Beverly Healthcare

September 9, 2016Dear *** ***,I am writing in response to a letter we received from the Revdex.com dated September 2, 2036, concerning crowns and buildups for the subscriber's spouse.The patient became effective January 1, 2015, and is covered by the *** *** *** ***
*** Insurance Plan (***) which is offered by the *** *** ** *** *** (***)United Concordia administers and underwrites *** for ***As a Federal plan, *** is not subject to review,We received a predetermination for crowns and buildupsThe Dentist Advisor determined that based on the information provided that the crowns were denied as the service is used to restore tooth structure lost from attrition, erosion, or abrasionThe buildups were not approved because buildups are only covered benefits if there is insufficient structure remaining to hold a crownAs adverse determination of benefits letter was sent to the member and provider advising of the outcome, along with an Explanation of Benefits,We received another predetermination for a crown and buildupThe Dentist Advisor determined that based on the information provided that the crown is denied as the service is used to restore tooth structure lost from attrition, erosion, or abrasionThe buildups were not approved because buildups are only covered benefits if there is insufficient structure remaining to hold a crownAs adverse determination of benefits letter was sent to the member and provider advising of the outcome, along with an Explanation of Benefits.We received an inquiry for a second review for crowns and buildupsthe Dentist Advisor determined that based on the information provided that the crowns are denied as the service is used to restore tooth structure lost from attrition, erosion, or abrasionThe buildups were not approved because buildups are only covered benefits if there is insufficient tooth structure remaining to hold a crownAn adverse determination of benefits letter was sent to the member and pro??d?r, advising of the outcome, along with an Explanation of Benefits.All claims are processed according to the terms of the subscriber's contract and the information reported on the claim formin the *** benefit booklet on page 30, it specifically Excludes coverage for Services to alter vertical dimension and for restore or maintain occlusion, Such procedures include, but are not limited to, equilibration, periodontal splinting, full mouth rehabilitation, and restoration for misalignment of teeth.At this time the claim is eligible for an appeal with information addressing the denialThe provider can file an appeal or behalf of the member and can request a phone call from an Advisor during the reviewThere is three level appeal process, two internally and one external appeal is allowed by The Office of Personnel Management (***)This would be the first appeal of the three appeal processThis request must be in writing and include the provider's telephone number and the days and times he is available for a phone call.Sincerely,Matthew SSpecialized Services Unit Representative

June 29, 2015Dear *** ***:I am writing in response to a your email that was accessed on June 23, 2015, concerning a preauthorization claim for a crown on Tooth Number by *** ** ***, DMD.*** *** is covered as the member under a Dental PPO group plan through *** ***
***The effective date of coverage was September 1, 2014, under group number ***The situs of the fully insured plan is in Pennsylvania.All claims are processed according to the terms of the subscriber’s contract and the information reported on the claim formUnited Concordia dental contracts include provisions requiring input from our Dentist Advisors to determine financial responsibilityWe are responsible for ensuring that payment is appropriate for the care our subscribers receiveOur dental review program fulfills this responsibility.A Dentist Advisor then reviews the case by studying claims history, reports, correspondence, and diagnostic informationFollowing the review, the claim is processed based on the Dentist Advisor’s opinion and the subscriber’s contractA provider may submit a request for a second review to our Dentist Advisor Unit disputing an advisor denialIf upheld, the provider or subscriber may request an appeal within days from receipt.Crown and Onlay approval is based on submitted documentationThe tooth must include at minimum a periapical radiograph, demonstrate a significant loss of tooth structure that the tooth cannot be adequately restored using a direct restoration such as an amalgam or composite; must demonstrate no significant bone loss and the periodontal condition is adequate with no evidence that periodontal treatment is needed and has no periapical pathologyIf a root canal was performed, the radiograph must show the entire apices and demonstrate that the root canal meets acceptable standards of care.On February 13, 2015, we received a preauthorization claim, number *** for a surface porcelain onlay on Tooth Number for *** ***On March 3, 2015, our Dentist Advisor, SAR***, DMD, performed an independent review and determined that based on the information submitted, no payment would be made because the service did not meet contractual requirements for paymentCrowns, inlays, and onlays are only covered when the tooth is extensively decayed and/or has a complete cusp fracture (not craze lines) and cannot be restored by an amalgam (silver filling) or a composite restoration (filling)Crown benefits are not available for teeth that may fracture in the futureThis was explained on the Explanation of Benefits statement sent to *** and *** *** dated March 5, 2015.On March 26, 2015, we received a preauthorization claim, number *** *** for a surface resin (white) posterior restoration on Tooth Number for *** ***The service was approved allowing $minus $deductible leaving $payable at percent or a $payment and member’s liability $($deductible and $coinsurance)This was explained on the Explanation of Benefits statement that was sent to *** *** and *** dated March 26, 2015.On April 17, 2015, we received a preauthorization claim, number *** for a porcelain ceramic crown on Tooth Number for *** ***On May 6, 2015, our Dentist Advisor, SAR***, DMD, performed an independent review and determined that based on the information submitted, no payment would be made because the service did not meet contractual requirements for paymentCrowns, inlays, and onlays are only covered when the tooth is extensively decayed and/or has a complete cusp fracture (not craze lines) and cannot be restored by an amalgam (silver filling) or a composite restoration (white filling)Crown benefits are not available for teeth that may fracture in the futureThis was explained on the Explanation of Benefits statement sent to *** and *** *** dated May 7, 2015.On May 21, 2015, we received a call from *** regarding the denial for a crown on Tooth Number We explained how a second review could be requested and at that time the provider can also request a call from the Dentist Advisor during the second review.On May 21, 2015, *** called back and asked us to explain how to request a second review to the providerThe representative called the dental office and per ***’s request allowed provider to fax information to representativeThis information was received on May 22, 2015, and forwarded to our Dentist Advisor for a second review (Inquiry Number ***).On May 22, 2015, our Dentist Advisor, MTA***, DDS, performed an independent review and spoke to provider (*** ***) and explained that due to no extensive breakdown, crowns and onlays are not covered to prevent fractures in the futureThis was also explained on the Explanation of Benefits statement dated May 28, 2015.*** *** is a participating provider and these denials are not billable to the patient unless *** signed a statement agreeing to pay for the services if they were not approved by her insurance.If you have any questions, please call Dental Customer Service at ###-###-####.SincerelyDeb R.Specialized Services Representative

I am responding to your email, which we received on June 8, 2017, concerning dental claims for the *** of *** ***, seen by *** *** *** ***,Due to the Federal Health Insurance Portability and Accountability Act (HIPAA Privacy Act), we are unable to respond with a patient's protected
health information without the subscriber's written ConsentI have enclosed a copy of our Request and Authorization for Disclosure of Health Information form for that purposePlease resubmit your request with this completed form if you need detailed information.Please contact me if you have any additional duestions

January 11, Dear *** ***:I am writing in response to your email received January 03, 2017, concerning a predetermination for *** ***.We have not received federally required HIPAA authorization from the complainant to release protected health information concerning this account
Therefore I cannot disclose any information regarding this accountI have enclosed a HIPAA authorization form for you to return with the subscriber's signaturePlease return if you would like to pursue this complaint further.Sincerely,Matthew S*** Specialized Services Unit Representative

August 23, 2017Dear *** ***:I am responding to your email, which we received on August 15, 2017, concerning the predetermination claim for dental services proposed for *** ** ***.*** ** *** is covered as the subscriber under a self-funded Dental PPO group plan through ***, for which United Concordia only provides administrative services.All claims are processed according to the terms of the subscriber’s contract and the information reported on the claim form, United Concordia dental contracts include provisions requiring input from our Dentist Advisors to determine financial responsibilityWe are responsible for ensuring that payment is appropriate for the care our subscribers receiveOur dental review program fulfills this responsibility.United Concordia Dentist Advisors review cases by studying claims history, reports, correspondence and diagnostic information such as radiographsFollowing the review, the claim is processed based on the Advisor's opinion and the subscriber's contract, All claims are eligible for two independent reviews.The first review of the predetermination claim was performed by a licensed Dentist Advisor and it was determined that the information submitted did not meet our criteria for a benefitAdditional information was submitted for a second review, including a separate narrative from an endodontist who evaluated the memberThis information was reviewed by a second licensed Dentist Advisor and it was determined that the services could not be approved due to the poor long-term prognosis of the tooth.Upon receipt of correspondence from the member we arranged for the member's provider to speak with a licensed Dentist AdvisorAfter the conversation it was our advisor's opinion that the information initially provided supported the original denial and the information provided with the second review supported the change in the denial reason.All available reviews have been utilized for this predetermination claim.Our determinations are made for coverage purposes only and cannot supersede the professional judgement of the treating dentistIn all situations, the dentist must-use their professional judgement to provide care they believe to be in the best interest of the patientAs always, the dentist and member are responsible for treatment decisions.Please contact me if you have any additional questions.Sincerely,Lauren GSrService Representative Dental Customer Service Specialized Service Unit

March 15, 2017Dear *** ***:I am responding to your email, which we received on March 10, 2017, concerning a claim for dental services provided for *** ***.Due to the Federal Health Insurance Portability and Accountability Act (HIPAA Privacy Act), we are unable to respond with a patient’s
protected health information without their written consentI have enclosed a copy of our Request and Authorization for Disclosure of Health Information form for that purposePlease resubmit your request with this completed form if you need more information.Please contact me if you have any additional questions.Sincerely,Laura BLead Customer Service Representative Dental Customer Service Specialized Services Unit

*** *** *** *** *** *** *** *** *** *** *** *** *** ***I am responding to your email dated October 8, 2015, concerning dental services for *** *** ***I called *** dental office and they are in the process of submittingadditional
information for an appeal.*** is the spouse under a PPO group dental plan through ***Her coverage was effective August 19, 2012, and cancelled on March 1, 2015, undergroup number ***The group is self-insured, for which United Concordia Companies Incorporated provides administrativeservices only.I am enclosing a “Request and Authorization for Disclosure of Health Information form which is a mandatory Federal HIPAA requirement in order to release certain information to youAt this time there is no form on fileMember/spouse should complete, sign and return the form tothe address at the bottom of page two

June 15, 2016Dear *** ***:I am responding to your email, which we received on June 10, 2016, concerning a claim for dental services provided for *** *** on March 30, 2016.Due to the Federal Health insurance Portability and Accountability Act (HIPAA Privacy Act), we are unable to respond
with a patient's protected health information without their written consentI have enclosed a copy of our Request and Authorization for Disclosure of Health information form for that purposePlease resubmit your request with this completed form if you need detailed information.Please contact me if you have any additional questions.Sincerely,Tamera S.SrService Representative Dental Customer Service Specialized Service Unit

The following information will assist you in contacting us if you need additional assistance. The information provided on this cover letter is not intended for the complainant.Specialized Services Unit Toll Free Number: ###-###-####Fax Number: ###-###-####Address: United Concordia Companies, Inc.P.O.BOX [redacted] Harrisburg, PA [redacted]Sincerely,Matthew S[redacted]Specialized Services Unit Representative

Upon review of original reply it was determined the Authorization Form had not been included. This form is also avaiable to the member online at www.ucci.com

November 1, 2016Dear [redacted]:I am writing in response to your email received October 27, 2016, concerning a claim for [redacted].We have not received federally required HIPAA authorization from the complainant to release protected health information concerning this account. Therefore we cannot...

disclose any information regarding this account. I have enclosed a HIPAA authorization form for you to return with the subscriber's signature. Please return if you would like to pursue this complaint further.Sincerely,Serena W. Specialized Services Unit Representative

August 08, 2017Dear [redacted]:I am responding to your email, which we received on August 04, 2017, concerning the predetermination claim for dental services proposed for [redacted].Due to the Federal Health Insurance Portability and Accountability Act (HIPAA Privacy Act), we are unable to...

respond with a patient’s protected health information without their written consent. I have enclosed a copy of our Request and Authorization for Disclosure of Health Information form for that purpose. Please resubmit your request with this completed form if you need detailed information.Please contact me if you have any additional questions,SincerelyLauren G. Sr. Service RepresentativeDental Customer Service Specialized Service Unit,

[To assist us in bringing this matter to a close, you must give us a reason why you are rejecting the response. If no reason is received your complaint will be closed as Answered]
 Complaint: [redacted]
I am rejecting this response because: Laura from United Concordia has not answered any of my questions and continues to respond with a form letter that is complete non-sense. That is very insulting that she cannot respond a real person instead of a United Concordia Robot.  She has not responded to the attached email I sent her weeks ago.In the words of my periodontist,  and I quote"  United Concordia, they sure make life difficult for dentists and patients" .   In the words of my General Dentist"  No one should have to go through this for a simple dental claim" 
Why does United Concordia not show any respect for its members?  
Why do they constantly play games and lei to patients and dentists?  Why
did you tell me that my dental office never requested a call when they
did?  Why do you constantly say that the dentist never sent the X ray to
stall the claim?  Why does your customer service constantly lie.  I have put up with 6 years of Lies from them.    Why do you not answer questions? How about this
very simple question.   How deep does a periodontal pocket have to be 
before its a covered benefit?    These are very simple questions and I
DEMAND an answer to them.
I am tired of Concordia twisting information and the lies...   There is no consistency to the statements.  The first determination was denied because the dental advisor did not see bone loss,  now on the second run its to much bone loss to the apex of the tooth.  oh then maybe the gum infection is advance.  The bone loss is between the tooth and the tooth is stable but needs the treatment.   Get  real Concordia, that's why it needs the treatment and United Concordia is denying the claim because they are committing FRAUD!     Who care about the OPINION of  a 2nd rate licenced dental advisor.?   How about some FACTS United Concordia.  I Demand to be sent all the scientific data that has been used.  I demand to know when you authorize treatment,  Were is the Scientific Information for a prognosis.   Insurance companies have no right to make a prognosis to deny a claim.  In that case they can deny anything and commit FRAUD and even when they approve a claim they still try not to pay it.   That is completely UNETHICAL.   United Concordia needs to be STOPPED, and exposed for what they really are.   They are a criminal organization who is robbing members, employers and dentists.   People need to know about this, Employers need to know and drop United Concordia.  I hope the Revdex.com posts this information and gets the word out so others don't have to go through what I am.   
Regards,
[redacted]

August 24, 2017Dear [redacted]:I am writing in response to your email received August 21, 2017, concerning a claim for [redacted] submitted by [redacted].We have not received federally required HIPAA authorization from the complainant to release protected health information concerning this...

account. Therefore we cannot disclose any information regarding this account. I have enclosed a HIPAA authorization form for you to return with the subscriber's signature. Please return if you would like to pursue this complaint further.Sincerely,Serena W. Specialized Services Unit Representative

Date Sent: 9/23/2016 12:36:38 PMSeptember 23, 2016Dear [redacted],I am writing in response to a letter we received from the Revdex.com dated September 15, 2016, concerning crowns and buildups for the subscriber's spouse.Regarding claim [redacted] we researched why the claim was paid and discovered that a claims processing error occurred and the services were approved without ever having being reviewed by a Denta! Advisor. The claim was processed and approved one day after receipt of the claim. The review process normally takes approximately three weeks. This claim should not have been paid. According to the plan benefit services rendered due to attrition, erosion, and abrasion are part of the exclusion. However, we will not be seeking a refund for this service.All claims are processed according to the terms of the subscriber's contract and the information reported on the claim form. In the [redacted] 2016 benefit booklet, section seven, under General Exclusions on page 29, the seventh bullet point specifically states: Services to alter vertical dimension and/or restore or maintain the occlusion. Such procedures include, but are not limited to, equilibration, periodontal splinting, full mouth rehabilitation, and restoration for misalignment of teeth.Teeth that are naturally ground down due to wear and tear are provided crowns to restore the normal vertical height of the teeth so that the patient's natural bite height is restored. This would be the same as altering the vertical dimension.On September 22, 2016, we received an inquiry requesting an appeal for the crowns in question. A letter will be sent to the subscriber and provider advising of the outcome once completed, which will advise of additional appeal rights if necessary.Sincerely,Matthew S.Specialized Services Unit Representative

[To assist us in bringing this matter to a close, you must give us a reason why you are rejecting the response. If no reason is received your complaint will be closed as Answered]
 Complaint: [redacted]
I am rejecting this response because:  I absolutely and categorically reject the response from United Concordia.  I need to ask, once again, and refer Mr. Mathew S[redacted] to Section 7, pages 28 and 29.   General Exclusions - Things We Do Not Cover of my United Concordia 2016 [redacted] plan DOES NOT include nor does it even show the 3-words, attrition, erosion or abrasion.   The 7th bullet on page 29 of the General Exclusions does NOT mention or show the words "attrition, erosion or abrasion."    Mr. S[redacted] has now advised me twice by phone calls that the Primary Reason for denying this Claim is due to the word "EROSION".   So once again, I need to ask for United Concordia Dental to explain this?I will be taking this latest response from United Concordia dtd Sept. 23, 2016 to my Wife's (and my) Dentist for their Professional Review, evaluation and opinion.   In addition, I will wait for the a response from my 1st Appeal letter rec'd by United Concordia on Sept. 22, 2016.   I will continue to exercise my Appeal Rights if necessary.
Regards,
[redacted]

December 16, 2015Dear [redacted]:I am responding to your email dated December 4, 2015, concerning a complaint you received from [redacted], concerning a claim submission problem by an out of network pediatric dentist. We received your email on December 7, 2015.We have not received federally...

required HIPAA authorization from the complainant to release protected health information concerning this account. Therefore, we can only provide a general response to the information you provided in this complaint.A claim for [redacted]'s service in question was received and sent to process as a priority. An Explanation of Benefits statement will be sent to [redacted] on December 18, 2015.Sincerely,Deb R

January 11, 2017Dear [redacted]:I am responding to your letter dated January 5, 2017, which we received on January 6, 2017, concerning customer service issues involving a claim.We have not received specific claim information or federally required HIPAA authorization from the Complainant as required...

before we can release protected health information concerning a claim,I have enclosed a HIPAA authorization form that the subscriber can complete and return to you for your resubmission of this request with that authorization, and with the specific claim information that you are questioning. If the subscriber has any questions concerning their dental plan, they may call Dental Customer Service at ###-###-####.Sincerely,Marta M., Specialized Service Unit Dental Customer Service

[To assist us in bringing this matter to a close, you must give us a reason why you are rejecting the response. If no reason is received your complaint will be closed as Answered]
 Complaint: [redacted]
I am rejecting this response because:If they would like to send me the Authorization, I would be happy to sign it and return it to them.  Please let me know if there is anything I can do to assist with this matter.
Regards,
[redacted]

Please find response with attachments