Avesis

Been with these clowns for 12 years. Get a letter from them yesterday stating that my vision coverage has been terminated, due to nonpayment of last quarter premium! No invoice or payment coupon has been received since 9/16/22, yet I was able to get an eye exam and glasses last month and avesis covered the claims!
No notice or warning of termination and it took 3 months to get the termination letter. So much for loyalty. GO WITH ANOTHER COMPANY FOR VISION CARE INSURANCE AND LEAVE THESE CLOWNS AT THE CIRCUS!

I had this plan due to work. I opted the higher premium plan so that I could get a better deal on my contacts. After my appointment, they said the contact benefit was $110. Drop in the bucket after being with VSP for years ($150-180 allowance). Then, I find out that the fitting fee is deducted from that tiny allowance. I was left with $45 to spend on my dailies. This doesn't even cover one month since my rx is different in each eye. What a waste of money.

My experience with Avesis Vision has been horrible, vastly inferior to any other insurance provider I have worked with in the past. And this across the board with all aspects of the firm- website, quality of information, provider resources, and last but also the worst, customer service.
Here is a short description of my experience, and the reason for my low opinion of this company:
I registered on their website and got the name/ address of a local in-network provider- Pearle Vision. I go to the provider, but they cannot pull up benefits information because the Avesis Provider Portal is down (Avesis has very limited hours for assistance via telephone) I set up an appointment for another day. But low and behold, Pearle Vision disappears from the provider list on Avesis website. PROBLEM ONE- Out dated information, clunky, unreliable online portal, limited telephone assistance.
Then I went to Eyeglass World, another in-network provider listed on the website. Same thing when the provider tries to pull up information, their Avesis Provider Portal is down.
PROBLEM TWO (Repeat)- Unreliable online portal, limited telephone assistance.
The provider suggested that I could pay retail and then submit a claim for reimbursement. I did that. Submitting the claim was comparatively easy through the website claim submittal form.
However, when I called Avesis customer service to follow up, they informed me that I would be reimbursed for half of what I am entitled to because the claim was not directly submitted by the provider. But, since I had just submitted a claim, Avesis would process it and cancel it so I can have it filed by the provider, and, to give this process a week. I go to the provider after a week, and they inform me that they cannot process since the Avesis Portal shows that the benefits have been claimed. I go to Avesis Patient Portal, and it says claim has been denied. At this point, I return the eyeglasses. PROBLEM THREE -Explanation of benefits is unclear. Benefit disbursement process is counter intuitive.
A month later a check from Avesis shows up. I call their Customer Service (which is a 3rd party call center in India with personnel who have very limited information) to tell them that I have voided the check since I returned the eyeglasses. The CS rep tells me that I need to mail them the check back via regular mail. I informed her that I cannot do that because (a) I have shredded the physical check, and (b) regular mail capability near me is greatly reduced. Also, this is 2022, and if you can accept a claim via online portal, you should be able to make a change to disbursement or void a check. It took 30 minutes for her to understand the issue and in the end she repeated the same line- “ you will need to physically mail in the check”. I asked for her supervisor, she put me on hold, told me the supervisor was unavailable and would call me back within the next 2 days. PROBLEM FOUR- Lack of coordination. Sub-par customer service.
After 2 days of not hearing from them, I called Avesis Customer Service again. The experience was almost identical to the first call, except:
The CS rep was a bit smarter and understood the issue faster, she accepted that they were a 3rd party call center and had limited information, and, that a supervisor would never call be back because she/ he had no additional information. PROBLEM FOUR- Almost non-existent customer service, a company that bets on selling policies on the cheap and skirting any responsibility for service by using the archaic “give the customer the run around” business strategy.
You would not want to waste your time with this company.

Buyer beware, normally Avesis and benefit departments usually tout the benefit allowance for a pair of glasses or contacts as $150 for one or the other each year. What they don't tell you in a benefit summary or on the card is this: The benefit applies in full to a contact lens purchase. You should expect to receive $150 in a plan year if you purchase contacts and apply Avesis insurance to the purchase. If you decide to purchase glasses then you will only have insurance applied up to $150. What that means is that if you purchase a frame that is less than $100-150 dollars you will only have benefit coverage of $50. So where is the other $100 benefit? Another $50 was applied to my lens purchase. The additional $50 is forgone because I purchased frames that were not designer with a cost of $300 or more. Bottom line is that you should apply the $150 to contacts and never to glasses because you will not ever receive the full benefit unless you pick out frames that are $300 or more and that is debatable because I'm sure Avesis will find a way to screw you out of the full benefit some how.

Why on earth do I need to submit a claim for reimbursement of an eye appointment by snail mail? Get with the times and allow patient to submit a claim on line with downloaded qualifying receipts and documents. Do you realize this would save your patients time and you money!?

This company is terrible. I had my son braces denied twice because "if you do not have this service done your medical health will be at risk." When is braces a health risk. My son has a speech impediment and needs to get braces to help correct this. I also pay for this insurance over $7000 a year for 3 children. This is terrible insurance and getting the run around and automated responses back.

Terrible service. My Avesis is in addition to Molina Plus and said dentures were covered up to $2000. My dentures were below this amount, even with xrays, but Avesis said I can only have one denture every 5 years. This is my first claim with them and the last time I had dentures was over 20 years ago and with a different company. This is kind of like buying only one shoe. Even my dentist has never heard of this.

This year I switched to Avesis. I submitted a claim for prescription eye glasses.It took them 8 weeks to process. However, they reimbursed me out-of-network coverage for the in-work service provider where I bought my glasses.
I called Avesis customer service center. Their answer is Avesis only pays in-network coverage to the service provider. Avesis pays out-of-network coverage for direct reimbursement to the members for in-network service. Avesis is so shameful to mislead customers.
I strongly suggest Avesis put the follow statement in printing so you do not mislead your members:
"Avesis direct reimburses to members only the out-of-network benefit despite the glasses are purchased from in-the-network providers".

Can not resolve a simple problem! After many calls and speaking to a supervisor who promised he would take care of it right away still no resolution and no return calls. The experience with you company has been noting short of a horrible experience for something that should have been as simple as giving my eye glass provider information as to how to file the claim. I am on Medicare with Kaiser and just had cataract surgery so I am entitled to pay 20% for my new glasses. Just the worst!

Review: This companies lab failed to produce a correct pair of glasses, twice. I except the first poorly produced pair after months to just be done with it. Hoping it was fluke and it is my insurance, I tried again. Same issue. So I needed to go out of network to get my glasses made (costing me more money). Once I did that, getting them to pay my out of network reimbursement as been near impossible. It has been going on for over 6 months. Now they are telling me that their own lab has submit a refund to their own company. They will do just about anything to keep from paying out.Desired Settlement: They need to pay the out of network reimbursement for the lenses without making me call back for another 6 months.

Business

Response:

I'm writing in response to your inquiry on behalf of a Vision plan member regarding reimbursement for his glasses obtained from an out of network provider.After researching the member's claim history in our files, we identified an oversight in how his out of network claim was processed. That claim was reprocessed yesterday and he will receive the additional payment for his glasses in the next few days. I called this morning and spoke with the member to inform his that he will receive the maximum allowed payment for the glasses he obtained, explained to him what the reimbursement would be, and apologized for the delay in payment and any dissatisfaction he experienced. He seemed to be pleased with our response and thanked me for calling him. Please be assured that it is Avesis' policy to provide the best possible services and support for all our members. I wish to thank you for bringing this matter to our attention so that we could identify and resolve this issue for the member. Sincerely,Mark B[redacted]Senior Vice President, OperationsAvesis Incorporated

Consumer

Response:

[A default letter is provided here which indicates your acceptance of the business's response. If you wish, you may update it before sending it.]

I have reviewed the response made by the business in reference to complaint ID [redacted] and find that this resolution would be satisfactory to me. I will wait until for the business to perform this action and, if it does, will consider this complaint resolved.

Regards,

Review: I pay into Avesis vision insurance by payroll deduction. I am supposed to get one eye exam and $100 toward contact lenses each year, but when I submitted my receipt for services from Total Eye Care on 10/8/15 my claim was denied because the staff at Avesis did not look at the second page of my invoice to see I paid the $375 bill with a check to Total Eye Care. I talked with a supervisor, Jenny Gomas by phone and she assured me she would contact Total Eye Care in Tempe AZ to get another copy of my receipt, but she has not followed through on her promise and it has been several weeks now. I would like to get my reimbursement for this expense.Desired Settlement: I would like reimbursement for my expenses asap in accordance with my benefits plan.

Business

Response:

Re: ID # [redacted]Dear Dispute Resolution Consultant:I'm writing in response to your letter on behalf of an Avesis member who complained that she had been incorrectly reimbursed for an eye care claim for services received by her on October 8, 2015. We reviewed our records with respect to the details provided by the complainant. She did call our Customer Service department on October 20,2015 regarding what she believed to be a claim that was processed in error. She spoke with one of our Supervisors who told her she would research the issue, have the claim reprocessed if indicated, and call her back with an update in 7-10 business days; the claims processing time line. Our Claims department researched the issue on her behalf and found that the complainant had indeed paid for the eye care visit in full with zero balance remaining. While it was being reprocessed, the complainant called again and asked for an update. She was advised on October 30, 2015 that the claim was reprocessed and would be paid in that week's check run and that she should receive it in the mail within the next week. The Customer Service Supervisor called her to follow up on the 13th, leaving a voice mail message, and was able to speak with her on October 16th , at which time the complainant reported that she had received her check for the correct reimbursement. As a matter of information, our claims processors have a 98% quality standard for correctly processing claims for reimbursement and frequent audits reveal that we are processing over 99 percent of all claims correctly. It is our policy and practice to provide the highest level of claims processing support and customer service. I sincerely regret that the initial claims processing overlooked a copy of the receipt on the second page and incorrectly paid the claim. Thank you for bringing this complaint to my attention.Sincerely,Mark B[redacted] / Senior Vice President, Operations

Review: On October 9, 2014 I spoke to a customer service representative at Avesis for the insurance Care Improvement Plus. Her name was [redacted]. The phone call was recorded and the reference number was [redacted]. I was requesting a breakdown of insurance benefits as we had a patient coming in for a new set of dentures. I asked [redacted] specifically if dentures were a covered benefits under this patients insurance policy. [redacted] informed me at this time that yes they were a covered benefit and limited to 1 per arch in 3 years and that they did not have to be pre approved. Also that they would be covered at 100%. This information was relayed to the patient and the patient decided to proceed with a new set as they would pay for them. The claim was sent in and the office received an EOB, an explanation of benefits, stating that the dentures were denied and they would not be paying for them as they are not a covered benefit. On October 23, 2014 I spoke to [redacted]'s supervisor, [redacted], who I explained all the information and what had happened and she informed me I could file an appeal and I would hear something in 72 hours. I faxed the appeal in and I have not heard anything yet. On October 23, 2014 I spoke to [redacted], reference # [redacted] stated that he did speak with [redacted] and she did send the appeal to ** and once they receive will follow up with us either verbally or by mail once the decision has been made. I have not heard anything in regards to appeal. On January 9, 2015 I spoke to [redacted] reference number [redacted] and she said they did receive the appeal but that there are no new notes in regards to appeal. I told [redacted] that I was told by [redacted] that I would hear something in 72 hours and that was on 10/29/14. [redacted] stated that she spoke to her supervisor and that my request to speak with someone higher up was forwarded to the supervisor over her supervisor and she will call me back today and also that my appeal was resent to **. I have not heard back from that supervisor or in regards to the appeal. I am tired of getting the run around from the insurance company. The patient in regards to this complaint received a $1400 pair of dentures based on the word of the insurance company. I have spoke to the patient and she said she can not pay for the denture and that had she known that insurance was not going to pay like they stated then she would not have gotten such an expensive set.Desired Settlement: I would like Avesis to pay the claim in question. Their customer care representative have the information that we go off in their hands, we take the word of these ccr's when asking about insurance benefits. The reason we ask for such information is to make sure the patient pays the correct amount for the product that they receive. My office now has a $1400 account and a patient with a free set of dentures. The way that Avesis has handled this situation is poorly.

Business

Response:

I'm writing in response to your letter of January 16,2015 on behalf of [redacted] of [redacted], AR concerning her desire for payment of a claim for dental services which was previously denied as a non-covered service.I've reviewed the records relating to this matter. It appears that Ms. [redacted] office was misinformed regarding the benefits for which the involved patient was eligible. It was a noncovered service, but this was not managed in a manner consistent with our processes or policy and the dental office and patient acted in good faith on inaccurate information. Avesis' policy and standard practice is to provide clear communications regarding members' covered services and to process claims and claims appeals, when they occur, in an accurate, timely manner. This morning, our Claims Manager reprocessed the claim for this patient and approved it for payment. Ms. [redacted] dental office will be paid $1438.00 for this service and the payment will be made next Wednesday during our weekly check run. I called and spoke with Ms. [redacted] this afternoon and apologized for her frustration and the miscommunication that occurred in this instance, and advised her of the payment to be made in the next week. She was very understanding and appreciative for the direct call to her office.I trust that this information will be helpful to you in responding to Ms. [redacted] complaint and I want to thank you for forwarding it to us. Please feel free to call on me if you have any additional questions regarding this matter. My office telephone number is ###-###-####, extension[redacted]. Thank you,[redacted]Quality Assurance CoordinatorAvesis###-###-#### X [redacted]

Review: I had to pay out of pocket for a dental checkup in January of 2015. I am supposed to be reimbursed, pending the processing of a claim sent to Avesis by the staff at my dentist's office. There have been NUMEROUS calls between me Avesis and between my dentist's office and Avesis to resolve the matter. Each time, I am told that Avesis did not receive the claim. My dentist's office sent the claim at least three times. We have been promised that the matter would be resolved, but nothing has happened, and it has been 11 months.Desired Settlement: Process the claim and communicate with my dentist's office staff.

Due to insurance mandates we where forced to pay for coverage thru this company for our children. We paid monthly premiums for their coverage but they did not even cover cleanings for our children. This is pathetic that hardworking americans are being forced to pay for services that they are not able to use. We were told the children had to visit the dentist exactly every six months to the day in order to use our benefit. Unfortunately the Dentist office does not work that way at least in our area. One child was 8 days short of 6 months. This is robbery!!!!!!

I submitted a claim for vision care in September 2014. I sent a claims form and a receipt itemized. Today is February 19, 2015 and the claim has not yet been resolved. I have called very frequently (every 2 weeks) to find out the status on my claim. Each time I call, I am told to send a claim form and the receipt showing "PAID IN FULL" ZERO BALANCE. The receipts shows this. The claims department tells me to send the same thing over and over again. I send the requested information over and over again. I have sent the forms along with the itemized receipt 5 times and this process is completed repeatedly. NOTHING Resolved IN 5 MONTHS but my premiums are paid on time each month. I am promised someone will call but no one ever does. I am frustrated because this should not happen. I just called a few minutes ago and I was told to send the information in again!!!! I will not renew my insurance with Avesis.

Review: My contract with Avesis states that they will cover the full costs of medically necessary contact lenses with no exclusions, however Avesis is refusing to pay the full amount for my medically necessary lenses. They are now stating that they will pay a maximum amount of $500, which is not written in my contract .Desired Settlement: The total amount of my lenses is $1000. I would like for Avesis to pay for the full amount to cover my medically necessary lenses as per my contact with them.

Business

Response:

February 24, 2016I'm writing in response to your inquiry on behalf of a vision plan member regarding the amounts covered for services under her insurance plan.In an effort to be sure we would clearly address the member's concern, I called to speak with her and obtain more specifics about her complaint. As of yesterday, we had only received a claim from her provider for a $35 office visit in December 2015, which was paid. Following that conversation, we called to speak with her provider's office, clarified the services she apparently received in late January 2016, and reached an agreement with them regarding payment in full for the services she received. The provider's office agreed to submit their claim today and will receive the agreed payment in full by next week. I have followed up with the member to explain more fully the specifics regarding the claim and to ensure she understands that she will not be responsible for any other costs related to the services she received. It was helpful to receive this inquiry because no claims had yet been received from the member's provider for the services provided her in January in order for us to be able to resolve this issue for her.Thank you,Mark B[redacted]Senior Vice President, OperationsAvesis Incorporated

Review: I signed up with avesis insurance for eye care coverage. I paid the first year premium in full. I have been trying to contact them since December to get my member number so I could use the insurance. I have left 5 messages. No return call. This is fraudDesired Settlement: get my money back the company has no customer service

Business

Response:

On March 17, 2014 Avesis’ Vice President of Operations, Mr. [redacted], contacted Mr. [redacted] to discuss his complaint and to offer his assistance. It was determined that Mr. [redacted] may have been calling the AZ Department of Administration for assistance. There was one call from Mr. [redacted] in our system on March 3, 2014. Mr. [redacted]’s request for a call back on this date was misrouted and Mr. [redacted] apologized to Mr. [redacted] for that experience. Mr. [redacted] explained that this is not consistent with Avesis’ policy or practice. Mr. [redacted] confirmed with Mr. [redacted] that he was seeking his member number. Mr. [redacted] requested a new ID card be sent to Mr. [redacted] and Mr. [redacted] was given Mr. [redacted]’s contact information if he does not receive the new ID card.

Should you require anything further please feel free to contact me at ###-###-####.

Thank you,

[redacted] |Quality Assurance Coordinator

Avesis Incorporated |Essential Benefits

A National Vision, Dental and Hearing Company

[redacted]

###-###-####|Fax ###-###-####|###-###-####|

[redacted]@avesis.com|www.avesis.com