A&A Home & Business Services

Initial Business Response /* (1000, 14, 2017/02/09) */
Anthem has reviewed the claims from provider [redacted], It looks like several claims were reprocessed towards In-Network benefits, but the issue is that Anthem did not include in the administrative decision to have the non-eligible amounts paid at...

100% of billed charges, which you could still be being billed for (or already have paid).
You are disputing the non-eligible amounts (which you can see on claims breakdown we put together below) not being paid, while some others have had them paid. This is because the administrative decision that was done did not specifically state that they should pay 100% non-eligible charges, but rather stated to have the claims processed towards in-network benefits. Per Anthem's records there is an appeal underway to have those non-eligible amounts addressed and considered for payment under reference #[redacted].
With that being said, we have made an administrative decision to adjust and pay the claims below with a Non Eligible amount (highlighted in yellow) to pay at billed charges from the provider with the exception of your, if any, responsibility based on your benefits. The claims highlighted in yellow have been adjusted today 02/09/2017 and will issue payment within two weeks. Anthem apologizes for any inconvenience this may have caused and appreciate your business going forward.
02/29/2016
Claim # [redacted]
-Total Charge: $18.40
- Member Responsibility - $3.68 (Coinsurance, deductible met prior)
- Non Eligible amount: $0
- Anthem paid: $14.72 (Check No. [redacted] - paid to provider in amount of $1,345.81, Cashed on 09/09/2016)
02/29/2016
Claim # [redacted]
-Total Charge: $73.90
- Member Responsibility - $13.29 (Coinsurance, deductible met prior)
- Non Eligible amount: $0
- Anthem paid: $60.61 (Check No. [redacted] - paid to provider in amount of $1,345.81, Cashed on 09/09/2016)
02/29/2016
Claim # [redacted]
-Total Charge: $766.80
- Member Responsibility - $0.00
- Non Eligible amount: $613.86 [redacted]
- Anthem paid: $152.94 (Check No. [redacted] - paid to provider in amount of $485.91, Cashed on 10/04/2016)
03/02/2016
Claim # [redacted]
- Total Charge: $174.00
- Member Responsibility - $0.00
- Non Eligible amount: $0.00
- Anthem paid: $174.00 (Check No. [redacted] - paid to provider in amount of $1,345.81, Cashed on 09/09/2016)
03/03/2016
Claim # [redacted]
- Total Charge: $664.50
- Member Responsibility - $0.00
- Non Eligible amount: $0.00
- Anthem paid: $664.50 (Check No. [redacted] - paid to provider in amount of $1,345.81, Cashed on 09/09/2016)
06/03/2016
Claim # [redacted]
- Total Charge: $730.00
- Member Responsibility - $0.00
- Non Eligible amount: $591.82 [redacted]
- Anthem paid: $138.18 (Check No. [redacted] - paid to provider in amount of $485.91, Cashed on 10/04/2016)
06/03/2016
Claim # [redacted]
- Total Charge: $669.00
- Member Responsibility - $0.00
- Non Eligible amount: $542.67 [redacted]
- Anthem paid: $126.33 (Check No. [redacted] - paid to provider in amount of $485.91, Cashed on 10/04/2016)
06/03/2016
Claim # [redacted]
- Total Charge: $55.20
- Member Responsibility - $0.00
- Non Eligible amount: $33.49 [redacted]
- Anthem paid: $21.71 (Check No. [redacted] - paid to provider in amount of $485.91, Cashed on 10/04/2016)
Thanks,
[redacted] I Manager I Customer Care, CO/NV ISG Call Center I Six Sigma Yellow Belt I Anthem, Inc.
[redacted] I
P: [redacted]-[redacted]-[redacted]
E: [redacted].[redacted]@[redacted].[redacted]
Initial Consumer Rebuttal /* (3000, 16, 2017/02/09) */
(The consumer indicated he/she DID NOT accept the response from the business.)
Anthem has completely misunderstood the complaint.
I am not questioning the payments for claims to [redacted] as a service provider.
My question continues to be with the change for [redacted] from out-of-network to in-network, I would have reached my in-network out of pocket maximum sooner and therefore would not have had to pay some of the co-pay and coinsurance monies later in the year with all other providers.
Anthem has still refused to provide the proper accounting to me nor have they provided any further refunding of over payments to me.