December 19, [redacted] ***Revdex.comEast 9th Street Suite 200Cleveland, Ohio 44115-1299Case ID: [redacted] Dear Ms***:I am writing in response to your letter dated December 15, 2014, regarding services rendered to the above member on 8/8/and 8/11/14, by *** [redacted] ***Both claims were originally denied on 9/18/The denial rational: this claim is being denied because prior approval was not completed by your health care professional for this serviceIt will be reviewed on appeal when your health care professional submits the clinical documentation supporting the medical necessity of the serviceSince the processing of the claim could not be completed the services were deniedThe provider may not hold the member liable for the denied chargesThe provider also receives a Remit, which explains clinical documentation is needed for review to determine medical necessity and benefits On 9/29/14, the member contacted Medical Mutual, through her My Health Plan (MHP) account, regarding the claim denials and the member was advised that the provider could not hold her responsible for the denied chargesThis information was correct, based on the above claim denial at that time.Once clinical documentation is received, the claim will be reviewed for medical necessityThe claim will be adjusted for benefits, based on the review determination and plan benefits, which may result in member liabilityOn 10/13/14, Medical Mutual received clinical documentation for reviewFor date of service 8/8/14, claim [redacted] , this claim was reviewed and the services were partially approvedTwo (2) of the lab services were deniedThe denial rational: this patient’s coverage excludes benefits for services or supplies which are experimental or investigative in natureTherefore, we are unable to provide payment for these chargesThe claim was adjusted accordingly and a new Explanation of Benefits (EOB) was issued to the member on 12/11/, which included the member’s appeal rights in the case of an adverse determination For date of service 8/11/14, claim [redacted] , this claim is currently in reviewOnce completed, the member will be notified of the review determinationRegarding the member’s points of contention:Medical Mutual can not address any discussion between the member and their physicianThe lab services performed are related to Gene Analysis, which is listed under Other Procedures/Services on the Prior Approval and Investigational Services listThe member has access to the list through her MHP accountThe reason why the member was told she had no liability and why she received a new EOB is addressed aboveAttached are the EOBs, Prior Approval list and Certificate of CoveragePlease refer to Exclusion in the CertificateIf you have any questions regarding this issue, please don’t hesitate to contact me Sincerely, [redacted] , Appeal Specialist IIMember Appeals departmentFax 216.687.7990Attachments
Revdex.com: I have reviewed the response made by the business in reference to complaint ID [redacted] , and have determined that this does not resolve my complaint For your reference, details of the offer I reviewed appear below It is obvious that Medical Mutual of Ohio has no intent to honor its contractual obligations or do what is honorable and moralHowever, I am responding to this matter in writing to insure that there is no misunderstanding that I do not agree with their response based upon the information I previously provided Furthermore, I wanted it to be noted that if Revdex.com closes this matter that is not because Medical Mutual has resolved the matter, a point I wish to make known for other consumers who might read this complaintAs a short concluding statement, I object to the handling of this matter by Medical Mutual of Ohio:First, Medical Mutual did knowingly state there was no liabilityThen when I informed them multiple times that I would seek to have the matter reviewed on behalf of the provider, Medical Mutual knowingly and with bad faith failed to state that by doing so I may become liable for services that I was not liable, Only Medical Mutual of Ohio had knowledge that by me requesting my provider to provide medical documents that I would take matter from a contractual issue with the provider and Medical Mutual to a matter now between the subscriber and Medical MutualSecond, Medical Mutual continues to inaccurately state the language in their contract which does not in state that Gene Analysis (en banc) is excludedRather it specifically state that certain Gene Analysis required prior approval Other services with respect to Gene Analysis is silentTherefore, again under generally accepted legal principles that contracts are construed first specificity and then against the drafter, the contract is to be read as not requiring prior approval for these servicesThird, Medical Mutual continues to state that its' interpretation in accordance with "their" internal standards Their simple argument is that the services were not medically necessary because Medical Mutual states it is not medically necessaryThat fails to answer the question of why Medical Mutual decided it was not medically necessary Despite multiple requests to know what those internal standards or procedures and/or facts used for this determination, Medical Mutual has yet to provide such Regards, [redacted]
Revdex.com: I have reviewed the response made by the business in reference to complaint ID [redacted] , and have determined that this does not resolve my complaint For your reference, details of the offer I reviewed appear belowThere are several points of contention regarding the business responseFirst, with respect to facts of this matter, there are several points of accuracy and contention It was I as the member who asked my physician to file paperwork to have this matter reviewed The provider, [redacted] did NOT file an appeal Rather it was only upon my request that my provider sent information to Medical Mutual of Ohio I was informed that I would have NO liability for the claimI was not informed that by my requesting my provider send information in to Medical Mutual that I would NOW incur liability, I relied on Medical Mutual of Ohio telling me that there was no liability, If I had known that by my requesting that physician send in information for Medical Review, I would not have requested such information be provided I believe that Medical Mutual of Ohio should have first informed me that I had no liability Second, if they were informed that I would be contacting my physician to get the medical information and let me proceed to do so when knowing that by doing so I would NOW have liability for the claimSecond, it accordance to my rights under the Member Rights, I have requested multiple times documentation that was submitted between the provider, physician and Medical MutualThis has been refused I am hereby requesting Medical Mutual honor their obligation to provide me this information and without delayRefusal to deny such documentation is hindering my right to file accurate prepare and file an appeal with sufficient informationLastly, in accordance with my Certificate of Coverage, I am entitled to specific information that was used in terms of protocol used by the Medical Reviewer to determine medical necessityThe EOB and paperwork provided here fails to follow the dictates set forth in the Certificate of CoverageWith respect to the last two points must be rectified promptly and completely to protect my rights of appeal through Medical Mutual, external review and subsequently through Department of Insurance as well as subsequent action that maybe afforded to me under the lawOnce the last two points are addressed, I can adequately respond to why the services were not experimental or investigatory As someone who has previously suffered subsequent vision loss as well as previously have been diagnosed with probable MS, optic neuritis and have both symptoms and clinical evidence that supports the conducting of these test, I believe knowing what was used by the Medical Reviewer I can repute and therefore demonstrate medical necessity and that such services are not experimental or investigatoryTime is of the essence as I have increasing vision lost (I am blind in one eye already) Regards [redacted]
May 8, 2015Nichole MeansRevdex.comEast 9th Street Suite 200Cleveland, Ohio 44115-1299Case ID: [redacted] Dear [redacted] ***:I am writing in response to your letter dated May 5, 2015, and the member’s additional concernsAttached is the renewal packet dated 10/14/14, sent to the memberThe letter does state that the member will automatically be enrolled in the MedMutual Classic Silver plan to make sure there is not a gap in coverageThe letter also states to please review your new premium and benefits below to see if this plan meets your needsPage seven (7) shows the deductible amount for single and family coverage on the Individual Product Plan chart for the Silver planAll plans are called/named using the single deductible amountThe maximum family network deductible of $7,per benefit period did not change from to However, the accumulation method did change from embedded to aggregate, as explained in the renewal documents and the response sent to the Revdex.com on 4/23/If you have any questions regarding this issue, please don’t hesitate to contact me Sincerely, [redacted] , Appeal Specialist IIMember Appeals departmentFax [redacted] Attachment
December 31, 2014*** ***Revdex.comEast 9th Street Suite 200Cleveland, Ohio 44115-1299Case ID: *** *** ***Provider: *** *** *** Reference LabDate of Service(s): 8/8/14, 8/11/14Claim(s): ***, ***Dear Ms***:I am writing in response to your letter dated December 22, 2014, regarding the member’s additional comments and points of contention.First point of contention:On 10/1/14, when Medical Mutual received the request for review, the member may have contacted the provider to request that they submit documents for review, but there was no letter from the member requesting a review or appealTherefore, this was reviewed as the provider’s first level of appeal. As previously stated, on 9/29/14, the member contacted Medical Mutual, through her My Health Plan (MHP) account, regarding the claim denials and the member was advised that the provider could not hold her responsible for the denied chargesThis information was correct at that time based on the claim denial. Customer Care Specialists can not guarantee that there will be no member liability if a claim denial is reviewed with medical recordsThis type of information is only determined after the review has been completed and the claim has been adjusted in accordance with the plan benefitsIn reviewing the member’s calls and MHP emails, it appears that this issue was not questioned or addressed. Customer Care Specialists can not tell a member or provider not to proceed with a review and deny them of their right to a full and fair review. Second and third points of contention:Regarding the member’s request for documents and rights, the member is referring to her rights as described in the Certificate of Coverage under Filing an Internal Appeal or External Review and the section on the Explanation of Benefits, which explains what to do if you disagree with a decision and want to appeal.Once the member has filed an appeal, and if the denial for benefits has been upheld, the member will be notified of their additional appeal rights and of their right to request documents related to the review determinationSince the member has not completed the mandatory first level of appeal, and a determination has not been made, documents are not available. If you have any questions regarding this issue, please don’t hesitate to contact me. Sincerely,*** ***, Appeal Specialist IIMember Appeals departmentFax
January 16, 2015*** ***Revdex.comEast 9th Street Suite 200Cleveland, Ohio 44115-1299Case ID: *** *** ***Provider: *** *** *** Reference LabDate of Service(s): 8/8/14, 8/11/14Claim(s): ***, ***Dear Ms***:I am writing in response to your letter dated January 13, 2015, regarding the member’s additional comments. On 9/10/14, 9/29/14, 10/1/and 10/2/14, the Customer Care Specialists (CCS) did provide the member with the correct information, that she was not liable for the denied charges, based on the claim denial issued on 9/18/14, which stated: this claim is being denied because prior approval was not completed by your health care professional for this serviceIt will be reviewed on appeal when your health care professional submits the clinical documentation supporting the medical necessity of the serviceMedical Mutual is not denying this fact and it was accurate at that time, which was prior to receiving documentation for review. Prior to a reviewing a denied claim for payment the CCS can not predict the review determination and/or determine member liabilityAs previously stated this type of information is only determined after the review has been completed and the claim has been adjusted in accordance with the plan benefits. Regarding prior approval, the description of the lab procedures performed includes hereditary gene analysisGenetic testing for inherited disorders does require prior approvalThis in listed in the Prior Approval and Investigational Services list under Medical/Surgical/DiagnosticIn this case the health care provider who reviewed the services determined that the services were experimental or investigative in natureTherefore, benefits are not available. In the Certificate of Coverage under Exclusions, benefits are excluded for services that are: Not Medically Necessary or do not meet Medical Mutual's policy, clinical coverage guidelines, or benefit policy guidelines.For Experimental or Investigational drugs, devices, medical treatments or procedures, except as specified.In the Certificate of Coverage under Right to Review Claims it states:When a claim is submitted, Medical Mutual will review the claim to ensure that the service was medically necessary and that all other conditions for coverage are satisfiedThe fact that a provider may recommend or prescribe treatment does not mean that it is automatically a covered service or that it is medically necessaryAs part of its review, Medical Mutual may refer to corporate medical policies developed by Medical Mutual (that may be obtained at Medical Mutual's website) as guidelines to assist in reviewing claims. Attached is the Certificate of CoverageIf you have any questions, please don’t hesitate to contact me. Sincerely,*** ***, Appeal Specialist IIMember Appeals departmentFax
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID ***, and have determined that this does not resolve my complaint. For your reference, details of the offer I reviewed appear below
[To assist us in bringing this matter to a close, we would like to know your view on the matter.]Medical Mutual admits to submitting a fax stating no pre-authorization was required on a CT scan. No request was ever made for a CT scan, however, Medical Mutuals issuance of this letter is what started the entire confusion process. Medical Mutual has declined to state (when asked repeatedly) why they issued this letter in the first place causing the confusion it has. I NEVER received this notice, it went to my medical provider, who told me to get the test done as it did not require pre-authorization. I would never have submitted to the test had I known this.Medical Mutual also states the request was denied due to "Not completing a full course of conservative treatment." This includes: "Four weeks of participating in physical therapy and/OR a home exercise program." "Stopping or limiting the activities that caused the pain." "The use of anti-inflamatory medication."In response:I did limit myself to home treatment due to the high costs of having to attend physical therapy. This treatment consisted of but was not limited to, light stretches, applying cold compresses to attempt to reduce EXCESSIVE swelling, and light leg exercises. Compression bandages were also applied to attempt to dissipate the large fluid build up that was present.2. This injury was sustained during martial arts training. I was UNABLE to participate in training for several weeks due to the injury. When I returned to training, I was still very limited on my participation due to the pain and swelling. As of today (November 17, 2014), my training is still more limited due to current pain in the knee.3. At my request, I did not want a prescription anti-inflamatory. I have taken Naproxen in the past, and it causes stomach issues with me. Instead, I took an over the counter ibuprofen to help with the inflammation.None of these eliminated the issue in the knee I had then and am still having today. There was serious concern of knee damage to the joints and/or possibly MCL and/or ACL. Medical Mutual states in their reply, "The provider may not hold the member liable for the denied charges." When I went for the MRI, I was REQUIRED to sign a letter of NNC (Notice of Non-Compliance). Since Medical Mutual issued the fax stating no pre-authorization was required, and I was told by my medical provider to get the test and no authorization number was issued, I reluctantly signed it in good faith Medical Mutual would not come back and do exactly what I am going through now. In short, I AM being held liable for the denied chargesIn Medical Mutuals reply to this complaint, MsMeyers states, "A letter was issued to the provider on 9-17-14. The provider has days from the receipt of this letter to request an additional level of appeal." I was NEVER told of this, and want to exercise the right to file this additional level of appeal. I am requesting to know how I can do this from Medical Mutual
Regards,
*** ***
April 29, 2015[redacted]Revdex.com2217 East 9th Street Suite 200Cleveland, Ohio 44115-1299Case ID: [redacted]:I am writing in response to your letter dated April 21, 2015, regarding the member’s request for a 7/1/14, policy termination date and premium...
refund for July and August 2014. This member had the Standard Market HSA 8000 Bronze family plan. On 12/21/13, Medical Mutual received the Exchange application for the policy to be effective 1/1/14. The monthly premium cost, including Federally Mandated Fees, was $990.31. The member received a monthly subsidy of $777.00 and the member’s monthly premium cost was $213.31. On 8/13/14, Medical Mutual received the member’s request to cancel her policy effective 8/13/14. On 8/14/14, the attached letter was issued to the member that stated that she needed to contact the Exchange to cancel her policy. On 8/22/14, Medical Mutual received notice from the Exchange to cancel the policy 9/4/14, and the policy was cancelled 9/4/14. The member contacted Medical Mutual on several occasions regarding this issue. Due to new guidelines established by the Centers for Medicare and Medicaid Services (CMS) issuers are now permitted to terminate a policy back to the date on the Exchange notice. The notice from the Exchange that was received on 8/22/14, was dated 8/20/14. Therefore, the member’s policy was cancelled 8/19/14. Medical Mutual does not have the flexibility to adjust the 8/19/14, termination date. The member does have appeal rights with the Exchange. The member may contact healthcare.gov or call 800.[redacted] to request an appeal. If approved, the Exchange will notify Medical Mutual. On 4/13/15, the member was refunded $82.57 for the unearned portion of the August premium. No additional refund is due. I apologize to Ms. Armocida for the incorrect information she received and for any inconvenience this issue has caused. Attached are the Exchange documents. If you have any questions regarding this issue, please don’t hesitate to contact me. Sincerely,[redacted], Appeal Specialist IIMember Appeals departmentAttachments
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that this does not resolve my complaint. For your reference, details of the offer I reviewed appear below. There are several points of contention regarding the business response. First, with respect to facts of this matter, there are several points of accuracy and contention. It was I as the member who asked my physician to file paperwork to have this matter reviewed. The provider, [redacted] did NOT file an appeal. Rather it was only upon my request that my provider sent information to Medical Mutual of Ohio. I was informed that I would have NO liability for the claim. I was not informed that by my requesting my provider send information in to Medical Mutual that I would NOW incur liability, I relied on Medical Mutual of Ohio telling me that there was no liability, If I had known that by my requesting that physician send in information for Medical Review, I would not have requested such information be provided. I believe that Medical Mutual of Ohio should have first informed me that I had no liability. Second, if they were informed that I would be contacting my physician to get the medical information and let me proceed to do so when knowing that by doing so I would NOW have liability for the claim. Second, it accordance to my rights under the Member Rights, I have requested multiple times documentation that was submitted between the provider, physician and Medical Mutual. This has been refused. I am hereby requesting Medical Mutual honor their obligation to provide me this information and without delay. Refusal to deny such documentation is hindering my right to file accurate prepare and file an appeal with sufficient information. Lastly, in accordance with my Certificate of Coverage, I am entitled to specific information that was used in terms of protocol used by the Medical Reviewer to determine medical necessity. The EOB and paperwork provided here fails to follow the dictates set forth in the Certificate of Coverage. With respect to the last two points must be rectified promptly and completely to protect my rights of appeal through Medical Mutual, external review and subsequently through Department of Insurance as well as subsequent action that maybe afforded to me under the law. Once the last two points are addressed, I can adequately respond to why the services were not experimental or investigatory. As someone who has previously suffered subsequent vision loss as well as previously have been diagnosed with probable MS, optic neuritis and have both symptoms and clinical evidence that supports the conducting of these test, I believe knowing what was used by the Medical Reviewer I can repute and therefore demonstrate medical necessity and that such services are not experimental or investigatory. Time is of the essence as I have increasing vision lost (I am blind in one eye already).
Regards
[redacted]
December 19, 2014[redacted]Revdex.com2217 East 9th Street Suite 200Cleveland, Ohio 44115-1299Case ID: [redacted]Dear Ms. [redacted]:I am writing in response to your letter dated December 9, 2014, regarding the member’s application for the HSA 6000 Bronze policy....
Although the member states she did not finish the application process, Medical Mutual did receive the member’s application on 12/1/14, for health, vision and dental coverage. The premium payment for $513.86 was deducted from the member’s account based on the information provided on the application. On 12/2/14, the member contact Medical Mutual to notify us that she did not want the coverage and requested a refund. According to our records the member was not advised that they would receive a refund within 1 day and the appropriate department was notified to initiate the refund.Premium payments can not be refunded until 14 days after the deduction. This gives the bank time to notify Medical Mutual if a check comes back rejected for any reason. On 12/8/14, the member was notified that the refund was in process. Medical Mutual does not reimburse for overdraft fees and a refund for $513.86 was issued to the member on 12/17/14. If you have any questions regarding this issue, please don’t hesitate to contact me. Sincerely,[redacted], Appeal Specialist IIMember Appeals departmentFax 216.687.7990
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that this does not resolve my complaint. For your reference, details of the offer I reviewed appear below.
It is obvious that Medical Mutual of Ohio has no intent to honor its contractual obligations or do what is honorable and moral. However, I am responding to this matter in writing to insure that there is no misunderstanding that I do not agree with their response based upon the information I previously provided. Furthermore, I wanted it to be noted that if Revdex.com closes this matter that is not because Medical Mutual has resolved the matter, a point I wish to make known for other consumers who might read this complaint. As a short concluding statement, I object to the handling of this matter by Medical Mutual of Ohio:First, Medical Mutual did knowingly state there was no liability. Then when I informed them multiple times that I would seek to have the matter reviewed on behalf of the provider, Medical Mutual knowingly and with bad faith failed to state that by doing so I may become liable for services that I was not liable, Only Medical Mutual of Ohio had knowledge that by me requesting my provider to provide medical documents that I would take matter from a contractual issue with the provider and Medical Mutual to a matter now between the subscriber and Medical Mutual. Second, Medical Mutual continues to inaccurately state the language in their contract which does not in state that Gene Analysis (en banc) is excluded. Rather it specifically state that certain Gene Analysis required prior approval. Other services with respect to Gene Analysis is silent. Therefore, again under generally accepted legal principles that contracts are construed first specificity and then against the drafter, the contract is to be read as not requiring prior approval for these services. Third, Medical Mutual continues to state that its' interpretation in accordance with "their" internal standards. Their simple argument is that the services were not medically necessary because Medical Mutual states it is not medically necessary. That fails to answer the question of why Medical Mutual decided it was not medically necessary. Despite multiple requests to know what those internal standards or procedures and/or facts used for this determination, Medical Mutual has yet to provide such.
Regards,
[redacted]
April 23, 2015[redacted]Revdex.com2217 East 9th Street Suite 200Cleveland, Ohio 44115-1299Case ID: [redacted]Dear [redacted]:I am writing in response to your letter dated April 21, 2015, regarding the member’s 2015 plan benefits.For 2014 the member had the Classic 3500 Silver...
family plan. The member had a $3,500.00 single deductible and a $7,000.00 family deductible. The accumulation method for the deductible was embedded, which means, claims will begin paying for a given member of a family when he or she meets their single deductible and/or when more than one family member combined meets the family deductible. Effective 1/1/15, the member has the Silver Classic 3500/7000 family plan. For a single plan the deductible is $3,500.00 and for the family plan the deductible is $7,000.00. The 2015 plan has an aggregate deductible accumulation, which means, the entire family deductible must be met before benefits are provided for any family member on a family plan. Page two (2) of the 2015 renewal packet the member received explained the changes to the plan. Regarding benefit changes it states: deductible accumulation is being changed. The entire family deductible must be met before benefits are paid by the carrier (for any family members) on a family policy. Medical Mutual can not offer the member the same plan they had in 2014, since this plan is no longer available and we do not offer discounted rates for new plans. Attached are the 2015 renewal packet and the 2014 and 2015 Certificates of Coverage. Please refer to the Summary of Benefits in the Certificates which explain the deductible accumulations. If you have any questions regarding this issue, please don’t hesitate to contact me. Sincerely,[redacted], Appeal Specialist IIMember Appeals departmentFax 216.[redacted]Attachments
December 19, 2014[redacted]Revdex.com2217 East 9th Street Suite 200Cleveland, Ohio 44115-1299Case ID: [redacted]Dear Ms. [redacted]:I am writing in response to your letter dated December 15, 2014, regarding services rendered to the above member on 8/8/14 and 8/11/14, by [redacted]...
[redacted]. Both claims were originally denied on 9/18/14. The denial rational: this claim is being denied because prior approval was not completed by your health care professional for this service. It will be reviewed on appeal when your health care professional submits the clinical documentation supporting the medical necessity of the service. Since the processing of the claim could not be completed the services were denied. The provider may not hold the member liable for the denied charges. The provider also receives a Remit, which explains clinical documentation is needed for review to determine medical necessity and benefits. On 9/29/14, the member contacted Medical Mutual, through her My Health Plan (MHP) account, regarding the claim denials and the member was advised that the provider could not hold her responsible for the denied charges. This information was correct, based on the above claim denial at that time.Once clinical documentation is received, the claim will be reviewed for medical necessity. The claim will be adjusted for benefits, based on the review determination and plan benefits, which may result in member liability. On 10/13/14, Medical Mutual received clinical documentation for review. For date of service 8/8/14, claim [redacted], this claim was reviewed and the services were partially approved. Two (2) of the lab services were denied. The denial rational: this patient’s coverage excludes benefits for services or supplies which are experimental or investigative in nature. Therefore, we are unable to provide payment for these charges. The claim was adjusted accordingly and a new Explanation of Benefits (EOB) was issued to the member on 12/11/14. , which included the member’s appeal rights in the case of an adverse determination. For date of service 8/11/14, claim [redacted], this claim is currently in review. Once completed, the member will be notified of the review determination. Regarding the member’s points of contention:Medical Mutual can not address any discussion between the member and their physician. The lab services performed are related to Gene Analysis, which is listed under Other Procedures/Services on the Prior Approval and Investigational Services list. The member has access to the list through her MHP account. The reason why the member was told she had no liability and why she received a new EOB is addressed above. Attached are the EOBs, Prior Approval list and Certificate of Coverage. Please refer to Exclusion 5 in the Certificate. If you have any questions regarding this issue, please don’t hesitate to contact me. Sincerely,[redacted], Appeal Specialist IIMember Appeals departmentFax 216.687.7990Attachments
December 11, 2014[redacted]Dispute Resolution SpecialistRevdex.com2800 Euclid Avenue, Fourth FloorCleveland, Ohio 44115-2408Case: [redacted]Dear Ms. [redacted]:I am writing in response to your request for instructions on how to file an appeal. The member must send a letter that clearly describes their reasons for appealing a decision, including documentation to support their request. They should mail or fax the appeal to: Medical Mutual Member Appeals department MZ: 01-4B-4809 P.O. Box 94580 Cleveland, OH 44101-4580 Fax: 216.687.7990 or 866.691.8260If you have any questions, please don’t hesitate to contact me.Sincerely,[redacted], Appeals Specialist IIMember Appeals departmentFax 216.687.7990
November 14, 2014
[redacted]
Dispute Resolution Specialist
Revdex.com
2800 Euclid Avenue, Fourth Floor
Cleveland, Ohio 44115-2408
Case: [redacted]
Dear Ms. [redacted]:
I am writing in response to your letter dated November 10, regarding MRI services rendered to...
the above member on 3/19/14, at Bethesda Hospital.
On 3/17/14, Dr. [redacted] submitted a prior authorization request. The fax transmission sheet noted the request was for a CT scan. On 3/18/14, the provider was notified that CT scans do not require prior authorization and a review was initiated for the MRI. Based on the medical documentation received, the reviewer determined that the service was not medically necessary. A denial letter was issued to the member and provider on 3/19/14.
On 8/18/14, Medical Mutual received the provider’s request for a first level of appeal. The request was denied. The denial rational: your patient sought treatment for his left knee pain. The information provided does not show that he completed a full course of conservative treatment. Conservative treatment consists of at least four weeks of participating in physical therapy and/or a home exercise program, stopping or limiting the activities that cause the pain along with the use of an anti-inflammatory medication. There were no test provided, such as a McMurray or Lachman’s, showing any looseness of the knee on the physical examination. A response was issued to the member and provider on 9/17/14. The provider has 60 days from receipt of this letter to request an additional level of appeal.
The provider may not hold the member liable or the denied charges. If the member is receiving a balance due notice, he should complete the attached Member Action Request form and submit a copy of the billing notice to the address indicated on the form. The appropriate department will contact the provider.
If you have any questions, please don’t hesitate to contact me.
Sincerely,[redacted], Appeals Specialist II
Member Appeals department
Fax 216.687.7990
November 14, 2014
[redacted]
Dispute Resolution Specialist
Revdex.com
2800 Euclid Avenue, Fourth Floor
Cleveland, Ohio 44115-2408
Case: [redacted]
Dear Ms. [redacted]:
I am writing in response to your letter dated November 10, regarding prescription benefits for...
the above member.
Effective 5/1/14, this member has group coverage through First Network Group. In accordance with the terms of the contract, Schedule of Benefits, if your prescription drug order is for a prescription drug that is available through the Home Delivery Prescription Drug program and you choose not to use the Home Delivery Prescription Drug program, you will be required to pay two times the appropriate copayment or coinsurance shown when your prescription order is filled beyond the third time within a 180-day period.
The member utilized the Home Delivery program, for a 90 days supply of her medication, on 6/23/14 and 10/2/14. The member is responsible for the $60.00 copayment applied to each claim. The member does have the freedom of choice and is not required to use the Home Delivery program, but they will be subject to the increased copayment.
Regarding the manufacture of the medication, this may change due to contracted rate negotiations with the manufacturer(s) of a product, availability of a medication, and market competitiveness. The member should contact Express Scripts to discuss options available to her.
Attached is the member’s Certificate of Coverage. If you have any questions, please don’t hesitate to contact me.
Sincerely,
[redacted], Appeals Specialist II
Member Appeals department
Fax 216.687.7990
May 8, 2015Nichole MeansRevdex.com2217 East 9th Street Suite 200Cleveland, Ohio 44115-1299Case ID: [redacted]Dear [redacted]:I am writing in response to your letter dated May 5, 2015, and the member’s additional concerns. Attached is the renewal packet dated 10/14/14, sent to the member. The letter does state that the member will automatically be enrolled in the MedMutual Classic 3500 Silver plan to make sure there is not a gap in coverage. The letter also states to please review your new premium and benefits below to see if this plan meets your needs. Page seven (7) shows the deductible amount for single and family coverage on the Individual Product Plan chart for the 3500 Silver plan. All plans are called/named using the single deductible amount. The maximum family network deductible of $7,000.00 per benefit period did not change from 2014 to 2015. However, the accumulation method did change from embedded to aggregate, as explained in the renewal documents and the response sent to the Revdex.com on 4/23/15. If you have any questions regarding this issue, please don’t hesitate to contact me. Sincerely,[redacted], Appeal Specialist IIMember Appeals departmentFax [redacted]Attachment
I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that this does not resolve my complaint. For your reference, details of the offer I reviewed appear below.As [redacted] noted, the letter I received from Medical
Mutual stated that I would be automatically enrolled in the MedMutual Classic
Silver plan (which was the same name as my existing plan which had a $
deductible), yet the apparently has no meaning as the plan I received has
a $deductibleWhat does the stand for in a family plan?
If my benefit were being cut in half, as it was, I would
have expected a clear explanation of how my new plan was different than my
existing plan, yet there was no mention of it in the letter but rather the large
difference between the plans was listed as a footnote to a table on the last
page
In short, I feel the
name of the plan was deceptive and led me to believe that I would be enrolled
in a similar plan to my existing plan called by the same name, and rather than
describing clearly the differences between the two plans in the letter I was
sent, the cut in benefits was listed as a footnote to a table on the last page
Regards,
[redacted]
December 19, [redacted] ***Revdex.comEast 9th Street Suite 200Cleveland, Ohio 44115-1299Case ID: [redacted] Dear Ms***:I am writing in response to your letter dated December 15, 2014, regarding services rendered to the above member on 8/8/and 8/11/14, by *** [redacted] ***Both claims were originally denied on 9/18/The denial rational: this claim is being denied because prior approval was not completed by your health care professional for this serviceIt will be reviewed on appeal when your health care professional submits the clinical documentation supporting the medical necessity of the serviceSince the processing of the claim could not be completed the services were deniedThe provider may not hold the member liable for the denied chargesThe provider also receives a Remit, which explains clinical documentation is needed for review to determine medical necessity and benefits On 9/29/14, the member contacted Medical Mutual, through her My Health Plan (MHP) account, regarding the claim denials and the member was advised that the provider could not hold her responsible for the denied chargesThis information was correct, based on the above claim denial at that time.Once clinical documentation is received, the claim will be reviewed for medical necessityThe claim will be adjusted for benefits, based on the review determination and plan benefits, which may result in member liabilityOn 10/13/14, Medical Mutual received clinical documentation for reviewFor date of service 8/8/14, claim [redacted] , this claim was reviewed and the services were partially approvedTwo (2) of the lab services were deniedThe denial rational: this patient’s coverage excludes benefits for services or supplies which are experimental or investigative in natureTherefore, we are unable to provide payment for these chargesThe claim was adjusted accordingly and a new Explanation of Benefits (EOB) was issued to the member on 12/11/, which included the member’s appeal rights in the case of an adverse determination For date of service 8/11/14, claim [redacted] , this claim is currently in reviewOnce completed, the member will be notified of the review determinationRegarding the member’s points of contention:Medical Mutual can not address any discussion between the member and their physicianThe lab services performed are related to Gene Analysis, which is listed under Other Procedures/Services on the Prior Approval and Investigational Services listThe member has access to the list through her MHP accountThe reason why the member was told she had no liability and why she received a new EOB is addressed aboveAttached are the EOBs, Prior Approval list and Certificate of CoveragePlease refer to Exclusion in the CertificateIf you have any questions regarding this issue, please don’t hesitate to contact me Sincerely, [redacted] , Appeal Specialist IIMember Appeals departmentFax 216.687.7990Attachments
Revdex.com: I have reviewed the response made by the business in reference to complaint ID [redacted] , and have determined that this does not resolve my complaint For your reference, details of the offer I reviewed appear below It is obvious that Medical Mutual of Ohio has no intent to honor its contractual obligations or do what is honorable and moralHowever, I am responding to this matter in writing to insure that there is no misunderstanding that I do not agree with their response based upon the information I previously provided Furthermore, I wanted it to be noted that if Revdex.com closes this matter that is not because Medical Mutual has resolved the matter, a point I wish to make known for other consumers who might read this complaintAs a short concluding statement, I object to the handling of this matter by Medical Mutual of Ohio:First, Medical Mutual did knowingly state there was no liabilityThen when I informed them multiple times that I would seek to have the matter reviewed on behalf of the provider, Medical Mutual knowingly and with bad faith failed to state that by doing so I may become liable for services that I was not liable, Only Medical Mutual of Ohio had knowledge that by me requesting my provider to provide medical documents that I would take matter from a contractual issue with the provider and Medical Mutual to a matter now between the subscriber and Medical MutualSecond, Medical Mutual continues to inaccurately state the language in their contract which does not in state that Gene Analysis (en banc) is excludedRather it specifically state that certain Gene Analysis required prior approval Other services with respect to Gene Analysis is silentTherefore, again under generally accepted legal principles that contracts are construed first specificity and then against the drafter, the contract is to be read as not requiring prior approval for these servicesThird, Medical Mutual continues to state that its' interpretation in accordance with "their" internal standards Their simple argument is that the services were not medically necessary because Medical Mutual states it is not medically necessaryThat fails to answer the question of why Medical Mutual decided it was not medically necessary Despite multiple requests to know what those internal standards or procedures and/or facts used for this determination, Medical Mutual has yet to provide such Regards, [redacted]
Revdex.com: I have reviewed the response made by the business in reference to complaint ID [redacted] , and have determined that this does not resolve my complaint For your reference, details of the offer I reviewed appear belowThere are several points of contention regarding the business responseFirst, with respect to facts of this matter, there are several points of accuracy and contention It was I as the member who asked my physician to file paperwork to have this matter reviewed The provider, [redacted] did NOT file an appeal Rather it was only upon my request that my provider sent information to Medical Mutual of Ohio I was informed that I would have NO liability for the claimI was not informed that by my requesting my provider send information in to Medical Mutual that I would NOW incur liability, I relied on Medical Mutual of Ohio telling me that there was no liability, If I had known that by my requesting that physician send in information for Medical Review, I would not have requested such information be provided I believe that Medical Mutual of Ohio should have first informed me that I had no liability Second, if they were informed that I would be contacting my physician to get the medical information and let me proceed to do so when knowing that by doing so I would NOW have liability for the claimSecond, it accordance to my rights under the Member Rights, I have requested multiple times documentation that was submitted between the provider, physician and Medical MutualThis has been refused I am hereby requesting Medical Mutual honor their obligation to provide me this information and without delayRefusal to deny such documentation is hindering my right to file accurate prepare and file an appeal with sufficient informationLastly, in accordance with my Certificate of Coverage, I am entitled to specific information that was used in terms of protocol used by the Medical Reviewer to determine medical necessityThe EOB and paperwork provided here fails to follow the dictates set forth in the Certificate of CoverageWith respect to the last two points must be rectified promptly and completely to protect my rights of appeal through Medical Mutual, external review and subsequently through Department of Insurance as well as subsequent action that maybe afforded to me under the lawOnce the last two points are addressed, I can adequately respond to why the services were not experimental or investigatory As someone who has previously suffered subsequent vision loss as well as previously have been diagnosed with probable MS, optic neuritis and have both symptoms and clinical evidence that supports the conducting of these test, I believe knowing what was used by the Medical Reviewer I can repute and therefore demonstrate medical necessity and that such services are not experimental or investigatoryTime is of the essence as I have increasing vision lost (I am blind in one eye already) Regards [redacted]
May 8, 2015Nichole MeansRevdex.comEast 9th Street Suite 200Cleveland, Ohio 44115-1299Case ID: [redacted] Dear [redacted] ***:I am writing in response to your letter dated May 5, 2015, and the member’s additional concernsAttached is the renewal packet dated 10/14/14, sent to the memberThe letter does state that the member will automatically be enrolled in the MedMutual Classic Silver plan to make sure there is not a gap in coverageThe letter also states to please review your new premium and benefits below to see if this plan meets your needsPage seven (7) shows the deductible amount for single and family coverage on the Individual Product Plan chart for the Silver planAll plans are called/named using the single deductible amountThe maximum family network deductible of $7,per benefit period did not change from to However, the accumulation method did change from embedded to aggregate, as explained in the renewal documents and the response sent to the Revdex.com on 4/23/If you have any questions regarding this issue, please don’t hesitate to contact me Sincerely, [redacted] , Appeal Specialist IIMember Appeals departmentFax [redacted] Attachment
December 31, 2014*** ***Revdex.comEast 9th Street Suite 200Cleveland, Ohio 44115-1299Case ID: *** *** ***Provider: *** *** *** Reference LabDate of Service(s): 8/8/14, 8/11/14Claim(s): ***, ***Dear Ms***:I am writing in response to your letter dated December 22, 2014, regarding the member’s additional comments and points of contention.First point of contention:On 10/1/14, when Medical Mutual received the request for review, the member may have contacted the provider to request that they submit documents for review, but there was no letter from the member requesting a review or appealTherefore, this was reviewed as the provider’s first level of appeal. As previously stated, on 9/29/14, the member contacted Medical Mutual, through her My Health Plan (MHP) account, regarding the claim denials and the member was advised that the provider could not hold her responsible for the denied chargesThis information was correct at that time based on the claim denial. Customer Care Specialists can not guarantee that there will be no member liability if a claim denial is reviewed with medical recordsThis type of information is only determined after the review has been completed and the claim has been adjusted in accordance with the plan benefitsIn reviewing the member’s calls and MHP emails, it appears that this issue was not questioned or addressed. Customer Care Specialists can not tell a member or provider not to proceed with a review and deny them of their right to a full and fair review. Second and third points of contention:Regarding the member’s request for documents and rights, the member is referring to her rights as described in the Certificate of Coverage under Filing an Internal Appeal or External Review and the section on the Explanation of Benefits, which explains what to do if you disagree with a decision and want to appeal.Once the member has filed an appeal, and if the denial for benefits has been upheld, the member will be notified of their additional appeal rights and of their right to request documents related to the review determinationSince the member has not completed the mandatory first level of appeal, and a determination has not been made, documents are not available. If you have any questions regarding this issue, please don’t hesitate to contact me. Sincerely,*** ***, Appeal Specialist IIMember Appeals departmentFax
January 16, 2015*** ***Revdex.comEast 9th Street Suite 200Cleveland, Ohio 44115-1299Case ID: *** *** ***Provider: *** *** *** Reference LabDate of Service(s): 8/8/14, 8/11/14Claim(s): ***, ***Dear Ms***:I am writing in response to your letter dated January 13, 2015, regarding the member’s additional comments. On 9/10/14, 9/29/14, 10/1/and 10/2/14, the Customer Care Specialists (CCS) did provide the member with the correct information, that she was not liable for the denied charges, based on the claim denial issued on 9/18/14, which stated: this claim is being denied because prior approval was not completed by your health care professional for this serviceIt will be reviewed on appeal when your health care professional submits the clinical documentation supporting the medical necessity of the serviceMedical Mutual is not denying this fact and it was accurate at that time, which was prior to receiving documentation for review. Prior to a reviewing a denied claim for payment the CCS can not predict the review determination and/or determine member liabilityAs previously stated this type of information is only determined after the review has been completed and the claim has been adjusted in accordance with the plan benefits. Regarding prior approval, the description of the lab procedures performed includes hereditary gene analysisGenetic testing for inherited disorders does require prior approvalThis in listed in the Prior Approval and Investigational Services list under Medical/Surgical/DiagnosticIn this case the health care provider who reviewed the services determined that the services were experimental or investigative in natureTherefore, benefits are not available. In the Certificate of Coverage under Exclusions, benefits are excluded for services that are: Not Medically Necessary or do not meet Medical Mutual's policy, clinical coverage guidelines, or benefit policy guidelines.For Experimental or Investigational drugs, devices, medical treatments or procedures, except as specified.In the Certificate of Coverage under Right to Review Claims it states:When a claim is submitted, Medical Mutual will review the claim to ensure that the service was medically necessary and that all other conditions for coverage are satisfiedThe fact that a provider may recommend or prescribe treatment does not mean that it is automatically a covered service or that it is medically necessaryAs part of its review, Medical Mutual may refer to corporate medical policies developed by Medical Mutual (that may be obtained at Medical Mutual's website) as guidelines to assist in reviewing claims. Attached is the Certificate of CoverageIf you have any questions, please don’t hesitate to contact me. Sincerely,*** ***, Appeal Specialist IIMember Appeals departmentFax
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID ***, and have determined that this does not resolve my complaint. For your reference, details of the offer I reviewed appear below
[To assist us in bringing this matter to a close, we would like to know your view on the matter.]Medical Mutual admits to submitting a fax stating no pre-authorization was required on a CT scan. No request was ever made for a CT scan, however, Medical Mutuals issuance of this letter is what started the entire confusion process. Medical Mutual has declined to state (when asked repeatedly) why they issued this letter in the first place causing the confusion it has. I NEVER received this notice, it went to my medical provider, who told me to get the test done as it did not require pre-authorization. I would never have submitted to the test had I known this.Medical Mutual also states the request was denied due to "Not completing a full course of conservative treatment." This includes: "Four weeks of participating in physical therapy and/OR a home exercise program." "Stopping or limiting the activities that caused the pain." "The use of anti-inflamatory medication."In response:I did limit myself to home treatment due to the high costs of having to attend physical therapy. This treatment consisted of but was not limited to, light stretches, applying cold compresses to attempt to reduce EXCESSIVE swelling, and light leg exercises. Compression bandages were also applied to attempt to dissipate the large fluid build up that was present.2. This injury was sustained during martial arts training. I was UNABLE to participate in training for several weeks due to the injury. When I returned to training, I was still very limited on my participation due to the pain and swelling. As of today (November 17, 2014), my training is still more limited due to current pain in the knee.3. At my request, I did not want a prescription anti-inflamatory. I have taken Naproxen in the past, and it causes stomach issues with me. Instead, I took an over the counter ibuprofen to help with the inflammation.None of these eliminated the issue in the knee I had then and am still having today. There was serious concern of knee damage to the joints and/or possibly MCL and/or ACL. Medical Mutual states in their reply, "The provider may not hold the member liable for the denied charges." When I went for the MRI, I was REQUIRED to sign a letter of NNC (Notice of Non-Compliance). Since Medical Mutual issued the fax stating no pre-authorization was required, and I was told by my medical provider to get the test and no authorization number was issued, I reluctantly signed it in good faith Medical Mutual would not come back and do exactly what I am going through now. In short, I AM being held liable for the denied chargesIn Medical Mutuals reply to this complaint, MsMeyers states, "A letter was issued to the provider on 9-17-14. The provider has days from the receipt of this letter to request an additional level of appeal." I was NEVER told of this, and want to exercise the right to file this additional level of appeal. I am requesting to know how I can do this from Medical Mutual
Regards,
*** ***
April 29, 2015[redacted]Revdex.com2217 East 9th Street Suite 200Cleveland, Ohio 44115-1299Case ID: [redacted]:I am writing in response to your letter dated April 21, 2015, regarding the member’s request for a 7/1/14, policy termination date and premium...
refund for July and August 2014. This member had the Standard Market HSA 8000 Bronze family plan. On 12/21/13, Medical Mutual received the Exchange application for the policy to be effective 1/1/14. The monthly premium cost, including Federally Mandated Fees, was $990.31. The member received a monthly subsidy of $777.00 and the member’s monthly premium cost was $213.31. On 8/13/14, Medical Mutual received the member’s request to cancel her policy effective 8/13/14. On 8/14/14, the attached letter was issued to the member that stated that she needed to contact the Exchange to cancel her policy. On 8/22/14, Medical Mutual received notice from the Exchange to cancel the policy 9/4/14, and the policy was cancelled 9/4/14. The member contacted Medical Mutual on several occasions regarding this issue. Due to new guidelines established by the Centers for Medicare and Medicaid Services (CMS) issuers are now permitted to terminate a policy back to the date on the Exchange notice. The notice from the Exchange that was received on 8/22/14, was dated 8/20/14. Therefore, the member’s policy was cancelled 8/19/14. Medical Mutual does not have the flexibility to adjust the 8/19/14, termination date. The member does have appeal rights with the Exchange. The member may contact healthcare.gov or call 800.[redacted] to request an appeal. If approved, the Exchange will notify Medical Mutual. On 4/13/15, the member was refunded $82.57 for the unearned portion of the August premium. No additional refund is due. I apologize to Ms. Armocida for the incorrect information she received and for any inconvenience this issue has caused. Attached are the Exchange documents. If you have any questions regarding this issue, please don’t hesitate to contact me. Sincerely,[redacted], Appeal Specialist IIMember Appeals departmentAttachments
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that this does not resolve my complaint. For your reference, details of the offer I reviewed appear below. There are several points of contention regarding the business response. First, with respect to facts of this matter, there are several points of accuracy and contention. It was I as the member who asked my physician to file paperwork to have this matter reviewed. The provider, [redacted] did NOT file an appeal. Rather it was only upon my request that my provider sent information to Medical Mutual of Ohio. I was informed that I would have NO liability for the claim. I was not informed that by my requesting my provider send information in to Medical Mutual that I would NOW incur liability, I relied on Medical Mutual of Ohio telling me that there was no liability, If I had known that by my requesting that physician send in information for Medical Review, I would not have requested such information be provided. I believe that Medical Mutual of Ohio should have first informed me that I had no liability. Second, if they were informed that I would be contacting my physician to get the medical information and let me proceed to do so when knowing that by doing so I would NOW have liability for the claim. Second, it accordance to my rights under the Member Rights, I have requested multiple times documentation that was submitted between the provider, physician and Medical Mutual. This has been refused. I am hereby requesting Medical Mutual honor their obligation to provide me this information and without delay. Refusal to deny such documentation is hindering my right to file accurate prepare and file an appeal with sufficient information. Lastly, in accordance with my Certificate of Coverage, I am entitled to specific information that was used in terms of protocol used by the Medical Reviewer to determine medical necessity. The EOB and paperwork provided here fails to follow the dictates set forth in the Certificate of Coverage. With respect to the last two points must be rectified promptly and completely to protect my rights of appeal through Medical Mutual, external review and subsequently through Department of Insurance as well as subsequent action that maybe afforded to me under the law. Once the last two points are addressed, I can adequately respond to why the services were not experimental or investigatory. As someone who has previously suffered subsequent vision loss as well as previously have been diagnosed with probable MS, optic neuritis and have both symptoms and clinical evidence that supports the conducting of these test, I believe knowing what was used by the Medical Reviewer I can repute and therefore demonstrate medical necessity and that such services are not experimental or investigatory. Time is of the essence as I have increasing vision lost (I am blind in one eye already).
Regards
[redacted]
December 19, 2014[redacted]Revdex.com2217 East 9th Street Suite 200Cleveland, Ohio 44115-1299Case ID: [redacted]Dear Ms. [redacted]:I am writing in response to your letter dated December 9, 2014, regarding the member’s application for the HSA 6000 Bronze policy....
Although the member states she did not finish the application process, Medical Mutual did receive the member’s application on 12/1/14, for health, vision and dental coverage. The premium payment for $513.86 was deducted from the member’s account based on the information provided on the application. On 12/2/14, the member contact Medical Mutual to notify us that she did not want the coverage and requested a refund. According to our records the member was not advised that they would receive a refund within 1 day and the appropriate department was notified to initiate the refund.Premium payments can not be refunded until 14 days after the deduction. This gives the bank time to notify Medical Mutual if a check comes back rejected for any reason. On 12/8/14, the member was notified that the refund was in process. Medical Mutual does not reimburse for overdraft fees and a refund for $513.86 was issued to the member on 12/17/14. If you have any questions regarding this issue, please don’t hesitate to contact me. Sincerely,[redacted], Appeal Specialist IIMember Appeals departmentFax 216.687.7990
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that this does not resolve my complaint. For your reference, details of the offer I reviewed appear below.
It is obvious that Medical Mutual of Ohio has no intent to honor its contractual obligations or do what is honorable and moral. However, I am responding to this matter in writing to insure that there is no misunderstanding that I do not agree with their response based upon the information I previously provided. Furthermore, I wanted it to be noted that if Revdex.com closes this matter that is not because Medical Mutual has resolved the matter, a point I wish to make known for other consumers who might read this complaint. As a short concluding statement, I object to the handling of this matter by Medical Mutual of Ohio:First, Medical Mutual did knowingly state there was no liability. Then when I informed them multiple times that I would seek to have the matter reviewed on behalf of the provider, Medical Mutual knowingly and with bad faith failed to state that by doing so I may become liable for services that I was not liable, Only Medical Mutual of Ohio had knowledge that by me requesting my provider to provide medical documents that I would take matter from a contractual issue with the provider and Medical Mutual to a matter now between the subscriber and Medical Mutual. Second, Medical Mutual continues to inaccurately state the language in their contract which does not in state that Gene Analysis (en banc) is excluded. Rather it specifically state that certain Gene Analysis required prior approval. Other services with respect to Gene Analysis is silent. Therefore, again under generally accepted legal principles that contracts are construed first specificity and then against the drafter, the contract is to be read as not requiring prior approval for these services. Third, Medical Mutual continues to state that its' interpretation in accordance with "their" internal standards. Their simple argument is that the services were not medically necessary because Medical Mutual states it is not medically necessary. That fails to answer the question of why Medical Mutual decided it was not medically necessary. Despite multiple requests to know what those internal standards or procedures and/or facts used for this determination, Medical Mutual has yet to provide such.
Regards,
[redacted]
April 23, 2015[redacted]Revdex.com2217 East 9th Street Suite 200Cleveland, Ohio 44115-1299Case ID: [redacted]Dear [redacted]:I am writing in response to your letter dated April 21, 2015, regarding the member’s 2015 plan benefits.For 2014 the member had the Classic 3500 Silver...
family plan. The member had a $3,500.00 single deductible and a $7,000.00 family deductible. The accumulation method for the deductible was embedded, which means, claims will begin paying for a given member of a family when he or she meets their single deductible and/or when more than one family member combined meets the family deductible. Effective 1/1/15, the member has the Silver Classic 3500/7000 family plan. For a single plan the deductible is $3,500.00 and for the family plan the deductible is $7,000.00. The 2015 plan has an aggregate deductible accumulation, which means, the entire family deductible must be met before benefits are provided for any family member on a family plan. Page two (2) of the 2015 renewal packet the member received explained the changes to the plan. Regarding benefit changes it states: deductible accumulation is being changed. The entire family deductible must be met before benefits are paid by the carrier (for any family members) on a family policy. Medical Mutual can not offer the member the same plan they had in 2014, since this plan is no longer available and we do not offer discounted rates for new plans. Attached are the 2015 renewal packet and the 2014 and 2015 Certificates of Coverage. Please refer to the Summary of Benefits in the Certificates which explain the deductible accumulations. If you have any questions regarding this issue, please don’t hesitate to contact me. Sincerely,[redacted], Appeal Specialist IIMember Appeals departmentFax 216.[redacted]Attachments
December 19, 2014[redacted]Revdex.com2217 East 9th Street Suite 200Cleveland, Ohio 44115-1299Case ID: [redacted]Dear Ms. [redacted]:I am writing in response to your letter dated December 15, 2014, regarding services rendered to the above member on 8/8/14 and 8/11/14, by [redacted]...
[redacted]. Both claims were originally denied on 9/18/14. The denial rational: this claim is being denied because prior approval was not completed by your health care professional for this service. It will be reviewed on appeal when your health care professional submits the clinical documentation supporting the medical necessity of the service. Since the processing of the claim could not be completed the services were denied. The provider may not hold the member liable for the denied charges. The provider also receives a Remit, which explains clinical documentation is needed for review to determine medical necessity and benefits. On 9/29/14, the member contacted Medical Mutual, through her My Health Plan (MHP) account, regarding the claim denials and the member was advised that the provider could not hold her responsible for the denied charges. This information was correct, based on the above claim denial at that time.Once clinical documentation is received, the claim will be reviewed for medical necessity. The claim will be adjusted for benefits, based on the review determination and plan benefits, which may result in member liability. On 10/13/14, Medical Mutual received clinical documentation for review. For date of service 8/8/14, claim [redacted], this claim was reviewed and the services were partially approved. Two (2) of the lab services were denied. The denial rational: this patient’s coverage excludes benefits for services or supplies which are experimental or investigative in nature. Therefore, we are unable to provide payment for these charges. The claim was adjusted accordingly and a new Explanation of Benefits (EOB) was issued to the member on 12/11/14. , which included the member’s appeal rights in the case of an adverse determination. For date of service 8/11/14, claim [redacted], this claim is currently in review. Once completed, the member will be notified of the review determination. Regarding the member’s points of contention:Medical Mutual can not address any discussion between the member and their physician. The lab services performed are related to Gene Analysis, which is listed under Other Procedures/Services on the Prior Approval and Investigational Services list. The member has access to the list through her MHP account. The reason why the member was told she had no liability and why she received a new EOB is addressed above. Attached are the EOBs, Prior Approval list and Certificate of Coverage. Please refer to Exclusion 5 in the Certificate. If you have any questions regarding this issue, please don’t hesitate to contact me. Sincerely,[redacted], Appeal Specialist IIMember Appeals departmentFax 216.687.7990Attachments
December 11, 2014[redacted]Dispute Resolution SpecialistRevdex.com2800 Euclid Avenue, Fourth FloorCleveland, Ohio 44115-2408Case: [redacted]Dear Ms. [redacted]:I am writing in response to your request for instructions on how to file an appeal. The member must send a letter that clearly describes their reasons for appealing a decision, including documentation to support their request. They should mail or fax the appeal to: Medical Mutual Member Appeals department MZ: 01-4B-4809 P.O. Box 94580 Cleveland, OH 44101-4580 Fax: 216.687.7990 or 866.691.8260If you have any questions, please don’t hesitate to contact me.Sincerely,[redacted], Appeals Specialist IIMember Appeals departmentFax 216.687.7990
November 14, 2014
[redacted]
Dispute Resolution Specialist
Revdex.com
2800 Euclid Avenue, Fourth Floor
Cleveland, Ohio 44115-2408
Case: [redacted]
Dear Ms. [redacted]:
I am writing in response to your letter dated November 10, regarding MRI services rendered to...
the above member on 3/19/14, at Bethesda Hospital.
On 3/17/14, Dr. [redacted] submitted a prior authorization request. The fax transmission sheet noted the request was for a CT scan. On 3/18/14, the provider was notified that CT scans do not require prior authorization and a review was initiated for the MRI. Based on the medical documentation received, the reviewer determined that the service was not medically necessary. A denial letter was issued to the member and provider on 3/19/14.
On 8/18/14, Medical Mutual received the provider’s request for a first level of appeal. The request was denied. The denial rational: your patient sought treatment for his left knee pain. The information provided does not show that he completed a full course of conservative treatment. Conservative treatment consists of at least four weeks of participating in physical therapy and/or a home exercise program, stopping or limiting the activities that cause the pain along with the use of an anti-inflammatory medication. There were no test provided, such as a McMurray or Lachman’s, showing any looseness of the knee on the physical examination. A response was issued to the member and provider on 9/17/14. The provider has 60 days from receipt of this letter to request an additional level of appeal.
The provider may not hold the member liable or the denied charges. If the member is receiving a balance due notice, he should complete the attached Member Action Request form and submit a copy of the billing notice to the address indicated on the form. The appropriate department will contact the provider.
If you have any questions, please don’t hesitate to contact me.
Sincerely,[redacted], Appeals Specialist II
Member Appeals department
Fax 216.687.7990
November 14, 2014
[redacted]
Dispute Resolution Specialist
Revdex.com
2800 Euclid Avenue, Fourth Floor
Cleveland, Ohio 44115-2408
Case: [redacted]
Dear Ms. [redacted]:
I am writing in response to your letter dated November 10, regarding prescription benefits for...
the above member.
Effective 5/1/14, this member has group coverage through First Network Group. In accordance with the terms of the contract, Schedule of Benefits, if your prescription drug order is for a prescription drug that is available through the Home Delivery Prescription Drug program and you choose not to use the Home Delivery Prescription Drug program, you will be required to pay two times the appropriate copayment or coinsurance shown when your prescription order is filled beyond the third time within a 180-day period.
The member utilized the Home Delivery program, for a 90 days supply of her medication, on 6/23/14 and 10/2/14. The member is responsible for the $60.00 copayment applied to each claim. The member does have the freedom of choice and is not required to use the Home Delivery program, but they will be subject to the increased copayment.
Regarding the manufacture of the medication, this may change due to contracted rate negotiations with the manufacturer(s) of a product, availability of a medication, and market competitiveness. The member should contact Express Scripts to discuss options available to her.
Attached is the member’s Certificate of Coverage. If you have any questions, please don’t hesitate to contact me.
Sincerely,
[redacted], Appeals Specialist II
Member Appeals department
Fax 216.687.7990
May 8, 2015Nichole MeansRevdex.com2217 East 9th Street Suite 200Cleveland, Ohio 44115-1299Case ID: [redacted]Dear [redacted]:I am writing in response to your letter dated May 5, 2015, and the member’s additional concerns. Attached is the renewal packet dated 10/14/14, sent to the member. The letter does state that the member will automatically be enrolled in the MedMutual Classic 3500 Silver plan to make sure there is not a gap in coverage. The letter also states to please review your new premium and benefits below to see if this plan meets your needs. Page seven (7) shows the deductible amount for single and family coverage on the Individual Product Plan chart for the 3500 Silver plan. All plans are called/named using the single deductible amount. The maximum family network deductible of $7,000.00 per benefit period did not change from 2014 to 2015. However, the accumulation method did change from embedded to aggregate, as explained in the renewal documents and the response sent to the Revdex.com on 4/23/15. If you have any questions regarding this issue, please don’t hesitate to contact me. Sincerely,[redacted], Appeal Specialist IIMember Appeals departmentFax [redacted]Attachment
I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that this does not resolve my complaint. For your reference, details of the offer I reviewed appear below.As [redacted] noted, the letter I received from Medical
Mutual stated that I would be automatically enrolled in the MedMutual Classic
Silver plan (which was the same name as my existing plan which had a $
deductible), yet the apparently has no meaning as the plan I received has
a $deductibleWhat does the stand for in a family plan?
If my benefit were being cut in half, as it was, I would
have expected a clear explanation of how my new plan was different than my
existing plan, yet there was no mention of it in the letter but rather the large
difference between the plans was listed as a footnote to a table on the last
page
In short, I feel the
name of the plan was deceptive and led me to believe that I would be enrolled
in a similar plan to my existing plan called by the same name, and rather than
describing clearly the differences between the two plans in the letter I was
sent, the cut in benefits was listed as a footnote to a table on the last page
Regards,
[redacted]