelled out in the EOB compared to my medical records. Admit your greed and malice, Aetna.

Sincerely,

**** ******
Business Response
Date: 04/04/2025
Dear Stewart Henderson:

Please see our response to complaint
#******** for **** ****** that was received by us on March 26, 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 member’s concerns we immediately reached out to
investigate. We found that the member’s appeal request was outside the timely filing
limit. As a one-time exception we will allow an appeal of the claim denial. We
have reached out to the member to obtain a written appeal request, and will
follow up with him directly with the resolution.

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,

William B.
Analyst, Executive Resolution
Executive
Resolution Team
Initial Complaint
Date:03/18/2025
Type:Product 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 had a Benefit Card with Aetna through ******* ********. I put in for a reimbursement for December of $300, as I have gotten October and November with same paperwork and same process. I called several times in December to ******* ********. I was told many different excuses and many different things they said they would do and didn't, such as: It's being processed, It's pending, It's back logged call back in a month, I'll send an urgent message to a different team to get this processed, It's being sent out should receive it in 7-10 business days, It went to the wrong address we'll get that resent call back in 30 days, It never got sent out, ******* ******** no longer works with Aetna call Aetna and file a grievance. I called Aetna and was given a case number that a grievance was filed they will call me in 7 business days. They didn't so I called them and was told a grievance was never filed because it has to be filed within 60 days of issue. Aetna agent said she would put in an urgent message to the task team and they should call by the end of the week. I am currently no longer a member of Aetna. There was an online portal I could see what process my reimbursement was in, but they shut it down, so I called and there was an option for 2024 ******* ******** claims Aetna did not tell me about not using ******* ******** anymore. I have been told to call ******* ******** and ******* ******** tells me to call Aetna. This has been going on for four months and I still have not received my reimbursement for December of $300.
Customer Answer
Date: 03/21/2025
Update:
Aetna sent a check for the full amount. Complaint is resolved.

Thank you.

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