Ambetter Peach State Health Plan

January 3, Revdex.com, IncAttn: Dispute Resolution Department NBroadway, Suite StLouis, MO RE: Case No( [redacted] ) Attn: Dispute Resolution Department: As part of the appeal process, the member’s account will be researched and any claims that require review will be done at that timeAs the appeal is currently in process, there is no resolution to provide the member at this timeOnce the appeal process has been completed, the member will be notified and an update will be provided to all parties Sincerely, [redacted] Compliance Specialist [redacted] Atlanta, GA Phone: [redacted] Toll-Free: [redacted] Fax: [redacted] @centene.com | PSHP.com

Complaint: [redacted] I am rejecting this response because: as mentioned, the provider list on the website is blatantly falseThis is fraudulent and misleadingAdditionally, I did not receive a call from a supervisor as promised, merely a call confirming the same information that I had already found myselfI want to speak with a supervisor [redacted] in Decatur informed me that they no longer accept Ambetter as an in-network provider as of June 2017, hence the day wait periodThis is contrary to the information provided in Ambetter's response to my ComplaintIt seems this information is more readily available to consumers rather than to Ambetter themselvesAgain, ONE provider (***) accepts this insurance- ALL other providers listed on Ambetter's website as "in-network" are no longer accepting this insuranceIf a provider is not in-network, there is a minimum day wait periodBecause of my injuries, my MRI needs to be done much soonerAgain, the only provider who can see me "in-network" (without the waiting period) is ***, who has no available appointmentsNevertheless, I pay premiums because I was under the impression that I could seek an MRI with all other providers listed on the website without the waiting period- which is simply untrueLastly, [redacted] promised that he would be emailing me a list of providers who will cover durable medical equipmentAs with the other promises from [redacted] and others, this was never done [redacted] never followed up and [redacted] the supervisor, never called as promisedThis is not just a complaint about receiving a response, it is a complaint about Ambetter's business practices and customer service as a wholeI want to speak with a supervisor and I want to escalate to the highest levelThis practice can legitimately hurt people who need medical treatment and it must be remediedI have also filed a complaint with the Insurance Commissioner of Georgia in hopes to find relief Sincerely, [redacted]

Complaint: [redacted] I am rejecting this response because: The response is not adequate, since I was not offered any resolution, just a promise to look into it within additional monthI have been told by dr.'s office that some of my debt is in Collections alreadyI was absolutely clear on what I expect Ambetter to do for my complaint to be closed which is “I want Ambetter to correct the wrongly processed claims: Claim Number- [redacted] , Claim- Number- [redacted] , Claim Number- [redacted] , Claim Number- [redacted] , and Claim Number- [redacted] (Service Details : ***) (date of service 12/01/2016.) Also, Ambetter should contact my providers immediately with corrected information regarding the claims listed aboveMoreover, I want to be notified when Ambetter contacts my providers“ Sincerely, [redacted]

February 9, Revdex.com, IncAttn: Dispute Resolution Department NBroadway, Suite StLouis, MO RE: Case No( [redacted] ) Attn: Dispute Resolution Department: In response to the complaint filed, please be advised that the member purchased the Ambetter policy from Peach State Health Plan through the Federally Facilitated Marketplace (FFM)Ambetter Enrollment has researched the concerns raised by the complainant and the following information was providedThe payment of $was not applied to the member's account It has been located and is now applied Voluntary withdrawal termination files were received from the Marketplace on January 13, At this time, the members are enrolled from January 1, to February 16, and the account is paid through January 31, The member will need to contact the Federal Marketplace in order to request any changes to the dates of coverage Any claims incurred as of January 1, can be submitted for processing Enrollment is currently set to end on February 16, Please allow hours for systems to update Sincerely, [redacted] Compliance Specialist [redacted] Atlanta, GA Phone: [redacted] Toll-Free: [redacted] Fax [redacted] @centene.com | PSHP.com

Initial Business Response /* (1000, 15, 2016/02/03) */
In response to the complaint filed by the member, please be advised that the member purchased an Ambetter policy from Peach State Health Plan through the Federally Facilitated Marketplace (FFM)Subsequently, the member contacted the Plan
between December 8, and December 16, related to concerns regarding her policy with the PlanUpon review of the member's concerns, the Plan was able to successfully resolve the member's concernsAn Ambetter Member Services Advocate contacted the member on January 29, to share the Plan's findings with her directlyCurrently, the member has no further concerns related to Ambetter by Peach State Health Plan
Initial Consumer Rebuttal /* (2000, 17, 2016/02/03) */
(The consumer indicated he/she ACCEPTED the response from the business.)

April 22, Revdex.com, IncAttn: Dispute Resolution Department NBroadway, Suite StLouis, MO RE: Case No(***) Attn: Dispute Resolution Department: In response to the complaint received on April 19, 2016, please be advised that the member purchased the
Ambetter policy from Peach State Health Plan through the Federally Facilitated Marketplace (FFM)The member’s complaint states that she went to the doctor and was advised that she could not be seen because Ambetter stated that a payment had not been madeThe member also stated that her bank verified that a payment was made and the check had been cashedHowever, the member states that her account has not been updated and she is unable to see a provider until this issue has been resolvedAccording to the member’s case records, the member had not contacted the plan related to the issues outlined in this complaintA member advocate reached out to Ms*** on April 21, in reference to her concernsThe member was advised that her account is current and paid through May 31, 2016. The member was satisfied with the information givenShould you have questions or need additional information, please feel free to email us at ***@CENTENE.COMSincerely, *** *** Compliance Specialist *** *** ** *** *** *** *** ** *** Phone: *** Toll-Free: *** Fax: *** ***@centene.com | PSHP.com

December 27, Revdex.com, IncAttn: Dispute Resolution Department NBroadway, Suite StLouis, MO RE: Case No(***) Attn: Dispute Resolution Department: In response to the complaint filed on December 18, 2016, please
be advised that the member purchased the Ambetter policy from Peach State Health Plan through the Federally Facilitated Marketplace (FFM).The member’s complaint states that she has several claims that have not been paid even though she feels that she met her deductibleThe member also states that she has filed an appeal in reference to this matter and has not received a response Based on a review of the member’s complaint and case records, it has been determined that the member’s appeal was misrouted in errorThe member states that she mailed her appeal to the address provided on her claims summaryThe appeal was received by the Arkansas Service Center on December 2, and routed to the incorrect queue at Peach State Health PlanThe Vice President of Customer Service at the service center states that there will be additional training for the representative who routed the appeal incorrectly as well as updates to their policy to include mailing a physical copy of the documents to the Health plan A copy of the appeal has been forwarded to Peach State Health Plan’s appeal department for reviewPlease see the attached acknowledgement letter that was sent to the member in reference to her concerns Sincerely,
*** *** Compliance Specialist *** *** ** *** *** *** Atlanta, GA Phone: *** Toll-Free: *** Fax: *** ***@centene.com | PSHP.com

June 20, Revdex.com, IncAttn: Dispute Resolution Department NBroadway, Suite StLouis, MO RE: Case No(***) Attn: Dispute Resolution Department: In response to the complaint filed on June 12, 2017, please be
advised that the member purchased the Ambetter policy from Peach State Health Plan through the Federally Facilitated Marketplace (FFM).The member’s complaint states that she has not received her refund that she was advised would be coming to herThe member’s concerns were forwarded to the Ambetter Enrollment Department for review and the following information was providedThe member had an address change request on March 4, to be updated to: *** *** *** *** *** *** *** ** ***The address was not updated in back systemsThe original refund check has been voided and a new check was processed and resent in the amount of $Outreach to the member was conducted on June 20, by a Member AdvocateThe member was advised that a refund check in the amount of $has been processed and mailed to *** *** *** *** *** *** *** ** *** as of June 19, and to allow 5-business days to receive the check. Sincerely, *** *** Compliance Specialist *** *** ** *** *** *** Atlanta, GA Phone: *** Toll-Free: *** Fax: *** ***@centene.com | PSHP.com

May 8, Revdex.com, IncAttn: Dispute Resolution Department NBroadway, Suite StLouis, MO RE: Case No(***) Attn: Dispute Resolution Department: The member states in her complaint that she made a payment online in
the amount of $She received two confirmation emails and the payment was processed twiceMember states she is seeking a refund of the additional paymentA follcall was extended to the member by an Ambetter Member Advocate on May 4, regarding her complaint. Case records shows that a refund of $was processed on May 3, 2017. The member confirmed that she received the refund on May 4, Sincerely, *** *** Compliance Specialist *** *** ** *** *** *** Atlanta, GA Phone: *** Toll-Free: 1-*** Fax: 1-*** ***@centene.com | PSHP.com

See attached document

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.
But I don't trust the company due the fact that I've been waiting for my refund  since January. I've verified my address many times with every customer service rep that I talked to.  So rather or not my address was correct wasn't the problem. And the representative fail to mentioned that there were numerous of refund checks  that was sent out supposedly and that was processed wrong or either they just didn't know where the check was. The last check was supposed to have been sent 2 months ago. I won't go into another spill, but I've been told many times that I should receive my refund in X amount of days and never receive it. So bottom line, once I actually have the refund will I truly be satisfied. I would like to also take a moment to say thank you all at Revdex.com for helping with resolving this drawn out issue. 
Sincerely,
[redacted]

July 13, 2017   Revdex.com, Inc. Attn: Dispute Resolution Department 211 N. Broadway, Suite 2060 St. Louis, MO 63102     RE: Case No. ([redacted])     Attn: Dispute Resolution Department:   The member stated in his complaint that he has been unable to get an...

appointment with an MRI provider as all of the providers listed on the Find A Provider (FAP) website do not take Ambetter or are closed.  The following providers have confirmed participation with the plan: [redacted] Atlanta, GA [redacted] Appointment available 7/26/2017     [redacted] Decatur, GA [redacted]   [redacted] stated that they schedule appointments 15 days out but said that if the member’s doctor could provide an authorization number, the member could be seen earlier. The member’s orthopedic provider, [redacted], was contacted to inquire about the authorization. The provider’s nurse advised that she would not be able to submit the request for the authorization because the provider was not an Emory provider.       A follow-up call was extended to the member on July 11, 2017 to advise of the above information. The member stated that he would remain with Emory to schedule the MRI since the appointment times for both providers were basically the same timeframe.     Sincerely,     [redacted] Compliance Specialist [redacted] Phone: [redacted] Toll-Free: [redacted] Fax: [redacted]@centene.com | PSHP.com

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.
Sincerely,
[redacted]

January 3, 2017   Revdex.com, Inc. Attn: Dispute Resolution Department 211 N. Broadway, Suite 2060 St. Louis, MO 63102     RE: Case No. ([redacted])     Attn: Dispute Resolution Department:   As part of the appeal process, the member’s account will be researched and any claims that require review will be done at that time. As the appeal is currently in process, there is no resolution to provide the member at this time. Once the appeal process has been completed, the member will be notified and an update will be provided to all parties.     Sincerely,     [redacted] Compliance Specialist [redacted] Atlanta, GA 30339 Phone: [redacted] Toll-Free: [redacted] Fax: [redacted]@centene.com | PSHP.com

Complaint: [redacted]
I am rejecting this response because: The response is not adequate, since I was not offered any resolution, just a promise to look into it within additional 2 month. I have been told by dr.'s office that some of my debt is in Collections already. I was absolutely clear on what I expect Ambetter to do for my complaint to be closed which is “I want Ambetter to correct the wrongly processed claims: Claim Number- [redacted], Claim- Number- [redacted], Claim Number- [redacted], Claim Number- [redacted], and Claim Number- [redacted](Service Details : [redacted]) (date of service 12/01/2016.) Also, Ambetter should contact my providers immediately with corrected information regarding the claims listed above. Moreover, I want to be notified when Ambetter contacts my providers. “
Sincerely,
[redacted]

July 20, 2017   Revdex.com, Inc. Attn: Dispute Resolution Department 211 N. Broadway, Suite 2060 St. Louis, MO 63102     RE: Case No. ([redacted])     Attn: Dispute Resolution Department:   On July 14, 2017 at 5:30pm, [redacted], Customer Service Supervisor, reached out to the member to discuss the concerns expressed in this complaint.  The member was unavailable, so a voicemail message was left containing his office hours and contact information.  [redacted] also contacted [redacted] from National Imaging Associates, LLC (NIA) in reference to the MRI. [redacted] stated that she was unable to locate an MRI request for the member.  Therefore, Mr. [redacted] reached out to Dr. [redacted]’s office regarding the request and a message was left on the voice mail of Christina Congol, the office manager to return the call.  [redacted] outreached to the member again on July 17, 2017 at 10:15am and twice that afternoon, 12:00pm and 4:20pm and there was no answer. At this time, Ambetter has not heard back from the member nor his provider’s office manager in reference to the member’s concerns. Please see the attached Unable to Reach You letter sent to the member.     Sincerely,     [redacted] Compliance Specialist

August 22, 2016   Revdex.com, Inc. Attn: Dispute Resolution Department 211 N. Broadway, Suite 2060 St. Louis, MO 63102     RE: Case No. ([redacted])     Attn: Dispute Resolution Department:   In response to the complaint filed on August 15, 2016, please be...

advised that the member purchased the Ambetter policy from Peach State Health Plan through the Federally Facilitated Marketplace (FFM).The member’s complaint states that she has several claims where her 20% coinsurance was charged prior to reaching her deductible. The member’s concerns were forwarded to the claims department for review and the following information was provided.   CLAIM# [redacted] CO-INSURANCE REMOVED 84.85 APPLIED TO DEDUCTIBLE CLAIM# [redacted] CO-INSURANCE REMOVED 70.87 APPLIED TO DEDUCTIBLE CLAIM# [redacted] CO-INSURANCE REMOVED 422.19 APPLIED TO DEDUCTIBLE CLAIM# [redacted] CO-INSURANCE REMOVED 29.28 APPLIED TO DEDUCTIBLE CLAIM# [redacted] CO-INSURANCE REMOVED 19.32 APPLIED TO DEDUCTIBLE CLAIM# [redacted] CO-INSURANCE REMOVED 119.00 APPLIED TO DEDUCTIBLe Should you have questions or need additional information, please feel free to email us at [redacted]@CENTENE.COM.   Sincerely,   [redacted] Compliance Specialist [redacted] Atlanta, GA 30339 Phone: [redacted] Toll-Free: [redacted] Fax: [redacted] [email protected] | PSHP.com

February 9, 2017   Revdex.com, Inc. Attn: Dispute Resolution Department 211 N. Broadway, Suite 2060 St. Louis, MO 63102     RE: Case No. ([redacted])     Attn: Dispute Resolution Department:   In response to the complaint filed, please be advised that the...

member purchased the Ambetter policy from Peach State Health Plan through the Federally Facilitated Marketplace (FFM). Ambetter Enrollment has researched the concerns raised by the complainant and the following information was provided. The payment of $82.02 was not applied to the member's account.  It has been located and is now applied.  Voluntary withdrawal termination files were received from the Marketplace on January 13, 2017. At this time, the members are enrolled from January 1, 2017 to February 16, 2017 and the account is paid through January 31, 2017.  The member will need to contact the Federal Marketplace in order to request any changes to the dates of coverage.  Any claims incurred as of January 1, 2017 can be submitted for processing.  Enrollment is currently set to end on February 16, 2017.  Please allow 48 hours for systems to update.     Sincerely,     [redacted] Compliance Specialist [redacted] Atlanta, GA 30339 Phone: [redacted] Toll-Free: [redacted] Fax[redacted]@centene.com | PSHP.com

Complaint: [redacted]
I am rejecting this response because: as mentioned, the provider list on the website is blatantly false. This is fraudulent and misleading. Additionally, I did not receive a call from a supervisor as promised, merely a call confirming the same information that I had already found myself. I want to speak with a supervisor. [redacted] in Decatur informed me that they no longer accept Ambetter as an in-network provider as of June 2017, hence the 15 day wait period. This is contrary to the information provided in Ambetter's response to my Complaint. It seems this information is more readily available to consumers rather than to Ambetter themselves. Again, ONE provider ([redacted]) accepts this insurance- ALL other providers listed on Ambetter's website as "in-network" are no longer accepting this insurance. If a provider is not in-network, there is a minimum 15 day wait period. Because of my injuries, my MRI needs to be done much sooner. Again, the only provider who can see me "in-network" (without the waiting period) is [redacted], who has no available appointments. Nevertheless, I pay premiums because I was under the impression that I could seek an MRI with all other providers listed on the website without the waiting period- which is simply untrue. Lastly, [redacted] promised that he would be emailing me a list of providers who will cover durable medical equipment. As with the other promises from [redacted] and others, this was never done. [redacted] never followed up and [redacted] the supervisor, never called as promised. This is not just a complaint about receiving a response, it is a complaint about Ambetter's business practices and customer service as a whole. I want to speak with a supervisor and I want to escalate to the highest level. This practice can legitimately hurt people who need medical treatment and it must be remedied. I have also filed a complaint with the Insurance Commissioner of Georgia in hopes to find relief. 
Sincerely,
[redacted]

Complaint: [redacted]
I am rejecting this response because: I have called Ambetter several times, and was told that they the check was cashed on March 29th and that they are trying to reach their corporate office then they will update my account.  My account was not updated until March 18th, after making several calls because I needed to have blood work up, finally I received a call stated this was updated.  I have been thru this last year after they cashed my check I was receiving numerous letter stating my account will be cancelled, knowing that the check was cashed.  At this point I am ok that they update my account.  I still believe they need to have better system in place. Sincerely,
[redacted]