Administrative Concepts, Incorporated

We are in receipt of the correspondence from the Revdex.com (Revdex.com) dated 1/21/15. Administrative Concepts, Inc. is a Third Party...

Administrator contracted to administrate claims on behalf of BCS Insurance Company for the policy offered to Norfolk State University participants. Oriel Rena [redacted] as a member of Norfolk State University, was insured under Policy Number [redacted] from 08/01/08 through 07/31/13.This letter is in response to your correspondence regarding concerns on file # [redacted] submitted by the Complainant named above. The Complainant, Oriel Rena Rivers, is writing regarding unpaid medical expenses submitted to our office for treatment rendered on 12/16/11 totaling $4,187.37.We have reviewed the concerns and issues noted by Ms. Rivers. Upon review of the documentation on file, we are missing an Explanation of Benefits from her primary carrier to resolve this claim. The plan Ms. [redacted] is enrolled under is an Excess plan and contains the following statement:If a Covered Person has other insurance, benefits under this plan will be paid on the unpaid balance after the other insurance has paid. No benefits are payable for any expense incurred for Accident or Sickness which is paid or payable by other valid and collectible insurance. This Plan will cover unpaid balances, deductibles and other eligible expenses not covered by other insurance. Benefits will be adjusted so that the total amount paid or payable under two insurance policies combined does not exceed 100% of the expenses which are incurred.We sent a request to the insured for the Explanation of Benefits from the Primary Carrier on 3/13/13 and again on 4/10/13. We have not received a response to those requests.Based on what is described in the complaint, there appears to be a misunderstanding in regards to the type of policy the insured is enrolled in. Although enrollment was mandatory for Norfolk University Students for the Accident plan, the plan was not a Primary policy and included the above statement indicating the policy will pay after other insurance has paid. There is no provision in the policy for the plan to act as primary dependent upon the location of a particular accident. As a result, the fact that the incident occurred on school grounds is not relevant to the determination of which insurance plan would act as primary coverage.In the complaint it is also indicated that ACI submitted the claim to Optima to obtain a denial or approval. This action was not taken by ACI and ACI is not responsible for the submission of claims to another carrier. On 3/27/13, an ACI Customer Service Representative received a call from Ms. [redacted] and our representative indicated we needed Explanation of Benefits from the primary carrier and requested the member to submit the information.At this time, this claim remains pended for the Explanation of Benefits from the primary carrier, which the member would need to supply to our office.If the member has any questions or concerns regarding claims or policy benefits, she may contact our office for assistance.Please let us know if you have any questions or require any additional information. Thank you.Sincerely,

[To assist us in bringing this matter to a close, you must give us a reason why you are rejecting the response. If no reason is received your complaint will be closed Administratively Resolved]
 Complaint: [redacted]
I am rejecting this response because:
I will not accept the offer until the issue is resolved. The business has been saying that they are waiting for these records for the past year, even though the records have been sent to them multiple times via mail and fax. I feel like they are dragging their feet in the matter and will accept their offer once I am contacted with a resolution in this matter.
Regards,
[redacted] ([redacted])

From: Revdex.com of Metro Washington DC<[email protected]>Date: Mon, Jan 5, 2015 at 11:15 AMSubject: Fwd: Revdex.com Consumer Complaint ID [redacted]To: [redacted] <[redacted]@myRevdex.com.org>
---------- Forwarded message ----------From: Jon P[redacted] <[redacted]@visit-aci.com>Date: Mon, Jan 5, 2015 at 11:13 AMSubject: Revdex.com Consumer Complaint ID [redacted]To: "[email protected]" <[email protected]>
[redacted],
 
We have issued payments in regards to the complaint submitted by [redacted]) on 12/29/14 as follows:
 
Claim [redacted]-16 we paid $7,367.04 on 12/29/14, check # [redacted] to [redacted].
Claim [redacted]-17 we paid $888.40 on 12/29/14, check # [redacted] to [redacted]
Claim [redacted]-18 we paid $599.76 on 12/29/14, check # [redacted] to [redacted].
Total payment of $8,855.20.
 
We consider this matter resolved from our perspective.  Please let us know if [redacted] has anything she sees as unresolved.  Thank you,
 
Jon P[redacted]
Vice President - Claims & Operations
Administrative Concepts, Inc.
994 Old Eagle School Road, Suite 1005
Wayne, PA 19087-1802
www.visit-aci.com
Phone ###-###-####
Fax ###-###-####

[A default letter is provided here which indicates your acceptance of the business's response.  If you wish, you may update it before sending it.]
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and find that this resolution is satisfactory to me. 
Regards,
[redacted]

[To assist us in bringing this matter to a close, you must give us a reason why you are rejecting the response. If no reason is received your complaint will be closed Administratively Resolved]
 Complaint: [redacted]
I am rejecting this response because:I will not accept the offer until the issue is resolved. The business has been saying that they are waiting for these records for the past year, even though the records have been sent to them multiple times via mail and fax. I feel like they are dragging their feet in the matter and will accept their offer once I am contacted with a resolution in this matter.
Regards,
[redacted])

We are in receipt of the correspondence from the Revdex.com (Revdex.com) dated 1/21/15. Administrative Concepts, Inc. is a Third...

Party Administrator contracted to administrate claims on behalf of BCS Insurance Company for the policy offered to Norfolk State University participants. Oriel Rena [redacted] as a member of Norfolk State University, was insured under Policy Number [redacted] from 08/01/08 through 07/31/13.This letter is in response to your correspondence regarding concerns on file # [redacted] submitted by the Complainant named above. The Complainant, Oriel Rena Rivers, is writing regarding unpaid medical expenses submitted to our office for treatment rendered on 12/16/11 totaling $4,187.37.We have reviewed the concerns and issues noted by Ms. Rivers. Upon review of the documentation on file, we are missing an Explanation of Benefits from her primary carrier to resolve this claim. The plan Ms. [redacted] is enrolled under is an Excess plan and contains the following statement:If a Covered Person has other insurance, benefits under this plan will be paid on the unpaid balance after the other insurance has paid. No benefits are payable for any expense incurred for Accident or Sickness which is paid or payable by other valid and collectible insurance. This Plan will cover unpaid balances, deductibles and other eligible expenses not covered by other insurance. Benefits will be adjusted so that the total amount paid or payable under two insurance policies combined does not exceed 100% of the expenses which are incurred.We sent a request to the insured for the Explanation of Benefits from the Primary Carrier on 3/13/13 and again on 4/10/13. We have not received a response to those requests.Based on what is described in the complaint, there appears to be a misunderstanding in regards to the type of policy the insured is enrolled in. Although enrollment was mandatory for Norfolk University Students for the Accident plan, the plan was not a Primary policy and included the above statement indicating the policy will pay after other insurance has paid. There is no provision in the policy for the plan to act as primary dependent upon the location of a particular accident. As a result, the fact that the incident occurred on school grounds is not relevant to the determination of which insurance plan would act as primary coverage.In the complaint it is also indicated that ACI submitted the claim to Optima to obtain a denial or approval. This action was not taken by ACI and ACI is not responsible for the submission of claims to another carrier. On 3/27/13, an ACI Customer Service Representative received a call from Ms. [redacted] and our representative indicated we needed Explanation of Benefits from the primary carrier and requested the member to submit the information.At this time, this claim remains pended for the Explanation of Benefits from the primary carrier, which the member would need to supply to our office.If the member has any questions or concerns regarding claims or policy benefits, she may contact our office for assistance.Please let us know if you have any questions or require any additional information. Thank you.Sincerely,

We have contacted the complainant and have issued claim payments on the claim that had been questioned.  All bills which were presented as outstanding are being paid on this claim.  ACI has fully resolved the claim and presented issue at this time.Thank you. Jon P[redacted]Vice President...

- Claims & Operations

December 10, 2014We are in receipt of the correspondence from the Revdex.com (Revdex.com) dated 12/01/14. Administrative Concepts, Inc. is a Third Party Administrator contracted to administrate claims on behalf of [redacted] of Insurance Companies/Federal Insurance Company for the policy...

offered to [redacted] Educational Foundation participants. [redacted] (son of the Complainant), as a member of [redacted] Educational Foundation, is insured under Policy Number [redacted] from 08/01/13 through 07/31/14.This letter is in response to your correspondence regarding concerns on file # [redacted] submitted by the Complainant named above. The Complainant, [redacted], is writing regarding unpaid medical expenses submitted to our office for treatment rendered to her son, [redacted], on 11/15/13 totaling $8,437.50 in payments made by [redacted].We have reviewed the concerns and issues noted by [redacted] regarding the expenses totaling $30,502.60, for which she paid $7,537.50 to the provider out of pocket and is seeking reimbursement. Upon review of the documentation provided, we are issuing payment totaling $7,537.50 to [redacted] for these expenses.Please be advised that, in order to process the $900 payment receipt submitted by [redacted] for the anesthesia services on 11/15/13, a copy of the billing and [redacted] of CA Explanation of Benefits statement are needed. Upon receipt, we will review and process accordingly.If the member has any questions or concerns regarding claims or policy benefits, she may contact our office for assistance.Please let us know if you have any questions or require any additional information. Thank you.Sincerely,Jennifer PClaims Supervisor

From: Revdex.com of Metro Washington DC<[email protected]>Date: Mon, Jan 5, 2015 at 11:15 AMSubject: Fwd: Revdex.com Consumer Complaint ID [redacted]To: [redacted] <[redacted]@myRevdex.com.org>---------- Forwarded message ----------From: Jon P[redacted] <[redacted]@visit-aci.com>Date: Mon, Jan 5, 2015 at 11:13 AMSubject: Revdex.com Consumer Complaint ID [redacted]To: "[email protected]" <[email protected]>[redacted], We have issued payments in regards to the complaint submitted by [redacted]) on 12/29/14 as follows: Claim [redacted]-16 we paid $7,367.04 on 12/29/14, check # [redacted] to [redacted].Claim [redacted]-17 we paid $888.40 on 12/29/14, check # [redacted] to [redacted]Claim [redacted]-18 we paid $599.76 on 12/29/14, check # [redacted] to [redacted].Total payment of $8,855.20. We consider this matter resolved from our perspective.  Please let us know if [redacted] has anything she sees as unresolved.  Thank you, Jon P[redacted]Vice President - Claims & OperationsAdministrative Concepts, Inc.994 Old Eagle School Road, Suite 1005Wayne, PA 19087-1802www.visit-aci.comPhone ###-###-####Fax ###-###-####

Review: My son, [redacted], was injured at a [redacted] School foot ball game on 10/19/2013. I was referred to a sports medicine doctor by the school athletic trainer. The doctor was a participating provider with my personal insurance, [redacted] of CA HMO. I paid cash for this doctor visit and for an MRI to determine the extent of injury to my son. The MRI revealed that he had a torn ACL and meniscus in his right knee that required surgical repair. The doctor referred us to an orthopedic surgeon, who again, was not covered by my personal insurance. I was told by [redacted] School that if I chose to go to doctors outside of my primary insurance, the school's secondary insurance company Administrative Concepts Inc (ACI) would reimburse me for all out of pocket expenses pertaining to this injury provided I supply ACI with denial letters/EOBs from my primary insurance [redacted] of CA for each procedure and provider with receipts detailing what I paid to each provider. I also confirmed this process with ACI on the phone with a representative named Josh. After researching different doctors, I decided to take my son to the surgeon referred by the original sports doctor and pay cash upfront for all procedures with the expectation to get reimbursed by ACI at a later date. I told each doctor and specialist when I took my son to it that he was a cash patient and would not be billing his insurance for the procedures as this is what I was advised to do by ACI. I obtained a billing statement and proof of payment from each provider and billed [redacted] on my own in order to obtain a denial letter or EOB from it in order to file a claim with ACI. Once received, I forwarded all EOBs and receipts to ACI for reimbursement. Again, I confirmed this was the proper procedure with Customer Service manager Raquel K[redacted] and the broker for [redacted] School, [redacted] of [redacted] on a conference call we all had in May, 2013. To this date, ACI has reimbursed me for all claims totaling $8989.30 based on the documentation I provided to it. There is one claim outstanding for [redacted]’s knee surgery on 11/15/2013 at the [redacted]. I obtained an EOB denying the charges from [redacted] on 10/3/2014 and forwarded it along with the receipts for what I paid to the [redacted] totaling $8437.50 to ACI on 10/6/14. The claim was for $30502.60 but I paid $8437.50 as a cash patient. I received an email from Raquel K[redacted] of ACI on 10/24/2014 asking me what happened to the difference between the billed amount of $30502.60 and what I paid the provider. She stated there is a discrepancy between the billed amount and what I paid the provider. I responded that I paid the cash amount quoted by the provider and the balance was discounted as “Same Day-timeof Bill” on the billing statement I obtained from the Surgery Center. The next correspondence I received from Ms. K[redacted] on 10/29/14 stated “The Claims Department has advised in order to finalize the claim for consideration of your reimbursement, Management is requesting all of your primary carrier's Explanation of Benefits for all services rendered for this injury. They have advised that the bills submitted did not contain any explanation as to why services were not considered by the primary. Please be advised, we need these for all dates of services.” I have spoken to Ms. K[redacted] on the phone as well and was told that my final claim will not be considered unless I go back to [redacted] and obtain EOBs or a letter explaining why all the previous claims were not considered. Please note, that I have already been reimbursed by ACI for all previous claims that it is requesting documentation from [redacted] for. In addition, I have already provided EOBs from [redacted] for all claims in question. I do not feel that I should have to back track and obtain more documentation from [redacted] for claims I have already been reimbursed for by ACI. I have contacted [redacted] and was told it already provided this information to me and will not provide anything else to me. I simply want to be reimbursed for the final claim in the amount of $8437.50 and feel I should be as ACI has the denial EOB from [redacted] and receipts proving what I paid to the [redacted]. I feel like ACI is doing everything it can in its power to not pay this final claim and to make me go away. It is being unfair. Also, in the meantime, [redacted] School terminated the services of the broker Arhtur J Gallagher & Co so I cannot obtain any help from it either.Desired Settlement: The only fair outcome is for ACI to reimburse me $8437.50 for the amount I paid to the [redacted] as I have provided all necessary documents requested.

Business

Response:

December 10, 2014We are in receipt of the correspondence from the Revdex.com (Revdex.com) dated 12/01/14. Administrative Concepts, Inc. is a Third Party Administrator contracted to administrate claims on behalf of [redacted] of Insurance Companies/Federal Insurance Company for the policy offered to [redacted] Educational Foundation participants. [redacted] (son of the Complainant), as a member of [redacted] Educational Foundation, is insured under Policy Number [redacted] from 08/01/13 through 07/31/14.This letter is in response to your correspondence regarding concerns on file # [redacted] submitted by the Complainant named above. The Complainant, [redacted], is writing regarding unpaid medical expenses submitted to our office for treatment rendered to her son, [redacted], on 11/15/13 totaling $8,437.50 in payments made by [redacted].We have reviewed the concerns and issues noted by [redacted] regarding the expenses totaling $30,502.60, for which she paid $7,537.50 to the provider out of pocket and is seeking reimbursement. Upon review of the documentation provided, we are issuing payment totaling $7,537.50 to [redacted] for these expenses.Please be advised that, in order to process the $900 payment receipt submitted by [redacted] for the anesthesia services on 11/15/13, a copy of the billing and [redacted] of CA Explanation of Benefits statement are needed. Upon receipt, we will review and process accordingly.If the member has any questions or concerns regarding claims or policy benefits, she may contact our office for assistance.Please let us know if you have any questions or require any additional information. Thank you.Sincerely,Jennifer PClaims Supervisor

Consumer

Response:

[A default letter is provided here which indicates your acceptance of the business's response. If you wish, you may update it before sending it.]

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

Regards,

Review: Claims management does not give a proper turn around timeClaims for an injury were sent in on 9/It was deniedTold then on 9/to send in letter of medical necessity and follow up in daysTold on October 4th they did not receive the letter for medical necessityResent letter of medical necessity with copy from fax that it had already been sent on 9/Confirmed that it was received and was being sent priority for review on 11/Called again on 11/First rep told me that claim was denied on 9/Asked them to look further at notesThen they tell me that it is over for reviewThen told they was bring it back over for priority (same conversation as on 9/and 11/26)Asked to speak to supervisorTold by her that it was deniedWent through the whole process again to be told that I should send a letter of appealAfter discussion of their policy and procedures that they have to follow, it is apparent that they did not follow policy or procedures as I was not directed to file a letter of appeal until I insisted on speaking to a supervisorWe have well over $that is being denied that they are classifying as a sickness and therefore denying even though we have a letter (that they told us we would need).Desired Settlement: 1- for them to pay the medical claims sustained from injury on 1/that is not paid by our private insurance company
2- that parents have access to review the claims on computer
Business
Response:
November 26,
As the benefits administrator for the Accident Insurance policy provided by [redacted] Inc., underwritten by [redacted] Insurance Company: this letter is in response to your correspondence received on 11/22/regarding concerns on case # [redacted] submitted by the Complainant named aboveAdministrative Concepts, Inc(ACI) is the Third Party Administrator on behalf of [redacted] Insurance Company
The Complainant, [redacted], is writing regarding medical expenses incurred by her daughter that were denied by our officeWe reviewed and processed these medical expenses according to policy languageThere are no specific benefits for this particular type of outpatient services in the plan
On 09/26/13, we received an appeal from the Complainant regarding the denial of claimed expensesWe reviewed the appeal and found that benefits may be available for these medical expenses under the Physician Outpatient expense benefit; however, additional information is required for us to review and make a determination as to whether or not these, benefits applyOn 11/18/13, we requested complete medical records from the provider, [redacted] M.Dand a copy of the request letter was sent to the Complainant for her records
We would like to resolve the claims in question, however to do so the additional information from Dr[redacted] is requiredACI will continue to request the information needed from the provider of services and copy the member on our requestsUpon receipt of the medical documentation requested, we will continue our review and processing of the claims in question on file with our office
We apologize for any confusion or miscommunications made by our office regarding these claims or our proceduresIf **[redacted] has any questions regarding the claims on file, policy benefits or claim procedures, she may contact our office for assistance
Please let us know if you have any questions or require any additional informationThank you
Sincerely

Review: First, I wrote two emails(Nov 6 and Nov 11) asking my claim status and what documents I need to process the claim. The auto reply said they will reply to me shortly. But till now 20 days past after the first email, I still did not get their reply.

Second, for the service on 6/15/2013, ACI requested medical necessity from Doctor. My doctor said the lab test I did is prenatal care requirement and she never encountered this situation that insurance company requires medical necessity for first visit of ob/gyn. My doctor wrote a letter stating that the service I received is part of prenatal care. ACI sent me a message with my doctor's name wrongly-spelled and requested potential impact on future services, which is not stated in their first claim process. Their first response is requesting medical necessity, but not requesting potential impact on future services.Desired Settlement: First, explain to me and my doctor why ACI needs medical necessity and potential impact on future services for first ob/gyn visit. Please explain why ACI's first response of the claim is not consistent with the further response, requesting more information.

Second, contact my doctor directly to solve this problem. ACI already have all information of my doctor.

Third, make sure to reply customers' emails.

Business

Response:

December 2, 2013

As the benefits administrator for the Accident and Health Insurance policy provided by [redacted] University, underwritten by [redacted] Insurance Company, this letter is in response to your correspondence received on 11/27/13 regarding concerns on case # [redacted] submitted by the Complainant named above. Administrative Concepts, Inc. (ACI) is the Third Party Administrator on behalf of [redacted] Insurance Company.

The Complainant, [redacted], is writing regarding unpaid medical expenses submitted to our office for treatment rendered on 06/15/13.

Upon receipt of the billing for the medical treatment provided on 06/15/13, we determined that additional information was required from the provider of services ([redacted]) and attending physician (Dr. [redacted]) in order for us to make a determination on the claim. The particular test ordered by Dr. [redacted] totaling $995.00 is not a standard test typically ordered for the Complainant’s condition.

Therefore, we requested a copy of the lab report from [redacted] and a letter of medical necessity from Dr. [redacted] for further review. Upon receipt of the information, we determined that additional details and explanation from Dr. [redacted] were necessary for us to completely review and make a determination on the claim. We requested a letter detailing the necessity of the treatment performed and the possible impact on any future services rendered. We have also contacted the provider via telephone to request this information.

We would like to resolve the claim in question, however to do so the additional information from Dr. [redacted] is required. ACI will continue to request the information needed from Dr. [redacted]’s office. Upon receipt of the medical documentation requested, we will continue our review of the claim in question.

We apologize for any confusion or non-response from our office regarding **. [redacted]’s claims and related questions. If she has any questions or concerns, she may contact our office for further assistance.

Please let us know if you have any questions or require any additional information. Thank you.

Sincerely,

Consumer

Response:

[To assist us in bringing this matter to a close, you must give us a reason why you are rejecting the response. If no reason is received your complaint will be closed Administratively Resolved]

Review: [redacted]

I am rejecting this response because:

Review: ACI was in the role of secondary insurance. All needed paperwork (as defined by them) was submitted to them on or about 4/2013. Since that time, they have dragged their feet, harassed service providers for additional information. A total of 34 claims (EOB and UB-04 or series 1500 forms) were supplied. They have bombarded service providers for additional requirements and in fact have 112 listed claims on their web site due to their inept methods and intentional delay tactics. Essentially ,they have created a paperwork mountain that they now use as another way to avoid paying. To be clear, the total value of the claims is $1,150. O have made numerous calls and my service provider shad supplied and resupplied the requested info (creating the mountain of claims). My many calls have typically gotten me no where and seldom gotten me any calls back. I called today and the result is that "our claims dept will review the dates I mentioned" and they will get back to me. If I hold my breath, I will clearly perish.Desired Settlement: I want the final claims with [redacted] Physical Therapy reviewed and completed without my having to make more phone calls and without the service provider ([redacted]) being asked to supply any more proof. They have paid some of the claims and all were for routine physical therapy, so all have the same justification. The recent wrinkle is that due to asking for more nonsense, ACI has created duplicate claims for 2 different providers ([redacted] and [redacted]) and the question is why are there 2 providers. There is only one, but ACI's insatiable desire to put off paying and bury service providers in onerous submissions of paperwork.

I want my money that they contractually owe, I want an apology and I want them listed as frauds in their dealings with claimants and service providers.

Business

Response:

October 28,2013

As the benefits administrator for the Accident

Insurance policy provided by [redacted], underwritten by [redacted] Insurance Company of [redacted], PA, this letter is in

response to your correspondence received on 10/21/13 regarding concerns

on case # [redacted] submitted by the Complainant named above.

Administrative Concepts, Inc. (ACI) is the Third Party Administrator on

behalf of [redacted] Insurance Company of [redacted], PA.

The

Complainant, [redacted], is writing regarding medical expenses

incurred by his son submitted to our office for processing that have not

yet been resolved. Please see the following spreadsheet of claimed

expenses received by our office. To date, all except those highlighted

have been paid. We would like to resolve and finalized those claims

highlighted, however to do so additional information is required. Please

see the comments section of the spreadsheet indicating what additional

information is needed. Request letters for the information needed were

previously sent to each provider of service, with copies of the letters

sent to the insured member (**. [redacted]’s son).

ACI will continue

to request the information needed from the appropriate providers of

services and copy the member on our request so he is aware of the steps

ACI is taking to resolve these claims.

Please let us know if you have; any questions or require any additional information. Thank you.

Sincerely,

Review: Policy Holder of Certificate since 06/01/98

Credit Union Group Plan

Failure to Honor Financial Insurance Trust Participating Financial Institution.

Contract Failure of $100,000.00 policy that has remained in force since 06/01/1998 purchased through group offer [redacted] credit Union and [redacted] banking.

Notice of claim, not payable until 12 mo disability which is 04/15/2013.

Proof of Loss : 90 Days after end of each period is for which an amount is payable. which is 07/15/2013 and they admitted received claim 06/21/2013. Therefore They Denied the first claim on a 15 year policy holder.Desired Settlement: [redacted], PA. [redacted]

p.o. box [redacted]

Honor the policy that we purchased in good faith Fifteen years ago,

pg. 4 Total Disability Benefit ( for more then 12 months) and

Page 8 Proofs of Loss ( within 90 day of period ending which amount is payable)

Failure to Honor Contract.

Business

Response:

{Please see attachment.}

Review: My son, [redacted], *, passed away on 8/10/13 and had a life insurance policy linked to his bank checking account. I have sent in all of the docementation stated on the claim form from the insurance company. The insurance company goes through an outside vendor to process of of the clai** for them. This outside vendor is looking for addtional information before they will pay the claim. The additional information needed was not on the claim form package but when my coroner sends the information via fax - they state that they are not receiving the fax. Plus the coroner has left 3 to 4 voicemail message with customer service and they have yet to call her back........Please the email address given on over the phone is erroring out. The orginal claim was sent in September 2013 and it is still pending due to needing this info. It is amazing how they are not getting this info and not calling back.Desired Settlement: I would have loved for someone to have picked up the [redacted] phone and asked why the coroner request was taking so long. Or called me for this information from the coroner - WHY does it always have to be the survivors job to chase things down. I would have like better customer service. It is too late for an apology.

Business

Response:

File ID # [redacted]

Complainant: [redacted]

Attached please find Administrative Concept's Inc.'s response to the complaint from **. [redacted].

A hard copy of the letter has also been mailed to ATTN: [redacted] at the address noted on the letter.

Thank you.

November 14, 2013

As the benefits administrator for the Insurance policy provided by Member Headquarters Association Inc., underwritten by [redacted] Insurance Company, this letter is in response to your correspondence received on 11/14/13 regarding concerns on case # [redacted] submitted by the Complainant named above. Administrative Concepts, Inc. (ACI) is the Third Party Administrator on behalf of [redacted] Insurance Company.

The Complainant, [redacted], is writing regarding our requests for additional information for review of the claim submitted to our office. We received the claim submission from **. [redacted] on 09/12/13 and determined additional information was required from the county coroner’s office for further review of the claim. On 09/24/13, we sent a request letter to [redacted], the coroner, and a copy of the letter was sent to **. [redacted] for her records. On 10/24/13, as we had not yet received the required information, we sent a 2nd request letter to **. [redacted] and a copy was mailed to **. [redacted] for her records.

The report from **. [redacted] was received in our office via fax on 11/06/13, and again on 11/10/13. **. [redacted] contacted our office on 11/07/13 to inquire as to the status of the request for additional information. At that time, we had not noted the receipt of the report into our system and therefore our Customer Service Representative was unaware that it had been received.

We have since reviewed the report provided by **. [redacted] and made a final determination on the claim. A letter explaining the final determination was mailed to the Estate of the [redacted] family on 11/12/13.

We apologize for any confusion or miscommunications made to **. [redacted] or **. [redacted] regarding the handling of this claim file. Should they have any additional questions or concerns, they may contact our office.

Please let us know if you have any questions or require any additional information. Thank you.

Sincerely,

Consumer

Response:

From: [redacted] <[redacted]>

Date: Mon, Nov 18, 2013 at 8:26 PM

Subject:Complaint #[redacted].

I have reviewed the response from ACI. I understand the unnoted account about the additional information from the coroner. I still don't understand why they do not call on the phone about needing additional information instead of by snail mail only or having the beneficiary following up. I don't understand why the Claim Forms don't list the full requirements prior to mailing in the original claim form. The additional information needed from the coroner I was told was required but not listed.

Thanks,

Business

Response:

File ID # [redacted]

Complainant: [redacted]

Attached please find Administrative Concept's Inc.'s letter in regards to the rejection of our response to the complaint from **. [redacted].

A hard copy of the letter has also been mailed to ATTN: [redacted] at the address noted on the letter.

Thank you.

November 20, 2013

As the benefits administrator for the insurance policy provided by Member Headquarters Association Inc., underwritten by [redacted] Insurance Company, this letter is in response to your correspondence received on 11/19/13 regarding concerns on case # [redacted] submitted by the Complainant named above. Administrative Concepts, Inc. (ACI) is the Third Party Administrator on behalf of [redacted] Insurance Company.

The Complainant, [redacted], is writing regarding our written requests to the coroner’s office for the documentation needed for review of her claim, inquiring why this information was not noted as required by the plan on the Claim Form.

The [redacted] Insurance Company Claim Form lists the specific standard information required from the claimant for review of a claim. The Claim Form includes a standard list of information and also states “we reserve the right to obtain additional information, as needed, to evaluate the claim” to inform the claimant of the standard documents needed and a potential need for additional documents. Since each case is different and evaluated individually, the information needed is different for every claim. We review each claim independently and request any additional information needed from the appropriate party formally in writing, in order to properly track and follow up on our requests.

We apologize for any confusion **. [redacted] experienced regarding the handling of her claim. Should she have any additional questions or concerns, she may contact our office.

Please let us know if you have any questions or require any additional information. Thank you.

Sincerely,

Consumer

Response:

[A default letter is provided here which indicates your acceptance of the business's response. If you wish, you may update it before sending it.]

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

Regards,