Alaska Community Development Corporation

Dear [redacted];This letter is in response to your inquiry dated May 5, 2015 to Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. (Health Plan) on behalf of [redacted]. The Inquiry was received on May 7, 2015.[redacted] stated in her complaint that she would like the Health...

Plan to approve coverage for maternity care and delivery in Virginia Beach, VA. She indicated that she would like to deliver her child close to where the father of the baby lives,[redacted] is enrolled with the Health Plan through the [redacted] Health Benefits ([redacted]) program. Jurisdiction for her contract resides with the Office of Personnel Management (OPM).Virginia Beach, VA is outside of the service area for Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc.Section 1 of the 2015 [redacted] Health Benefit Program's ([redacted]) [redacted] benefit brochure states the following:"This Plan is a health maintenance organization (HMO). We require you to use specific physicians, hospitals, and other providers. Through the Mid-Atlantic Permanente Medical Group, PC (Medical Group), we will coordinate your health care services, including among other things, when care is medically necessary and what treatment is appropriate.”If a member requests coverage for services that are not covered under their benefit policy, the member's physician will refer the member to the Member Services Call Center to request a member benefit determination. The Member Services Call Center Would need the name of the physician and/or facility, the phone number, the address, and the reason for the request.Health Plan attempted to enter a member request for coverage of maternity care and delivery to be provided in Virginia Beach, VA. However, [redacted] did not provide the name of the physician or the hospital to complete her request.Ms. Debbie J[redacted] Communications Specialist with the Health Plan, made four (4) attempts to reach [redacted]. Ms. J[redacted] left detailed messages for [redacted] to call her back with the name, address, and phone number of the physician and hospital in Virginia Beach, VA. To date, [redacted] has not provided the requested information to the Health Plan.If you and/or [redacted] have any additional questions, please contact Keyla W[redacted] at ###-###-####,Sincerely,Daisy SSenior Manager, Member Services

This letter is in response to your inquiry dated September 21, 2016 to Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. (Health Plan) on behalf of [redacted] and [redacted]. The inquiry was received on September 27, 2016.The Complainants stated a Health Plan...

representative informed them that they did not have Coverage for a breast pump. **. and [redacted]. [redacted] purchased a breast pump at their own expense.After the purchase, another Health Plan representative advised **. and [redacted]. [redacted] that they have coverage for breast pumps. The complainants submitted a claim for reimbursement but it was denied. The Complainants are requesting reimbursement in the amount of $311.64.On behalf of the Health Plan, I apologize for the inconvenience this situation has caused **. and [redacted]. [redacted]. Health Plan has initiated an appeal on behalf of the complainants to review the denial of reimbursement for a breast pump. **. and [redacted]. [redacted] will receive an acknowledge letter under separate cover which explains the appeals process.If you and/or **. [redacted] have any additional questions, please contact Keyla W[redacted] at ###-###-####.Sincerely,Daisy S[redacted] Manager, Appeals and Correspondence

Dear [redacted]:This letter is in response to your inquiry dated August 26, 2016 to Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. (Health Plan) on behalf of [redacted] The inquiry was received on August 30, 2016.[redacted] expressed his dissatisfaction with the services that...

he received from Drs. Paul M[redacted], Brian H[redacted], Sweta V[redacted], Humira S[redacted], Anuj T[redacted] and Frank G[redacted].Providing quality medical care is one of our most important values. A copy of [redacted]'s letter was forwarded to the staff in the Quality Management Department for review. This review may involve staff and doctors from Kaiser Permanente and the particular medical specialty involved. The quality review process helps Kaiser Permanente Continue to improve the way we deliver care and service to our members.Our review is performed under special provisions of the federal Health Care Quality Improvement Act (HCOIA) [redacted], and state laws. These laws encourage physicians to participate in identifying issues and improving care for patients. These laws also guarantee confidentiality to physicians or providers that take part in the quality review process. As a result, Our goal is to balance your need for information and the need to follow these laws. To find this balance, Kaiser Permanente has developed a process to look into member concerns. This process is described below. A copy of [redacted]'s letter was also forwarded to the Physician Chief of the Northern Virginia Service Area, Dr. Cheryl K[redacted] for review.A team of Patient Safety experts and physicians have met, thoroughly investigated and discussed this case. Their findings revealed that the medical care provided to [redacted] was appropriate. Health Plan has a clear plan of action and recommendations for his continued care in place and have Communicated that to [redacted].If you and/or [redacted] have any additional questions, please contact Keyla W[redacted] at ###-###-####.Sincerely,Daisy S

November 16, 2015[redacted]Revdex.com of Metro Washington DC and Eastern.Pennsylvania 1411 K St. NW, 10th Floor Washington, DC 20005-3404RE: Complainant: [redacted]ID #: [redacted] Member Number: [redacted]Dear [redacted]:This letter is in response to your inquiry dated November...

2, 2015 to Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. (Health Plan) on behalf of **. [redacted]. The inquiry was received on November 6, 2015.[redacted] stated that in his complaint that he is being billed by [redacted] Hospital for the medical services provided to him from November 27, 2014 through November 28, 2014.The Health Plan contacted [redacted] Hospital's Billing Department to inquire about [redacted]'s account balance. The Health Plan was informed that [redacted] is being billed his cost share of $693.70 for the consultation and outpatient surgery services provided to him on November 28, 2014 by Dr. [redacted] of [redacted] Healthcare Services.The claim was processed for payment on June 24, 2015 and $693.70 was applied towards [redacted]'s applicable co-insurance.According to the Summary and Cost Share Section of the 2015 Group Evidence of Coverage (EOC), Specialty care office visits are subject to a $40 Copayment per visit. Also, [redacted] is responsible for 30% of the allowable charge for outpatient Surgery Services.If you and/or [redacted] have any additional questions, please contact Keyla W[redacted] at ###-###-####.Sincerely,Cheryl T[redacted] Director, Appeals and Correspondence

[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]

This letter is in response to your inquiry dated September 6, 2016 to Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc. (Health Plan) on behalf of [redacted]. The inquiry was received on September 8, 2016.[redacted] stated in her complaint that her check payment for the...

amount of $50 that Was Submitted to the Health Plan in January 2016, was not cashed. Member Contacted the Health Plan in February 2016 and paid $50 over the phone. Her check payment was cashed in March 2016. Member did not receive a refund.According to our records, [redacted] owed a $200 co-payment for an outpatient Surgical procedure performed on April 20, 2015. Her $50 payment was applied towards the charge.[redacted]'s appointment on April 5, 2015 was a post-operative visit and the Health Plan should not have billed her a $20 co-payment. Therefore, she will be receiving a refund for $20. If you and/or [redacted] have any questions, please Contact me directly at ###-###-####.Sincerely,Cathleen M[redacted] Appeals and Resolution Specialist Member Services