American Specialty Health Inc

Revdex.com:
I have reviewed the response made by the business in reference to complaint ID ***, and find that this resolution would be satisfactory to me, IF it is carried out as promised. One note regarding the handling of faxed claims, the business response from representative *** *** stated "ASH
does not maintain a fax number for the receipt of claims. Claims sent to other unrelated ASH fax
numbers may not be received in the correct department." However, I would like to point out that the instructions on the ASH website (***) give two options for submissions of claimsOption A states "Obtain your medical records yourself for the dates of service you want verified as medically necessary and send that information by fax to the fax number below or by mail to ASH Group at the address below." Option B states: "Ask your non-participating practitioner to communicate directly with ASH Group to verify medical necessityIf your practitioner is willing to do this on your behalf, we have developed reporting tools for your practitioner to useThe practitioner can assist you in meeting your obligation to obtain medical necessity verification by: Completing the Medical Records Cover Sheet (***) ..... He or she may fax the Medical Records Cover Sheet along with the forms to ASH Group at the number below or mail the forms to the address below." If no fax number is maintained for the receipt of claims, why is a cover sheet with fax numbers provided for the appropriate routing of faxed claims, and why is the fax referred to on both options? Further, it is highly questionable that both faxed and mailed copies of the claims both were never received and appropriately processed.In good faith, I will respond to MsMatthews offer of personal expedited processing and attempt to obtain a copy of the documentation from my chiropractor (in the hopes that they kept a copy of what they mailed to ASH), and I will submit this claim directly to herI will wait for the business to perform the promised action and, if it does, will consider this complaint resolved.Regards,*** ***

ASH has contacted the complainant directly and resolved the case. I have spoken directly to Ms*** and her chiropractor. ASH will be honoring the unlimited visits for Ms*** for the calendar year of based on ***'s direction. I provided Ms*** my direct contact
information for anything further. She can reach me by email at *** or by phone at ###-###-####. Thanks*** ***American Specialty Health

]
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID ***, and find that this resolution would be satisfactory to me. Iwill wait for the business to perform this action and, if it does, will consider this complaint resolved
Regards,
*** ***

Revdex.com:
I have reviewed the response made by the business in reference to complaint ID ***, and have determined that this proposed action would not resolve my complaint. For your reference, details of the offer I reviewed appear below
I called *** at *** ext *** several times and left a message asking to call me back but have not received a phone call to clarify ASH's decision, and my says to respond to Revdex.com are approachingSince the pediatric patient has a history of elbow/ shoulder pain that gets exacerbated when his physical therapy stops, the PT and pediatrician both agree to continue therapy till the pain has been gone for few months and the growing joint is more stable as the therapy has significantly reduced painI would appreciate if ASH can approve 1X week visit for remaining as we are well within the physical therapy limits allowed by *** per subscriber.Also, my son was gone for a school trip and has visits left including a visit planned todayI called *** to check on currently approved dates, but they said ASH is closedASH's letter to Revdex.com and copied to me says currently approved visits need to be completed by 10/16/while *** says 10/6/Since *** says ASH is the decision maker, I am assuming ASH letter to me is correct and currently approved visits can be completed by 10/16/15.
Regards,
*** ***

Revdex.com:
I have reviewed the response made by the business in reference to complaint ID ***, and have determined that this proposed action would not resolve my complaint. For your reference, details of the offer I reviewed appear below.Well - this just goes to show how *** up the insurance industry is. It is quite sad that the right hand has no idea what the left hand is doing. I received a letter from *** on March 10, 2015, stating that these chiropractor visits from October/November had been approved. My chiropractor also told me that *** finally reimbursed her for those visits. I guess *** forgot to tell that to American Specialty Health. So technically ASH Group's proposed action doesn't resolve the complaint because *** already resolved it.I'm done dealing with these ***. It's just a waste of time
Regards,
*** ***

ASH has searched in all possible locations but cannot locate the required documents or confirm that they were submitted. We apologize for any inconvenience it causes but we would need the documentation resubmitted. It can be faxed to *** or emailed to ***. Thanks

The attached letter to the complainant has been placed in the mail today, 1/16/15. Thanks

Ms. [redacted]’s complaint indicates that she does not agree with determinations that were made related to the claims and the amount of treatment ASH found to be medically necessary.  The complaint states that ASH denied 7 out of 11 physical therapy appointments.  The complaint goes on to say...

that Ms. [redacted] faxed her medical information on multiple occasions in 2015 and 2016 and that ASH lost the faxes. ASH has reviewed the concerns and would like to clarify the requirements. ASH performs medical necessity review on behalf of [redacted] for out-of-network claims. Ms. [redacted]’s provider, [redacted], MPT, is not contracted with ASH and is not a participating provider under Ms. [redacted]’s [redacted] plan.   Dr. [redacted] submitted 2 claims for Ms. [redacted] to [redacted] with the following dates of service: 05/20/15, 05/27/15, 06/16/15, 07/21/15, 07/27/15, 08/06/15, 08/27/15, 08/31/15 and 09/10/16. [redacted] forwarded these claims to ASH to determine medical necessity. ASH did request medical records to support the claim information submitted.   As a note, if the medical records are not received initially, ASH will send up to three requests for additional information per claim to give the member and provider every opportunity to submit documentation that may support the medical necessity of services rendered. The claims grid below shows the date of those request letters sent by ASH to both Ms. [redacted] with a separate carbon copy to Dr.  [redacted] on the dates identified in the claims grid below. Claim Number ASH Received Date Date of Service Date Request for Additional Information Requested [redacted] 10/22/2015 05/20/15-09/10/15 10/26/15, 11/30/15 and 12/11/2015           ASH received the practitioner’s documentation on 04/01/2016, from Ms. [redacted].  ASH reviewed the medical records and a response was sent on 04/05/2016 Ms. [redacted] expressed concern in her complaint that her information submitted by fax was lost or misplaced by ASH.  Faxes received by ASH are logged for tracking and we have confirmed that our records indicate that we did not receive any successful fax transmissions from Ms. [redacted] outside of the 4/1/2016 set of her medical records. After receipt of the records, a peer clinical reviewer evaluated the documents submitted for medical necessity.  Based on the review for these claims, the clinical reviewer observed that the treating provider’s notes did not provide a clear clinical picture of Ms. [redacted]’s condition at the start of care or the progress made through her treatment. The documentation submitted did not include a description of the injury or complaint onset, patient medical history, exam findings or functional impact on Ms. [redacted].  The daily treatment notes reviewed by ASH’s clinical reviewer were noted to be vague and did not have objective clinical findings to support the treatment plan.  .  These findings were provided in a response letter on 04/05/16 to the treating practitioner, Dr. [redacted], and to Ms. [redacted].  The letter included specific rationale for why the visits were not approved as medically necessary based on the materials submitted.  The name and extension of the reviewer as well as the steps to appeal the decision, including Dr. [redacted]’s ability to discuss the rationale for why the visits were not approved with the clinical reviewer were included in the letter.   We have reviewed our records and do not see any call logs indicating that the practitioner contacted the reviewer to discuss.  On 09/01/16 ASH had a peer reviewer reached out by phone to Dr. [redacted] and left a message inviting Dr. [redacted] to call back to discuss Ms. [redacted]’s treatment further in light of the concerns noted in Ms. [redacted]’s complaint.  As of today, our records indicate that Dr. [redacted] has not yet called back.  Tell us why here...

Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that this proposed action would not resolve my complaint.  For your reference, details of the offer I reviewed appear below.
Passing the blame to the insurance carrier is unacceptable. I've attached one example of a member benefits we received from ASH. It shows two different benefit summaries a week apart.
Regards,
[redacted]

[redacted] complaint indicates that they are receiving inconsistent member benefit information related to the patient’s financial responsibility, Copay and Deductibles.  The complaint states that their office manager will contact ASH and verify the benefits and then a few days later they...

will receive different benefit information that would result in a higher out of pocket expense for the member and this is leading to member dissatisfaction and potential loss of patients for [redacted] office.     American Specialty Health (ASH) has reviewed the concerns and would like to clarify that ASH partners with multiple health plans to administer chiropractic services including members that treat with [redacted] office.  ASH provides member benefit information upon inquiry from contracted provider offices based on the information available to ASH from the health plan at the time of the call.  While health plan clients update benefit information with ASH on a routine basis, apparent discrepancies between available data and information reported by providers can arise.  In such circumstances, ASH will conduct outreach to our health plan clients to confirm the applicable benefit information to resolve the situation.   While no specific member is identified in the Revdex.com complaint, to further address the concerns raised, ASH has reviewed all call logs between [redacted] office and ASH from the date identified in the complaint (11/21/16) to present.  ASH relies on accurate information from our health plan partners in providing us eligibility and benefits information and it appears that based on the call logs reviewed that additional outreach did result in the need to reprocess impacted claims.  ASH continues to work with our health plan clients to receive accurate and current information so that such discrepancies are minimized.    ASH apologizes for any inconvenience this may have caused. Below are summaries of the calls related to verification of eligibility and benefits and, if applicable, the subsequent reprocessing of the claims for the dates of service involved.   On 11/21/16 [redacted] from the office called to inquire about the claims status for one of their members whose date of service was 07/20/16.  [redacted] was advised that the payment was applied to the member’s deductible.  It was determined that this was accurate information and the member had in fact not met their deductible. Another call came into ASH on 11/21/16 regarding another patients benefits and claims for dates of service 09/14/16, 10/12/16, 01/26/16 and 11/09/2016.  [redacted] with the office was advised that allowed costs for all dates of service were applied towards the member’s deductible.  [redacted] stated that the deductible should have been met and not applied to these dates of service.  Eligibility research was conducted in the form of outreach to the health plan to verify the discrepancy between what ASH had on file and what was being stated by the office.   In response to the outreach, the health plan subsequently informed ASH that the member did not have a deductible, but rather was responsible only for a copayment.  The claims were subsequently reprocessed without a deductible on 11/30/2016 and paid accordingly.  On 12/02/16 [redacted] called requesting chiropractic benefits information for one of their patients. The dates of service in question were 11/07/16 and 11/21/2016.  [redacted] said that the benefits for these dates should have applied only a copay and not have included a deductible for the member’s cost share requirements.  An eligibility research request was again completed by reaching out to the health plan and verifying benefits as there was a discrepancy between what ASH had on file from the health plan and what the office was presenting. Through this additional outreach, ASH confirmed that there was a copayment of $10 but that no deductible applied.  The claims were reprocessed on 12/05/16 and [redacted] was contacted on that date advising of the resolution. On 12/12/16, a call came in from [redacted] to check claim status for dates of service 11/16/16-12/08/16.  [redacted] advised that the member has a copayment of $10 and not a deductible.  The claims were sent for re-verification of the benefits ASH had on file and through additional outreach to the health plan to verify the discrepancy, it was confirmed that the member did have a $10 copayment and that no deductible applied.    The claims were subsequently reprocessed on 01/12/17.  [redacted] with [redacted] called on 12/21/16 about dates of service 11/16/16, 11/18/16 and 12/14/16 for another one of their patients.  The claims were sent for re-verification of the benefits ASH had on file.  Through additional outreach to the health plan to verify the discrepancy, ASH confirmed that the member did have a $10 copayment and that no deductible applied. Claims were reprocessed on 01/06/17.  As stated above, ASH relies on accurate information from our health plan partners in providing us eligibility and benefits information and we continues to work with our health plan clients to receive accurate and current information.    ASH apologizes for any inconvenience this may have caused.   If there are any additional questions or concerns you may contact [redacted] 800-848-3555 extension [redacted].

Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that this proposed action would not resolve my complaint.  For your reference, details of the offer I reviewed appear below.
My chiropractor already forwarded the requested information to ASH Group.  I guess the ASH people need to look a little harder to locate that communication.
Regards,
[redacted]

please see attached letter being placed in the mail to the copmlainant today. April 20, 2015[redacted]RE:      Response to RevDex.com (Revdex.com) Complaint ID #[redacted] Ms. [redacted],American Specialty Health (ASH) has...

reviewed the complaint you
submitted to the Revdex.com regarding claims for services rendered to you by
chiropractor [redacted].  Your
complaint questioned the denial of claims from July, August and September,
2014.  You also expressed concern that
claims for similar services had been paid in May and June, 2014, and again in
October, 2014. Your benefit program requires verification of medical necessity for
services to be considered covered under your plan, whether those services are
rendered by a participating practitioner or a non-participating practitioner.  In this case, since you sought services from
a non-participating practitioner, you are responsible for ensuring that
sufficient information for verification of medical necessity has been submitted
in order to allow your claims to be processed.    In this case, records were submitted on 7/31/14 for dates of service
5/31/14 – 6/28/14 for 1 new patient exam and 8 office visits.  The submitted request was processed under
MNR#10500197 and reviewed for DOS 05/31/14 to 06/28/14.  The Medical Necessity Review (MNR) Response
letter sent to you and copied to Dr. [redacted] indicated that 8 office visits during
that range of dates were approved and the new patient exam was denied.  The new patient exam was denied because this
service had been previously submitted for payment and was a duplicate.  Under the program administered by ASH on
behalf of Empire Blue Cross Blue Shield, members can receive payment for the
first five visits of the calendar year to a chiropractic practitioner without
the need for medical necessity verification. 
After the first five visits of the year or after a request for medical
necessity verification is submitted, any other services require submission of
medical records to ASH for clinical evaluation. Even though these initial
office visits for these dates of service in 2014 were approved, the response
letter called attention to significant deficiencies in the documentation
submitted. For example, the MNR Response letter outlined what additional detail
would be needed should additional treatment be needed.  Such information was noted as including
specific findings and clinical details within your treatment records such as
appropriately documented range of motion findings.  The detail and rationale for services that
were noted in our response are necessary to verify why the particular services
requested, such as the new patient exam, were medically necessary. .   On 11/11/14, an MNR form requesting DOS 07/01/14 to 08/29/14 for 1
established patient exam and 16 office visits was submitted.  The submitted request was processed under
MNR#10604375.  The requested services
were denied as not medically necessary and you and Dr. [redacted] were provided
detailed information regarding the rationale for this clinical denial.  The denial reasons communicated included that
the range of motions findings were not clearly described so that the treatment
provided could be verified as medically necessary.  Likewise, the daily chart notes did not
provide significant enough detail about your condition to verify the medical
necessity of the services rendered.  ,
orthopedic testing was not performed,. 
The denied services also included requests related to Thermography.  The denial reasons specified that those
requests were denied because current clinical studies do not support the usefulness
of Thermography in evaluating your documented conditions, e.g., subluxations or
pain in the spine or arms and legs.   On 12/23/14 an MNR form requesting DOS 09/01/14 to 09/29/14 for 1
established patient exam and 7 office visits, 1 neurological test
(electrodiagnostic surface EMG) and 1 cervical x-ray was submitted.  The submitted request was processed under
MNR#[redacted].  The requested services
were clinically denied as not medically necessary.  The response letter to you and Dr. [redacted] outlined
that the requested examination was denied because the submitted findings did
not meet the criteria for an examination. 
The letter went on to state that the requested dates of service were
denied because the palpatory findings were not clearly described, the range of
motion findings were not clearly described, orthopedic testing was not
performed, the daily chart notes were inadequate, and the need for
electrodiagnostic testing was not supported in the medical record as there was
no documentation of a neurological examination being performed that would have
supported the need for electrodiagnostic testing.  On 01/12/15 Dr. [redacted] spoke with the
clinical reviewer that had rendered this determination.  The clinical reviewer discussed the case with
Dr. [redacted] and identified to him the deficiencies and inadequacies within the
medical records.  He reviewed with Dr.
[redacted] the objective reporting requirements, and faxed to Dr. [redacted]
information about appropriate documentation to assist Dr. [redacted] and provide
him with a packet of forms he may use to address these concerns.  The clinical reviewer also provided an
explanation on how he may submit a ReOpen form along with additional
information for reconsideration of these determinations based on that
information.  On 02/10/15, a ReOpen/Modification for MNR#[redacted] was submitted for
DOS 09/01/14 to 09/29/14 for 1 established patient exam and 7 office
visits.  Despite additional information
being provided, the requested services were clinically denied as not medically
necessary as the new information did not support the medical necessity of the
services performed.  Specifically, a Back
Index form and a Low Back Pain and Disability Questionnaire indicating some low
back pain and some low back limitations were submitted along with a Neck Index
form that you completed.  The score on
the Neck Index form was “0”, indicating no neck pain, no restrictions in
activity and the ability for you to perform normal activities without neck
pain.  The notification letter included
information that clinical committees have determined adjusting the upper
cervical spine (neck area) to treat chief complaints unrelated to the cervical
spine (e.g., lumbar or lower back pain) is not established as clinically
effective, is not professionally recognized (not widely accepted and used) and
is considered to be scientifically implausible. On 12/23/14 an MNR form requesting DOS 10/02/14 to 10/27/14 for 1
established patient exam and 8 office visits was submitted.  The requested services were clinically denied
as not medically necessary under MNR#[redacted]. 
The notification letter to you and Dr. [redacted] indicated that the
services were denied because the submitted information did not meet the
criteria for an established patient exam, the daily chart notes were inadequate
and did not provide significant details about the your condition, and that the
submitted information was generic and did not contain specific information
regarding your treatment.  On 01/12/15,
Dr. [redacted] had a clinical discussion about MNR#[redacted] (involving DOS
10/02/14 to 10/27/14 for 1 established patient exam and 8 office visits) with
the clinical reviewer that reviewed the case. 
During the conversation Dr. [redacted] provided additional clinical
information sufficient for this clinical review to approve five office
visits.  The discussion did not provide
sufficient clinical information to approve the established patient exam or the
remaining three office visits.Based on the information above, the main cause of the discrepancy
between services being approved and being denied is related to the
documentation submitted by Dr. [redacted].  At
this time, you can work with Dr. [redacted] to obtain additional documentation to
submit to ASH for further review of medical necessity or you can file an appeal
directly with your health plan.  Should you have any questions, please contact me directly at
[redacted] extension [redacted].Sincerely,[redacted]Senior Manager, Clinical OperationsAmerican Specialty Health

The attached letter was mailed to the complainant today.  Thanks!February 25, 2015[redacted]...

[redacted]                                   ...⇄ RE:      Response to Complaint
Filed with the Revdex.com (Complaint ID [redacted])American Specialty Health Group (ASH Group) received your complaint
from the Revdex.com (Revdex.com) related to your concerns about your [redacted]
plan and services you received from your chiropractor, Lori Pinto, D.C.  Dr. Pinto is not participating with ASH Group
at this time and is considered an out of network practitioner. [redacted] has
contracted with ASH Group to perform verification of medical necessity for
their customers’ out-of-network chiropractic benefits on behalf of [redacted].  [redacted] benefit plans may require verification
of medical necessity for services to be considered covered services. ASH Group
implements its review process in accordance with the coverage requirements
specified in your [redacted] issued benefit plan. 
ASH Group begins verifying medical necessity for claims involving
out-of-network benefits after the first five visits of each calendar year per
unique patient/provider combination.  In
this case, [redacted] did pay your first five visits in 2014.  For services supported by ASH Group, [redacted]
then forwards related claims that require medical necessity verification to ASH
Group.  If documentation that medical
necessity has been verified is not already on file for out-of-network claims,
then ASH Group requests medical records from the customer, with a copy to the
treating practitioner, in order to verify medical necessity.  You are responsible for submission of such
records to support the medical necessity of the services; however, some
practitioners will voluntarily do this on behalf of their patient. You can
submit the records directly if your practitioner is not willing to submit
records on your behalf.  While your submitted complaint states that your chiropractor has
submitted the records related to dates of service 10/10/14 and 11/10/14, ASH
Group does not have those records on file. 
To expedite processing, those records can be sent directly to me by fax
at [redacted] or by email at [redacted].  Should you have any further questions, please contact me directly at
[redacted] extension [redacted].Sincerely,[redacted]Senior Manager, OperationsAmerican Specialty Health

Tell us why here...
Mr. [redacted]’s complaint indicates that his chiropractor is receiving incorrect benefit information related to Mr. [redacted]’s financial responsibility, i.e. his copay and deductible obligations.  The complaint states that Mr. [redacted] believed he had met his deductible before receiving treatment from his chiropractor.  However, when the claims for his chiropractic dates of service (5/11, 6/15, 6/20.) were processed, a deductible was applied.  
American Specialty Health (ASH) has reviewed the concerns and would like to clarify that ASH partners with multiple health plans to administer chiropractic benefits including Mr. [redacted]’s health plan.  Providers, like Mr. [redacted]’s chiropractic provider, who are contracted with ASH, will contact ASH to verify eligibility and ASH responds to those inquiries based on the information available to ASH from the member’s health plan at the time of the inquiry.  While health plan clients update benefit information with ASH on a routine basis, the information may not always be the most current and discrepancies can arise.  In such circumstances, ASH will conduct outreach to our health plan clients to confirm the applicable benefit information to resolve the situation.
ASH has reviewed the claims for Mr. [redacted] involving dates of service 5/11, 6/15 and 6/20. While information available to ASH at the time the claims were processed indicated that the benefit amounts were to be applied to Mr. [redacted]’s deductible,   it appears that subsequent research and outreach did result in that information being updated to show that Mr. [redacted] had already met his deductible before the dates of service in question.  As such, ASH has reprocessed the claims without the deductible being a factor.  ASH continues to work with our health plan clients to receive accurate and current information so that such discrepancies are minimized.  ASH apologizes for any inconvenience this may have caused.
The dates of service affected were reprocessed as follows:
·         05/11/17 was reprocessed with no deductible on 05/18/17 under claim number [redacted].  The amount paid on this claim is $42.28. 
·         06/15/17 was reprocessed under claim number [redacted] with no deductible on 06/28/17. The resulting payment on this claim was $42.28.
·         06/20/17 reprocessed under claim number [redacted] with no deductible applied on 07/05/17.  A payment was issued in the amount of $42.28.
As stated above, ASH relies on our health plan partners to provide us the most timely and accurate eligibility and benefits information.  We continue to work with our health plan clients to ensure we receive accurate and current information.    ASH apologizes for any inconvenience this may have caused.   If there are any additional questions or concerns you may contact [redacted].

Good afternoon,ASH has spoken directly with the complainant and is working to resolve the claims issues and ensure proper .  ASH apologized to the complainant for the inconvenience this issue has caused.  The complainant has agreed to work with ASH on follow up and final resolution of this...

issue.

Mr. [redacted]’ complaint indicates that ASH has failed to respond to his practitioner’s request for medical necessity verification.  He also states that ASH is refusing to take his calls and will only speak to his practitioner or [redacted]. 
Mr. [redacted]’ practitioner, [redacted], submitted...

a request for medical necessity verification on 1/29/16.  At that time, ASH did not have the practitioner’s information loaded into the processing system, which is necessary to complete handling of the request.  This caused a delay in processing and the review was not completed until 2/13/16.  All services submitted for review were deemed medically necessary. 
The ASH departments responsible for the intake and subsequent clinical review of the medical necessity reviews have found themselves in an unforeseen increase in inventory of requests coupled with a temporary shortage of staff—this has in turn led to the delay noted above.  ASH is utilizing all means possible to quickly recover from this current backlog causing delay in the process and improve current turnaround times.
In regards to the complaint that ASH won’t speak to Mr. [redacted] directly, [redacted], which is Mr. [redacted]’ health plan, has not delegated ASH for customer service. Therefore, ASH is not permitted to take calls from customers of [redacted] health plans.  Mr.[redacted] can contact [redacted] directly for any issues related to ASH and [redacted] will coordinate with the appropriate parties at ASH to provide a response. 
ASH apologizes for the delays in handling of the medical necessity review noted above.  ASH has outreached to Mr. [redacted]’ practitioner to advise that the patient cannot be billed when waiting for medical necessity verification.  If Mr. [redacted] receives a bill, he can contact [redacted] for further action.

ASH would like to provide clarification on the covered dates and the unpaid services.
The approved medical necessity review has date of services for 6 office visits for the date range 8/25/15-10/06/15, indicating that the 6 visits must be completed on or before 10/06/15.  As per instructions on practitioner response form (the form the treating physical therapist received), the treating physical therapist (PT) can submit a Reopen/Modification form to request a date extension up to 30 days so member can utilize those 2 remaining  already approved visits that were not completed on or prior to 10/06/15.  At this time, the treating PT has not requested a date extension or any additional treatment beyond what was already approved.
 
For any additional continued care beyond the already approved timeframe, the practitioner (treating PT) can submit a new request for medical necessity review with updated clinical findings to be reviewed for medical necessity. Medical necessity determinations are made based on individual patient factors and ASH clinical practice guidelines.  In addition, individual benefit limitations may include coverage exclusions as well as maximum allowable number of visits.

Previously I filed Revdex.com complaint #[redacted] regarding this same issue. American Specialty Health Systems, Inc. said they corrected my deductible amount in their system so future charges from [redacted] Chiropractic would show my deductible had been met, therefore my charge should be $4.40 instead of showing $44.00 being applied to my deductible and that I owe the $44.00. I have since received two more Explanation of Benefits (EOB's) showing I owe $44.00 and it will be applied to my deductible. They did not fix the issue as they claimed. I asked for two resolutions 1)fix my account so I no longer receive incorrect EOB's 2)contact [redacted] at [redacted] Chiropractic and resolve her open issues with multiple patients having the same issue I have. American Specialty never contacted [redacted] Chiropractic and they said they fixed my account. I had email issues and by the time they were fixed I found my Revdex.com complaint #[redacted] had been closed because I had not responded in time. I am still requesting these two resolutions be made.1)fix my account so I no longer receive incorrect EOB's 2)contact [redacted] at [redacted] Chiropractic and resolve her open issues with multiple patients having the same issue I have. This creates an enormous amount of work for her and her patients. Her extra work causes increased costs in my healthcare.

Ms. [redacted]’s complaint indicates she is owed $161.99 for unreimbursed health club membership costs between January and June, 2015.  The complaint states that ASH has neither responded to her calls nor acknowledged receipt of the faxed gym membership receipts or attendance logs. Ms. [redacted] stated...

that she sent all receipts and fitness attendance logs to ASH via email on 3/29/16 requesting $195.99 and to date has only received a check for $34 on 4/18/16. She stated she called customer service twice, including once on 6/9/16, and was advised an agent would look into it and return her call. She stated she has received no follow-up. Ms. [redacted] requests the remaining funds ($161.99) be overnighted to her. ASH administers an Exercise Rewards Program for Empire members, including Ms. [redacted]. Under this program, Ms. [redacted] qualifies for gym membership reimbursements up to $200 per six month period. In order to receive the $200 per six month period, Ms. [redacted] is required to submit a Gym Reimbursement Request Form as well as gym membership receipts and gym attendance records. ASH is in receipt of Ms. [redacted]’s July to December 2015 Gym Reimbursement Request Form, gym membership receipts and attendance logs as received on 2/9/16. ASH issued Ms. [redacted] reimbursement for the July to December 2015 period on 3/7/16 ($79) and 3/21/16 ($58).On 3/29/16, Ms. [redacted] sent an email with additional supporting documentation including yoga studio attendance logs and bank statements as proof of payment. The supporting documentation included dates spanning 2015, from January to December, and a note requesting additional reimbursement as the reimbursement allowance had not yet been exhausted for the period July through December 2015. As a result of the additional information, ASH issued $34 to Ms. [redacted] on 4/18/16. As a result of this complaint, ASH has again reviewed all documents Ms. [redacted] provided. She submitted one Gym Reimbursement Form for the July through December 2015 period but has not submitted a Gym Reimbursement Form for the period of January through June 2015. The submitted fitness attendance logs confirm 45 visits, however, 50 visits are required for reimbursement. To date, Ms. [redacted]  has not met the visit requirement for the first half of 2015 and has not provided a Gym Reimbursement Form. Ms. [redacted] called ASH three regarding the status of her claim for July through December 2015.  The first call occurred 3/7/16, and as ASH received the claim for July-December 2015 on 2/29/16, the member was advised that her claim was in process and could take up to 30 days to complete.  The second call occurred 3/11/16 where the member was advised she would receive two checks totaling $79 and that additional information (gym reimbursement receipts) was required to complete the additional portion of her claim. Ms. [redacted] agreed to submit this information, which was received and reimbursed by ASH on 4/18/16 ($34). The final call on file occurred on 6/14/16 and Ms. [redacted] stated she submitted a claim for $350 but had not received the full amount.  The agent reviewed the payments the member received ($79, $58, $34) and advised she would research the remainder of the claim.  No follow-up was completed and the agent has been coached on the process to ensure commitments to members are provided. The Sr. Director of Claims reached out to Ms. [redacted] on her cell phone on 7/20/16 to provide her direct contact information and review the reasons she has not received reimbursement for the January through June 2015 timeframe. They reviewed the 45 fitness visits ASH has and Ms. [redacted] agreed to provide, via direct email to the Sr. Director of Claims, the 5 remaining attendance logs and a Gym Reimbursement Form for January through June 2015. Upon receipt, the Sr. Director of Claims will expedite the claim handling and appropriate reimbursement owed to Ms. [redacted].   [redacted]Sr. Director, ClaimsExt: [redacted]

Attached you will find the response to the complainant that was placed in the mail today. Thanks April 7, 2015[redacted]
[redacted]RE:      Response to your
complaint submitted to the Revdex.com (ID[redacted]...

[redacted],American Specialty Health has reviewed the complaint you submitted to
the Revdex.com (Revdex.com) related to claims submissions for your
treatment.  While we understand that your
provider may have faxed claims to us, unfortunately such a submission is not an
appropriate manner to submit claims to us. 
Claims for chiropractic services under your health plan are required to
be submitted to ASH on paper. Research of our records has not revealed that
your claims were recorded as having been received.  To help remedy your situation in relation to
these claims, you or your
chiropractor can submit claims directly to me for expedited handling.  The claims in issue here can be emailed to me
at [email protected] or mailed to me at: [redacted].  Please make sure to address
the claims to my attention for faster handling.  Our records indicate that during a call on 1/23/15 between you and ASH
staff you were advised ASH had no claims on file for your services.  At that time, you indicated that your
chiropractor had faxed in the claims. The representative then told you that
claims sent by fax are rejected.  During a
subsequent call you made on 2/6/15, an ASH representative also informed you that
the claims were still not on file.  The
ASH agent advised that claims can only be mailed or submitted online and that
faxed claims are not accepted.  The agent
did indicate that claims are processed in a different location and that if
something had recently been submitted and wasn’t on file yet, then there would
not be a way for the representative to confirm it had been received.  Information received via mail or on-line
usually is processed and available in our files within five business days.For clarification on the information you were
provided, ASH does not throw out claims sent via fax.  However, ASH does not maintain a fax number
for the receipt of claims.  Claims sent
to other unrelated ASH fax numbers may not be received in the correct department.  Additionally, the agent that indicated that
claims are processed at a different location than where they are received was
incorrect.  In fact, all claims properly
mailed to the designated address are received by ASH in a designated central
location to ensure timely and appropriate handling.  Such documents are scanned upon receipt for
processing and tracking.  Once scanned,
the documents are available to our staff in various locations to access
electronically in order to expedite processing.  ASH apologizes for any incorrect information
provided to you during your calls.  We
strive to provide the best customer service and will use your feedback as a
tool for coaching training.  Again, to help resolve the current issue, you or
your chiropractor can submit those claims directly to me for expedited
handling.  The claims can be emailed to
me at [redacted] or mailed to me at: [redacted].  Please make sure to address
the claims to my attention for faster handling. 
Please note that this is an exception to assist you with this current
matter.  Should you have any questions, please contact me directly at [redacted]
extension [redacted].Sincerely,[redacted]Senior Manager, Clinical OperationsAmerican Specialty Health? ?