Anthem Blue Cross Blue Shield in Missouri

Dear Revdex.com: This letter is in response to your inquiry concerning the above case that involves member, [redacted] *** We have reviewed the complaint case number [redacted] Unfortunately, we must have member consent to process with the complaintPlease make sure the authorization includes the following informationMember nameMember identification numberMember date of birthMember addressFull name of the party who is authorized to act on the member's behalfClear indication that the party is authorized to file an appeal and or grievance on the member's behalfDate(s) for which the authorization appliesLegible member signature We regret any inconvenience or frustration the member has experienced Thank you again for contacting us Sincerely, [redacted] Grievances and Appeals Analyst Grievances and Appeals

Initial Business Response /* (1000, 10, 2015/07/08) */
This letter is in response to your inquiry concerning the above case
Based on the federal regulations of Health Insurance Portability and Accountability Act HIPPA we are unable to answer your inquiry without the specific authorization and
release of the complainantThe Revdex.com is not considered a Regulatory Agency and is therefore, required to provide a copy of the HIPPA authorization with the inquiry to our office
If our review documents no action has been taken on behalf of the member prior to the receipt of this inquiry, we will address accordinglyIf additional correspondence is necessary, we will also address directly to the member
We regret we are unable to provide any further assistance to your officeHowever, federal regulations, including those applicable to any of the new Health Care Reform regulations prevent us from releasing any further information to a non-authorized designee
Thank you for allowing us the opportunity to address this concern
Sincerely,
*** ***
Grievances and Appeals Analyst
Grievances and Appeals

Formal response letter attached. Issue resolved through Marketplace. Thank you. April 15, 2017Revdex.comServing Eastern Missouri & Southern IllinoisDispute Resolution DepartmentNBroadway, Ste2060StLouis MO 63102RE: Member Name: *** ***Revdex.comCase ID:
***Anthem Case Number: ***Dear Dispute Resolution Department:This letter is in response to your recent inquiry concerning the above caseThank you forproviding the required HIPAA authorization.At the time of this inquiry, *** *** was a participant under the Anthem Silver Pathway Xproduct purchased through the Federally Facilitated Marketplace (Exchange)As outlinedin Mr***’s Individual Contact: This Contract is offered through a public marketplaceoperated by the state and/or federal government as part of the Patient Protection and AffordableCare Act (“Marketplace”); all enrollment changes must be made through the Marketplace by you.We reviewed calls documented by Member Service and found no calls from The first calldocumented requesting policy cancellation is dated April 10, 2017, from Mrs***.Documentation reads that Mrs*** was instructed to coordinate the cancellation through theMarketplace.On April 14, 2017, the Marketplace submitted escalation, ***, to cancel Mr***’smembershipThe narrative reads: Per HICS case, consumer requested to cancel autoenrollment, but issuer has no record of the requestPer ISG *** ***, renewed January 1,2017, and shows a January 1, 2017, paid to dateProcessing termination, as requested, andsending letter to confirmMr*** should receive a copy of this letter shortly.Our records indicate Mr***’s Anthem Silver Pathway * *** policy has been cancelledeffective January 1, By copy of this letter, we are advising Mr*** that his account is ata zero balanceIn addition, no overdue premium notices have been communicated to the creditagencies.Thank you for allowing us the opportunity to address this concern.Anthem Blue Cross Blue ShieldGrievances and Appeals** *** ** ***Sincerely,*** ***Melody BurgessGrievances and Appeals Risk Analyst II/LeadGrievances and Appeals Regulatory Unit

Initial Business Response /* (1000, 6, 2015/04/21) */
Dear Dispute Resolution Department:
This letter is in response to your inquiry concerning the above case
Based on the federal regulations of Health Insurance Portability and Accountability Act HIPPA we are unable to answer your inquiry
without the specific authorization and release of the complainantThe Revdex.com is not considered a Regulatory Agency and is therefore, required to provide a copy of the HIPPA authorization with the inquiry to our office
If our review documents no action has been taken on behalf of the member prior to the receipt of this inquiry, we will address accordinglyIf additional correspondence is necessary, we will also address directly to the member
We regret we are unable to provide any further assistance to your officeHowever, federal regulations, including those applicable to any of the new Health Care Reform regulations prevent us from releasing any further information to a non-authorized designee
Thank you for allowing us the opportunity to address this concern
Sincerely,
*** ***
Grievances and Appeals Analyst
Grievances and Appeals
Initial Consumer Rebuttal /* (3000, 9, 2015/04/23) */
Attached is the HIPPA release formI hope I have completed this correctlyPlease let me know if anything else is needed
Thank you
***
Final Business Response /* (1000, 15, 2015/07/07) */
07/08/15: Mediator sent introductory email with the case linkThe signed HIPPA form is attached
07/08/15: I am unable to access Revdex.com site and I need the information sent by email
Per my voicemail this afternoon, we are still unable to access your siteWe have worked with your IT department and are still unable to access the site
Please email me a copy of the HIPAA authorization for this member
Also, this member is not a Missouri member and we provided that information to her on April 20,
07/09/15: We reviewed the HIPAA authorization with our Privacy Manager and found that it is an invalid authorizationThere are blanks that are not completedAlso, one of the requirements is that there must be an expiration date and that is not providedAt this time, we are unable to move forward with a reviewPlease provide a valid HIPAA authorization via email to me once obtainedWe will pend our inquiry until 7/for the valid authorizationAt that time, we will close our inquiry
07/13/15: Mediator sent email to the business with the HIPPA form attached
07/14/15: The form is still incomplete
07/16/15: I tried to contact you a couple of times and left voice mailsI have not received a corrected authorization, so we have closed our caseOnce we have received a valid authorization, we will be glad to re-open our caseFor planning purposes, I will be out of the office until 7/20/at a.mCST
07/16/15: I need the specific date of the chargeWe see that all her claims have been paid

Our records reflect that on March 14, 2016, we were requested to review the case identified in this inquiry. Unfortunately, after reviewing our member records, and cross referencing with the address provided, we have ben unable to locate the member identified in this inquiry. Therefore,
we respectfully request a complete copy of the member identification number or clarification of the identification number, including the prefix be provided. Additionally, a HIPAA authorization from the member allowing us to disclose information related to his contract is required.
Please let us know if you have any questions

Response letter attached. Thank you

The analyst who was assigned this case was out unexpectedly on Friday.  The attached response letter was mailed to your office.  We were unable to access the site on Friday.  We apologize for the confusion.  The analyst will respond directly to the member.Also, I should be the...

primary user on this site.  My email address is:  [redacted]@anthem.com.  Please change your records.  Thanks.

Dear Revdex.com:   This letter is in response to your inquiry concerning the above case that involves member, [redacted].    We have reviewed the complaint case number [redacted].  Unfortunately, we must have member consent to process with the complaint. Please...

make sure the authorization includes the following information. Member nameMember identification numberMember date of birthMember addressFull name of the party who is authorized to act on the member's behalfClear indication that the party is authorized to file an appeal and or grievance on the member's behalfDate(s) for which the authorization appliesLegible member signature We regret any inconvenience or frustration the member has experienced.  Thank you again for contacting us.    Sincerely,   [redacted] Grievances and Appeals Analyst Grievances and Appeals

Initial Business Response /* (1000, 11, 2016/03/04) */

We are unable to document additional information to the portal for this case.   Therefore, we are providing the following information provided to  us from the FEP member services agent that assisted:   I spoke with the member Mr. [redacted] and he was upset that he was getting the...

run around for FEPBlue Dental for the additional dental insurance , I did a conference call with him and  Benefeds and spoke with Peter member called them 02/24/16 which was after open season and they did registration for him but was cancelled due to it not being open season.  Member has never been enrolled with FEP Blue Dental .   I’m mailing  Mr. [redacted] information regarding Dental Blue  and sending him a list of ppo providers in his area for dental because he said he was given a list of providers that are in Illinois .  I told member to call me mid-November  during open season and I will do anther conference call with Benefeds to help him get enrolled into their dental plan.  I give Mr. [redacted] my direct  phone number.  Member is satisfied.   Mr. [redacted] should now continue to work directly with the member services representative that assisted him.   Thank you

May 4, 2016   Dispute Resolution DepartmentRevdex.com211 N. Broadway, Suite 2060St. Louis, MO...

63102                                     �...⇄ Re:                   [redacted]                                   ...⇄ Member #:       [redacted]                                   ...⇄ NAIC#:           [redacted]                                   ...⇄ Case #:                        [redacted]                                   ...⇄ Our Case #      [redacted] Dear Revdex.com: This letter is in response to your inquiry concerning the above case that involves member, [redacted].  Mr. [redacted], subscriber of the policy and spouse of [redacted] enrolled in a fully insured, non-grandfathered, non-ERISA governed, Blue Access PPO contract offered through Mr. [redacted]’s employer, [redacted].  Our records indicate the members enrolled with an effective date of November 1, 2012, and remain active.          Mr. [redacted] presented concerns regarding payment for Emergency Services provided by [redacted] Hospital to Ms. [redacted] on November 16, 2015.  He stated that he had called Anthem and confirmed that the hospital Emergency room was in network; however learned post service the physicians were out of the network.  He is dissatisfied that an out of network physician practices within an in network facility and does not feel he should be held responsible for the remaining balance. We reviewed the claim number [redacted] for Emergency Room services provided by a non-participating medical provider on November 16, 2015, with a total charge of $5,081.00.  The claim processed on December 8, 2015, and the Plan sent the member a reimbursement check in the amount of $1,803.67, for the services rendered.  Due to the out of network status, the Plan reimburses the member rather than the provider of service.  We show that the claim adjusted on April 28, 2016, and reflects the services as paid in full.  The Plan mailed a second reimbursement check to the member in the amount of $3,277.33.  The reimbursement check amounts total the full amount billed by the provider.  The member should forward a payment for the full amount billed to the provider.We trust that this information is helpful and thank you for allowing us to be of assistance.  Should you require additional information, please fax us at, 1-[redacted].   Thank you again for contacting us.   Sincerely, [redacted]Grievances and Appeals AnalystGrievances and Appeals  Enclosures (Revdex.com Only)

October 17, 2017Revdex.comServing Eastern Missour & Southern...

IllinioisDispute Resolution Department[redacted]St Louis MO 63102RE: Member Name : [redacted]Revdex.com Case No. : [redacted]Anthem Case No. : [redacted]Dear Dispute Resolution Department:This letter responds to your recent inquiry concerning the above case. Thank you forproviding the required HIPAA authorization.Ms. [redacted] is a participant under an Anthem Silver Pathway X 5300 S06 productpurchased through the Federally Facilitated Marketplace (Exchange). Ms. [redacted]policy effective date is May 1, 2017.Ms. [redacted] states that she called several times to confirm her benefits, and asked aboutthe deductible and the provider she was going to see. She states that on each occasionshe was told she would only have a $20.00 copayment. She is now being billed for$160.00.We reviewed calls documented by Member Service and found no calls prior to her carebeing received. We do show that Ms. [redacted] used the IVR telephone system two timeson August 8, 2017; however, it does not appear she spoke with a representative.As outlined in Ms. [redacted]’s Individual Contract on page 3 of the Schedule of CostShares and Benefits section, it states, “The Deductible applies to all Covered Serviceswith a Copayment and/or Coinsurance, including 0% Coinsurance, except for: In-Network Preventive Care Services required by law, Pediatric Vision Services, Services,listed in the chart below, that specifically indicate that the Deductible does not apply.”Regarding the deductible for network it states, “$200.00.” The non-network deductiblestates, “$10,600.00.” On page 6 regarding doctor office visits in-network for primaryAnthem Blue Cross Blue ShieldGrievances and Appeals[redacted]In Missouri, (excluding 30 counties in the Kansas City area) Anthem Blue Cross and Blue Shield is the trade name of[redacted]. ([redacted]), [redacted]), and [redacted] andcertain affiliates administer non-HMO benefits underwritten by [redacted] and HMO benefits underwritten by [redacted], Inc. [redacted]and certain affiliates only provide administrative services for self-funded plans and do not underwrite benefits. Independentlicensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies,Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.care physician, chiropractor office visits and retail health clinic services it states,“Deductible does not apply; $20 Copayment 0% Coinsurance.” For network specialistoffice visits it states, “$0 Copayment 25% Coinsurance.” For non-network specialistvisits it states, “$0 Copayment 50% Coinsurance.” The deductible would still apply forspecialist visits.There are separate benefits that apply for mental health and substance abuse services.On page 7, for an outpatient office visit, which is what was billed, it states, “$0Copayment 25% Coinsurance.” The deductible would apply before the coinsurance if itwas not met. The provider Ms. [redacted] saw was Dr. [redacted], who is not in herplan’s network. For out-of-network mental health benefits, it states, “$0 Copayment50% Coinsurance.”It appears that the claims have processed correctly according to the provisions of Ms.[redacted]’s health care plan. We did not find that incorrect information was quoted for thiscare. We have enclosed a copy of the current list of network Psychiatrists within a 20mile radius of Ms. [redacted]’s home zip code. This list was found on our web sitewww.anthem.com, using her prefix of [redacted].We did not find where Ms. [redacted] submitted a written grievance/appeal related to herconcerns. If You Have a Complaint or an Appeal is outlined beginning on page 82 of Ms.[redacted]’s Individual Contract (Contract). Should she disagree with our response, her nextoption would be to submit a grievance/appeal.Thank you for allowing us the opportunity to address this concern.Sincerely,[redacted]Grievances & Appeals Regulatory UnitEnclosure(s): current list of network PsychiatristsCC: [redacted]

On [redacted], we received notification from you that the complainant had not responded and you have closed the case.  Also, further inquiries should be sent to the following shared mailbox.  [redacted]@anthem.com.

Response letter attached.

September 27, 2016Revdex.comServing Eastern Missouri & Southern IllinoisDispute Resolution Department211 N. Broadway, Ste. 2060St. Louis MO 63102RE: Member Name: [redacted]Revdex.com Case ID #: [redacted]Anthem Case #: [redacted]Dear Dispute Resolution Department:This letter is in...

response to your recent inquiry concerning the above case.Based on the federal regulations of the Health Insurance Portability and Accountability Act(HIPAA), we are unable to answer your inquiry without the specific authorization and release ofthe complainant. The Revdex.com is not considered a Regulatory Agency and istherefore, required to provide a copy of the HIPAA authorization with the inquiry to our office.If our review documents no action has been taken on behalf of the member prior to the receipt ofthis inquiry, we will address accordingly. If additional correspondence is necessary, we will alsoaddress directly to the member.We regret we are unable to provide any further assistance to your office. However, federalregulations, including those applicable to any of the new Health Care Reform regulations preventus from releasing any further information to a non-authorized designee.Thank you for allowing us the opportunity to address this concern.Sincerely,[redacted]Grievances and Appeals Risk Analyst IIGrievances and Appeals

This letter responds to the above-referenced inquiry dated July 14, 2016.   [redacted] enrolled as the subscriber of a fully insured non-ERISA, non-grandfathered Missouri Silver Pathway PPO individual policy administered by  Anthem Blue Cross and Blue Shield and underwritten by Healthy...

Alliance Life Insurance Company and effective October 1, 2015- November 1, 2015.  The  policy was not purchased through the Marketplace.    In the inquiry to your office, Mr. [redacted] stated that when he enrolled he paid for the first month premium with his company credit card, and enrolled  in auto-pay at that time.  He explained that following the initial payment, the monthly premium was not charged to the credit card.  He stated that he  requested a review for reinstatement, but has not heard back.  He is requesting reinstatement of the coverage provided under the medical and dental  policy.   We researched the issues brought to our attention in Mr. [redacted]’s inquiry.  We would now like to provide you with our findings.  According to the  Enrollment and Billing Department the reinstatement request was denied.  The investigation found no evidence of an Anthem error.     We reviewed the Payment Method for Individual Applications, and Mr. [redacted] selected Option 2 for payment.   Option 2 states the member may  choose a payment option for the INTIAL premium payment, with a bill sent to the member every month after.   Option 2, gives instruction to deduct or  bill for the initial payment only, whereas Option 1 allows an automatic premium payment for both initial and all future monthly premiums due.     Invoices, grace letters and cancellation letters were mailed to the address we had on file at that time.  We do not show record of an address change  request prior to December 25, 2016, when the request was delivered by the United States Postal Service.   We received a first level appeal from Mr. [redacted] on June 13, 2016, with a response due no later than July 12, 2016.   A written decision letter dated  July 12, 2016, was mailed to Mr. [redacted].  It advised that we received an address change on December 25, 2016.  We do not show any record of an  address change request prior to December 25, 2016.  The letter contained copies of the invoices, grace letters and cancelation letters mailed to the  address on file.  Unfortunately the previous decision to deny reinstatement was upheld.  The decision letter advised of the additional rights that may be  available Mr. [redacted].   We received a copy of the inquiry from The Missouri Department of Insurance.  We provided a response on July 5, 2016 advising of the same information  presented above.  The Missouri Department of Insurance agent reviewed the findings we presented.    The agent forwarded a response to the member and Plan.  We received a copy of the notification dated July 20, 2016, which advised that as a result of  the inaction taken to provide a current mailing address, Anthem Blue Cross Blue Shield cannot be found at fault.    Based on the first appeal decision letter, Mr. [redacted] has an opportunity to request a second level appeal, if he wishes to pursue.   We trust that this information is helpful and thank you for allowing us to be of assistance.  Should you require additional information, please contact us  directly at 1-[redacted].  You may also fax your request to 1[redacted].    Thank you again for contacting us.    Sincerely,   [redacted] Grievances and Appeals Analyst Grievances and Appeals