My health insurance company has hired American Specialty Health to administer claims for alternative health care, of which I am entitled to 30 visits per year (or more with proper documentation, so I have been told. Well, it seems that about every 4 or 5 visits to my acupuncture/Eastern Health practitioner my claims start being denied. I have a chronic, severe back condition and this treatment has been making a world of difference. I, yet again, now find I will have to fight with ASH over denied claims. I am beyond fed up!
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] ***
Attached you will find the response to the complainant that was placed in the mail todayThanks April 7, [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 paperResearch 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/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 claimsThe 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 ***.Sincerely, [redacted] Senior Manager, Clinical OperationsAmerican Specialty Health? ?
ASH has worked directly with the complainant and her provider's office to resolve this complaintThe member's employer group was incorrectly loaded into the ASH system with calendar year benefits rather than benefit year This caused denials for maxed benefits that were incorrectASH has corrected this issue and reprocessed claims In addition, ASH has informed the practitioners office who agreed to cease billing the complainant for the claims in questionIf the complainant has any additional concerns, she can contact me directly at [redacted] Thanks
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.ehis 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/and 6/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/was reprocessed with no deductible on 05/18/under claim number [redacted] The amount paid on this claim is $ · 06/15/was reprocessed under claim number [redacted] with no deductible on 06/28/The resulting payment on this claim was $ · 06/20/reprocessed under claim number [redacted] with no deductible applied on 07/05/ A payment was issued in the amount of $ 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] [redacted] ***
please see attached letter being placed in the mail to the copmlainant todayApril 20, [redacted] ***RE: Response to Better Business Bureau (Revdex.com) Complaint ID # [redacted] Ms***,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, You also expressed concern that claims for similar services had been paid in May and June, 2014, and again in October, 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/for dates of service 5/31/– 6/28/for new patient exam and office visits The submitted request was processed under MNR#and reviewed for DOS 05/31/to 06/28/ The Medical Necessity Review (MNR) Response letter sent to you and copied to Dr [redacted] indicated that 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 evaluationEven though these initial office visits for these dates of service in were approved, the response letter called attention to significant deficiencies in the documentation submittedFor 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/to 08/29/for established patient exam and office visits was submitted The submitted request was processed under MNR# 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/an MNR form requesting DOS 09/01/to 09/29/for established patient exam and office visits, neurological test (electrodiagnostic surface EMG) and 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/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/to 09/29/for established patient exam and 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 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 implausibleOn 12/23/an MNR form requesting DOS 10/02/to 10/27/for established patient exam and 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/to 10/27/for established patient exam and 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 ***.Sincerely, [redacted] Senior Manager, Clinical OperationsAmerican Specialty Health
ASH apologizes for the confusion on the issueWe were not aware that [redacted] had paid the claims ASH does not pay these particular claims directly and is not made aware when they are paid If you have further issues, you are welcome to contact me at [redacted] ext *** Thanks [redacted] Senior Manager, Operations
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 *** Mr [redacted] ’ practitioner, [redacted] **, submitted a request for medical necessity verification on 1/29/ 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/ 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, ***, which is Mr [redacted] ’ health plan, has not delegated ASH for customer serviceTherefore, 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
American Specialty Health received a Revdex.com (Revdex.com) complaint from member [redacted] ***She stated she has two claims on file that have been denied due to a lack of referral from her primary care physician (PCP) to the chiropractor from whom she sought treatmentMs***’s complaint indicates that her chiropractic and radiologist faxed the referral to ASH multiple timesHer attempts to contact American Specialty Health resulted in an inability to locate the referral and a commitment from the agent to follwith her after researching furtherMs [redacted] did not receive the follshe requested and would like to have her two claims approved/paid ASH administers an in-network chiropractic benefit for [redacted] members, including Ms***, but a referral from a PCP must be on file in order to approve claimsASH researched to confirm if a referral was on file for Ms***It was notThe ASH Supervisor mentioned in the complaint reached out to [redacted] ’s Outside Referrals Department on 7/1/and confirmed [redacted] did not have the PCP referral on fileShe then reached out to Ms***’s PCP, Dr [redacted] ***, and left a message requesting she forward the member’s referral to [redacted] ’s Outside Referrals Department [redacted] followed up with [redacted] ’s Outside Referrals Department for a second time on 7/20/and was again advised the referral was not on file ASH escalated the member’s concern to [redacted] ’s Pain Management Coordinator on 7/20/It was identified that [redacted] received follfrom the member’s PCP on 7/11/and the referral was granted [redacted] ’s Outside Referrals Department sent the referral to ASH on 7/22/ASH loaded the referral and reprocessed both claims on file to payThe member will receive payment next week The SrDirector of Claims outreached to the member to apologize for the inconvenience and to advise both claims would be paid to her next week
Ms***’s complaint indicates she is owed $for unreimbursed health club membership costs between January and June, The complaint states that ASH has neither responded to her calls nor acknowledged receipt of the faxed gym membership receipts or attendance logsMs [redacted] stated that she sent all receipts and fitness attendance logs to ASH via email on 3/29/requesting $and to date has only received a check for $on 4/18/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 callShe stated she has received no follow-upMs [redacted] requests the remaining funds ($161.99) be overnighted to herASH administers an Exercise Rewards Program for Empire members, including Ms***Under this program, Ms [redacted] qualifies for gym membership reimbursements up to $per six month periodIn order to receive the $per six month period, Ms [redacted] is required to submit a Gym Reimbursement Request Form as well as gym membership receipts and gym attendance recordsASH is in receipt of Ms***’s July to December Gym Reimbursement Request Form, gym membership receipts and attendance logs as received on 2/9/ASH issued Ms [redacted] reimbursement for the July to December period on 3/7/($79) and 3/21/($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 paymentThe 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 As a result of the additional information, ASH issued $to Ms [redacted] on 4/18/As a result of this complaint, ASH has again reviewed all documents Ms [redacted] providedShe submitted one Gym Reimbursement Form for the July through December period but has not submitted a Gym Reimbursement Form for the period of January through June The submitted fitness attendance logs confirm visits, however, visits are required for reimbursementTo date, Ms*** has not met the visit requirement for the first half of and has not provided a Gym Reimbursement FormMs [redacted] called ASH three regarding the status of her claim for July through December The first call occurred 3/7/16, and as ASH received the claim for July-December on 2/29/16, the member was advised that her claim was in process and could take up to days to complete The second call occurred 3/11/where the member was advised she would receive two checks totaling $and that additional information (gym reimbursement receipts) was required to complete the additional portion of her claimMs [redacted] agreed to submit this information, which was received and reimbursed by ASH on 4/18/($34)The final call on file occurred on 6/14/and Ms [redacted] stated she submitted a claim for $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 follwas completed and the agent has been coached on the process to ensure commitments to members are providedThe SrDirector of Claims reached out to Ms [redacted] on her cell phone on 7/20/to provide her direct contact information and review the reasons she has not received reimbursement for the January through June timeframeThey reviewed the fitness visits ASH has and Ms [redacted] agreed to provide, via direct email to the SrDirector of Claims, the remaining attendance logs and a Gym Reimbursement Form for January through June Upon receipt, the SrDirector of Claims will expedite the claim handling and appropriate reimbursement owed to Ms*** [redacted] SrDirector, ClaimsExt: ***
Revdex.com: I have reviewed the response made by the business in reference to complaint ID [redacted] , and find that this resolution would be mostly satisfactory to me I will wait for the business to perform this action and, if it does, will consider this complaint resolved.I appreciate the company responding and acknowledging their delaysWhat is missing in this response is a commitment to (1) hire more staff or take other action to avoid future delays and (2) improve communication with patients and providers so then know when (or if) medical necessity reviews will be completedI cannot fully accept the resolution until I see the company has indeed committed to such actions Regards, [redacted]
Previously I filed Revdex.com complaint # [redacted] regarding this same issueAmerican Specialty Health Systems, Incsaid 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 $instead of showing $being applied to my deductible and that I owe the $I have since received two more Explanation of Benefits (EOB's) showing I owe $and it will be applied to my deductibleThey did not fix the issue as they claimedI 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 haveAmerican Specialty never contacted [redacted] Chiropractic and they said they fixed my accountI 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 timeI 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 haveThis creates an enormous amount of work for her and her patientsHer extra work causes increased costs in my healthcare
Revdex.com: I have reviewed the response made by the business in reference to complaint ID [redacted] , and find that this resolution would be satisfactory to me I will wait for the business to perform this action and, if it does, will consider this complaint resolved Regards, [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 "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" - As I said in my first complaint [redacted] "Today, 5/9, Blue agreed to conference call with me & my chiropractor, then me & American Specand confirmed to American my deductible had been met Blue Cross call ref # [redacted] Per [redacted] Hat American, she notated her log that my deductible was met She said she couldn't update American's system to show my deductible was met She would not allow Blue Cross and me to speak with anyone who could fix the issue She said I would have to again talk with my chiropractor, then Blue who will take weeks to file a claim then conference call American again which I refused to accept She then said she would submit an "eligibility research" claim, ref # [redacted] to fix my deductible." - This is an attempt by ASH to blame BCBS for not giving them the information.On 5/9/17, ASH was notified my deductible was met I asked for the following resolution: "1) Confirm to me via email my eligibility research claim [redacted] has been resolved to where I will not get erroneous statement any longer 2) Call my chiropractor, Thacker Chiropractic ###-###-####, speak to Melody and resolve the current open billing issues My chiropractor has to pay Melody which in turn causes my office visit rates to increase."ASH's response below on 6/says " 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." I appreciate the apology however, I would more appreciate fixing the issue with my statements and Thacker Chiropractor's open issues.- Again ASH is attempting to blame BCBS for this error they still have not resolved.ASH goes on to say "ASH relies on our health plan partners to provide us the most timely and accurate eligibility and benefits information." However, they were notified I had met my deductible the several times Thacker Chiropractic called them explaining the issue and when Blue Cross and I called them This is the third time ASH tries to blame BCBS when this issue was created by ASH and [redacted] H at ASH did not have the desire to fix my issue.ASH says these following dates have been "reprocessed" meaning a payment was finally made, I received two statements of benefits, one for the wrong charge and one for the corrected charge This is confusing and takes time from both Thacker and me to track down The dates are: "(04/06/17, 04/24/17, 05/02/and most recently 06/08/17)" - Please note, BCBS and I talked with ASH to resolve this on 5/9, ASH responded to my compliant saying the issues have been resolved on 6/ I have since received statements showing my deductible has not been met for 5/11, 6/15, 6/20.My second Revdex.com complaint [redacted] was also closed before I could respond The same ASH answer was givenit was BCBS' fault and it's been fixed It's obviously not fixed and Thacker Chiropractic has not received resolution on their outstanding claims I still believe this should be listed as one complaint per error billed This would be a total of so far.I've contacted ASH with BCBS I've issued two Revdex.com complaints I've been told the issue is fixed twice Yet, I have three more explanations of benefits showing I have to meet my deductible This is a great way for ASH to deny legitimate payments to providers like Thacker keeping cash in the hands of ASH longer If it were only me, I could understand it being a one-time issue The complaints I've read and the volume of issues Thacker has makes me believe this is the standard process of handling claims to keep high cash on hand.I still want my issue fixed and Thacker's issues resolved Thank you for your help Regards, [redacted]
March 4, [redacted] , [redacted] ** *** RE: Response to ComplaintFiled with the Revdex.com (Complaint ID [redacted] ) American Specialty Health Group (ASH Group) received your complaintfrom the Revdex.com (Revdex.com) related to your concerns regarding claimsthat have been denied due to an address issueASH Group has researched your complaint and found that there was anerror made on ASH Group’s part that caused the incorrect denial of claims ASH Group’s records show that you submittedthe proper documentation in a timely manner in order to add a new addresslocation Unfortunately, there was amanual error that caused your primary address to be deleted from the ASH Groupsystem Your address has now beenaccurately updated in ASH Group’s system and is reflecting on the websitecorrectly as well ASH Group hasidentified all of the claims that denied in error and has reprocessed thoseclaims for payment Applicable interesthas been applied to claims that required interest to be paid All payments were processed as of 2/27/andpaid to you electronically through Electronic Funds Transfer ASH Group apologizes for the inconvenience this error has caused youand that we were unable to resolve it soonerASH Group appreciates you provding this feedback as we use this type ofinformation and feedback to improve processes to better serve ourcustomers Should you have any questions, please contact me directly at800-972-extension ####Sincerely, [redacted] Senior Manager, OperationsAmerican Specialty Health
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
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] ***
Attached you will find the response to the complainant that was placed in the mail todayThanks April 7, [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 paperResearch 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/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 claimsThe 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 ***.Sincerely, [redacted] Senior Manager, Clinical OperationsAmerican Specialty Health? ?
ASH has worked directly with the complainant and her provider's office to resolve this complaintThe member's employer group was incorrectly loaded into the ASH system with calendar year benefits rather than benefit year This caused denials for maxed benefits that were incorrectASH has corrected this issue and reprocessed claims In addition, ASH has informed the practitioners office who agreed to cease billing the complainant for the claims in questionIf the complainant has any additional concerns, she can contact me directly at [redacted] Thanks
Good afternoon, These concerns were addressed in the initial response and there is no additional information at this time Thank you [redacted]
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.ehis 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/and 6/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/was reprocessed with no deductible on 05/18/under claim number [redacted] The amount paid on this claim is $ · 06/15/was reprocessed under claim number [redacted] with no deductible on 06/28/The resulting payment on this claim was $ · 06/20/reprocessed under claim number [redacted] with no deductible applied on 07/05/ A payment was issued in the amount of $ 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] [redacted] ***
please see attached letter being placed in the mail to the copmlainant todayApril 20, [redacted] ***RE: Response to Better Business Bureau (Revdex.com) Complaint ID # [redacted] Ms***,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, You also expressed concern that claims for similar services had been paid in May and June, 2014, and again in October, 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/for dates of service 5/31/– 6/28/for new patient exam and office visits The submitted request was processed under MNR#and reviewed for DOS 05/31/to 06/28/ The Medical Necessity Review (MNR) Response letter sent to you and copied to Dr [redacted] indicated that 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 evaluationEven though these initial office visits for these dates of service in were approved, the response letter called attention to significant deficiencies in the documentation submittedFor 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/to 08/29/for established patient exam and office visits was submitted The submitted request was processed under MNR# 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/an MNR form requesting DOS 09/01/to 09/29/for established patient exam and office visits, neurological test (electrodiagnostic surface EMG) and 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/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/to 09/29/for established patient exam and 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 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 implausibleOn 12/23/an MNR form requesting DOS 10/02/to 10/27/for established patient exam and 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/to 10/27/for established patient exam and 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 ***.Sincerely, [redacted] Senior Manager, Clinical OperationsAmerican Specialty Health
ASH apologizes for the confusion on the issueWe were not aware that [redacted] had paid the claims ASH does not pay these particular claims directly and is not made aware when they are paid If you have further issues, you are welcome to contact me at [redacted] ext *** Thanks [redacted] Senior Manager, Operations
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 *** Mr [redacted] ’ practitioner, [redacted] **, submitted a request for medical necessity verification on 1/29/ 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/ 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, ***, which is Mr [redacted] ’ health plan, has not delegated ASH for customer serviceTherefore, 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
American Specialty Health received a Revdex.com (Revdex.com) complaint from member [redacted] ***She stated she has two claims on file that have been denied due to a lack of referral from her primary care physician (PCP) to the chiropractor from whom she sought treatmentMs***’s complaint indicates that her chiropractic and radiologist faxed the referral to ASH multiple timesHer attempts to contact American Specialty Health resulted in an inability to locate the referral and a commitment from the agent to follwith her after researching furtherMs [redacted] did not receive the follshe requested and would like to have her two claims approved/paid ASH administers an in-network chiropractic benefit for [redacted] members, including Ms***, but a referral from a PCP must be on file in order to approve claimsASH researched to confirm if a referral was on file for Ms***It was notThe ASH Supervisor mentioned in the complaint reached out to [redacted] ’s Outside Referrals Department on 7/1/and confirmed [redacted] did not have the PCP referral on fileShe then reached out to Ms***’s PCP, Dr [redacted] ***, and left a message requesting she forward the member’s referral to [redacted] ’s Outside Referrals Department [redacted] followed up with [redacted] ’s Outside Referrals Department for a second time on 7/20/and was again advised the referral was not on file ASH escalated the member’s concern to [redacted] ’s Pain Management Coordinator on 7/20/It was identified that [redacted] received follfrom the member’s PCP on 7/11/and the referral was granted [redacted] ’s Outside Referrals Department sent the referral to ASH on 7/22/ASH loaded the referral and reprocessed both claims on file to payThe member will receive payment next week The SrDirector of Claims outreached to the member to apologize for the inconvenience and to advise both claims would be paid to her next week
Ms***’s complaint indicates she is owed $for unreimbursed health club membership costs between January and June, The complaint states that ASH has neither responded to her calls nor acknowledged receipt of the faxed gym membership receipts or attendance logsMs [redacted] stated that she sent all receipts and fitness attendance logs to ASH via email on 3/29/requesting $and to date has only received a check for $on 4/18/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 callShe stated she has received no follow-upMs [redacted] requests the remaining funds ($161.99) be overnighted to herASH administers an Exercise Rewards Program for Empire members, including Ms***Under this program, Ms [redacted] qualifies for gym membership reimbursements up to $per six month periodIn order to receive the $per six month period, Ms [redacted] is required to submit a Gym Reimbursement Request Form as well as gym membership receipts and gym attendance recordsASH is in receipt of Ms***’s July to December Gym Reimbursement Request Form, gym membership receipts and attendance logs as received on 2/9/ASH issued Ms [redacted] reimbursement for the July to December period on 3/7/($79) and 3/21/($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 paymentThe 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 As a result of the additional information, ASH issued $to Ms [redacted] on 4/18/As a result of this complaint, ASH has again reviewed all documents Ms [redacted] providedShe submitted one Gym Reimbursement Form for the July through December period but has not submitted a Gym Reimbursement Form for the period of January through June The submitted fitness attendance logs confirm visits, however, visits are required for reimbursementTo date, Ms*** has not met the visit requirement for the first half of and has not provided a Gym Reimbursement FormMs [redacted] called ASH three regarding the status of her claim for July through December The first call occurred 3/7/16, and as ASH received the claim for July-December on 2/29/16, the member was advised that her claim was in process and could take up to days to complete The second call occurred 3/11/where the member was advised she would receive two checks totaling $and that additional information (gym reimbursement receipts) was required to complete the additional portion of her claimMs [redacted] agreed to submit this information, which was received and reimbursed by ASH on 4/18/($34)The final call on file occurred on 6/14/and Ms [redacted] stated she submitted a claim for $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 follwas completed and the agent has been coached on the process to ensure commitments to members are providedThe SrDirector of Claims reached out to Ms [redacted] on her cell phone on 7/20/to provide her direct contact information and review the reasons she has not received reimbursement for the January through June timeframeThey reviewed the fitness visits ASH has and Ms [redacted] agreed to provide, via direct email to the SrDirector of Claims, the remaining attendance logs and a Gym Reimbursement Form for January through June Upon receipt, the SrDirector of Claims will expedite the claim handling and appropriate reimbursement owed to Ms*** [redacted] SrDirector, ClaimsExt: ***
Revdex.com: I have reviewed the response made by the business in reference to complaint ID [redacted] , and find that this resolution would be mostly satisfactory to me I will wait for the business to perform this action and, if it does, will consider this complaint resolved.I appreciate the company responding and acknowledging their delaysWhat is missing in this response is a commitment to (1) hire more staff or take other action to avoid future delays and (2) improve communication with patients and providers so then know when (or if) medical necessity reviews will be completedI cannot fully accept the resolution until I see the company has indeed committed to such actions Regards, [redacted]
Previously I filed Revdex.com complaint # [redacted] regarding this same issueAmerican Specialty Health Systems, Incsaid 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 $instead of showing $being applied to my deductible and that I owe the $I have since received two more Explanation of Benefits (EOB's) showing I owe $and it will be applied to my deductibleThey did not fix the issue as they claimedI 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 haveAmerican Specialty never contacted [redacted] Chiropractic and they said they fixed my accountI 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 timeI 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 haveThis creates an enormous amount of work for her and her patientsHer extra work causes increased costs in my healthcare
Revdex.com: I have reviewed the response made by the business in reference to complaint ID [redacted] , and find that this resolution would be satisfactory to me I will wait for the business to perform this action and, if it does, will consider this complaint resolved Regards, [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 "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" - As I said in my first complaint [redacted] "Today, 5/9, Blue agreed to conference call with me & my chiropractor, then me & American Specand confirmed to American my deductible had been met Blue Cross call ref # [redacted] Per [redacted] Hat American, she notated her log that my deductible was met She said she couldn't update American's system to show my deductible was met She would not allow Blue Cross and me to speak with anyone who could fix the issue She said I would have to again talk with my chiropractor, then Blue who will take weeks to file a claim then conference call American again which I refused to accept She then said she would submit an "eligibility research" claim, ref # [redacted] to fix my deductible." - This is an attempt by ASH to blame BCBS for not giving them the information.On 5/9/17, ASH was notified my deductible was met I asked for the following resolution: "1) Confirm to me via email my eligibility research claim [redacted] has been resolved to where I will not get erroneous statement any longer 2) Call my chiropractor, Thacker Chiropractic ###-###-####, speak to Melody and resolve the current open billing issues My chiropractor has to pay Melody which in turn causes my office visit rates to increase."ASH's response below on 6/says " 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." I appreciate the apology however, I would more appreciate fixing the issue with my statements and Thacker Chiropractor's open issues.- Again ASH is attempting to blame BCBS for this error they still have not resolved.ASH goes on to say "ASH relies on our health plan partners to provide us the most timely and accurate eligibility and benefits information." However, they were notified I had met my deductible the several times Thacker Chiropractic called them explaining the issue and when Blue Cross and I called them This is the third time ASH tries to blame BCBS when this issue was created by ASH and [redacted] H at ASH did not have the desire to fix my issue.ASH says these following dates have been "reprocessed" meaning a payment was finally made, I received two statements of benefits, one for the wrong charge and one for the corrected charge This is confusing and takes time from both Thacker and me to track down The dates are: "(04/06/17, 04/24/17, 05/02/and most recently 06/08/17)" - Please note, BCBS and I talked with ASH to resolve this on 5/9, ASH responded to my compliant saying the issues have been resolved on 6/ I have since received statements showing my deductible has not been met for 5/11, 6/15, 6/20.My second Revdex.com complaint [redacted] was also closed before I could respond The same ASH answer was givenit was BCBS' fault and it's been fixed It's obviously not fixed and Thacker Chiropractic has not received resolution on their outstanding claims I still believe this should be listed as one complaint per error billed This would be a total of so far.I've contacted ASH with BCBS I've issued two Revdex.com complaints I've been told the issue is fixed twice Yet, I have three more explanations of benefits showing I have to meet my deductible This is a great way for ASH to deny legitimate payments to providers like Thacker keeping cash in the hands of ASH longer If it were only me, I could understand it being a one-time issue The complaints I've read and the volume of issues Thacker has makes me believe this is the standard process of handling claims to keep high cash on hand.I still want my issue fixed and Thacker's issues resolved Thank you for your help Regards, [redacted]
March 4, [redacted] , [redacted] ** *** RE: Response to ComplaintFiled with the Revdex.com (Complaint ID [redacted] ) American Specialty Health Group (ASH Group) received your complaintfrom the Revdex.com (Revdex.com) related to your concerns regarding claimsthat have been denied due to an address issueASH Group has researched your complaint and found that there was anerror made on ASH Group’s part that caused the incorrect denial of claims ASH Group’s records show that you submittedthe proper documentation in a timely manner in order to add a new addresslocation Unfortunately, there was amanual error that caused your primary address to be deleted from the ASH Groupsystem Your address has now beenaccurately updated in ASH Group’s system and is reflecting on the websitecorrectly as well ASH Group hasidentified all of the claims that denied in error and has reprocessed thoseclaims for payment Applicable interesthas been applied to claims that required interest to be paid All payments were processed as of 2/27/andpaid to you electronically through Electronic Funds Transfer ASH Group apologizes for the inconvenience this error has caused youand that we were unable to resolve it soonerASH Group appreciates you provding this feedback as we use this type ofinformation and feedback to improve processes to better serve ourcustomers Should you have any questions, please contact me directly at800-972-extension ####Sincerely, [redacted] Senior Manager, OperationsAmerican Specialty Health
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