Blue Cross Blue Shield of Arizona, Inc.

Review: I received a bill showing that I owe over $5,000 even though I have paid my bill regularly and on time. I have called customer service 3 times. Each time I was told that this is a mistake and that they would contact the Accounting Department via email. I was told that the Accounting Department would call me back. I was told that a corrected bill would be issued. Today I received a bill, once again, showing that I owe over $5,000. When I called, their automated system said I haven't paid since August 2014. This is incorrect. I asked [redacted] in customer service if I needed to show them my bank statements and she told me that she would have Accounting call me back. I asked if my insurance was going to be cancelled and she told me that she would have Accounting call me back.Desired Settlement: I want my account to show that is current and paid to date. I do not owe over $5,000 according to my records as well as those at Blue Cross Blue Shield of Arizona. I want my bill fixed.

Business

Response:

On behalf of Blue Cross Blue Shield of Arizona (BCBSAZ), I am responding to theRevdex.com’s complaint case#[redacted] filed by BCBSAZ member [redacted], concerning incorrect billing statements received for her IndividualBCBSAZ coverage plan. I hope this information is helpful.When your correspondence was received, we initiated a priority review of the concerns Ms. [redacted] brings to yourattention. Our records do not document our receipt of a release authorizing usto share protected information with your agency, therefore, due to privacyconsiderations, I am limited in the information I am able to share. I can however, tell you that our review determined prior processing to this member’s BCBSAZ coverage plan had in fact, created an outof balance accounts receivable situation that affected the plan’s premiumbillings. This error has been corrected and Ms. [redacted] has been contacted withconfirmation and our apologies for any inconvenience caused. We believe thisissue is being resolved to the member’s satisfaction. I hope this information is helpful. We do appreciate the opportunity to reviewthis situation for our member and thank you for bringing it to ourattention. If you have additionalquestions or information regarding this situation, please feel free to contactme.Sincerely, [redacted]Corporate OmbudsmanOffice of the PresidentBlue Cross® Blue Shieldof Arizona[redacted]

Consumer

Response:

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: Approximately one month ago I submitted a prescription to be filled at a local pharmacy and was told that my insurance, Blue Cross/ Blue Shield of Arizona, required a prior authorization to be submitted by the doctor in order for the prescription to be covered under my insurance.

Remaining faithful to this obligation, I had my doctor fill out an official Blue Cross/ Blue Shield of Arizona prior authorization form, included with it the required 2 doctors office notes and had the entirety of the paper work to Blue Cross/ Blue Shield of Arizona on 2/25/14. The following Tuesday, the 4th of March, after having heard nothing from the company for a week, I called the customer service line to find out any information regarding the processing of my request.

An outsider contractor, [redacted], is responsible for phone based pharmacy benefits customer service for Blue Cross/ Blue Shield of Arizona and I spoke with a customer service representative at this business. The representative informed me that Blue Cross/ Blue Shield had not received my faxed prior authorization forms. I requested that the representative contact Blue Cross/ Blue Shield to confirm this on the phone. After [redacted] called Blue Cross/ Blue Shield I was informed that Blue Cross/ Blue Shield had received the prior authorization forms but had misplaced them at some point in the past week and had now found them. I was also told that Blue Cross/ Blue Shield would be placing the prior authorization under "urgent" status and that this would expedite the process to no more than 72 hours. I was told this on Tuesday the 4th of March.

I called again on Thursday the 6th of March to inquire about the process and was told it had not been completed. I called again on the 7th of March, a full 72 hours after the process had been expedited to "urgent," to inquire about the process and was told that it had not been completed. I explained to the customer service representative that the 72 hours for processing had passed and that I expected my prior authorization to be processed that day. I also informed them that I was out of my medication and would have to pay several hundred dollars for it the following day if I did not obtain approval of coverage from Blue Cross/ Blue Shield in the next few hours. I was told I would receive a call back when the process had been completed. I received no call back on the 7th of March. On the 8th of March I was forced to pay full price, over 200 dollars, for my medication as it is a maintenance medication and I am unable to go even a single day without it.

The following Monday, the 10th of March, I again contacted [redacted] to inquire about the process and was told that an "urgent" account for my prior authorization had not yet been created. I informed them that the 72 hour time limit had already been exceeded by 3 days and I found it unacceptable that an expedited prior authorization had taken this long. I requested that they again contact Blue Cross/ Blue Shield and they did so promptly by phone. I was told, after they had contacted Blue Cross/ Blue Shield, that the prior authorization would be up for review the same day, the 10th of March and that I would receive a call back on either the 10th of March or the morning of the 11th of March regarding the decision. At the end of the business day on the 11th of March, after not receiving any phone call regarding the decision, I again called to inquire about the process. I was informed, counter to prior claims, that the "urgent" account had not yet been created. I informed the representative that this ran counter to the claims made yesterday and that I wanted them to contact Blue Cross/ Blue Shield again. After they called Blue Cross/ Blue Shield, I was told that representatives at Blue Cross/ Blue Shield were aware of the situation and would contact me when the decision had been made. With no other recourse, I decided to wait until the following day to call again.

Today, the 12th of March, I placed my most recent phone call regarding the status of my prior authorization and was informed that the "urgent" account had yet to be created for my prior authorization, counter to claims made the day before and the day before that. I demanded that Blue Cross/ Blue Shield be contacted immediately and that the issue be resolved immediately and that I was exceedingly frustrated that Blue Cross/ Blue Shield continued in its failure to process my prior authorization in a timely manner. The representative at [redacted] had a senior representative contact Blue Cross/ Blue Shield by phone and was told that the prior authorization had still not been up for review yet but that it would be sent to review. Blue Cross/ Blue Shield informed [redacted] and myself that they had no definite timeline for the amount of time needed to complete this process. I was transferred directly by phone to the senior representative at [redacted] to explain my issue and was informed that this issue had been "directly" addressed and that, despite previous failures, this current attempt would be successful. I informed this senior representative that I would call back tomorrow, the 13th of March to confirm the review had taken place.

I am lodging this complaint because, after many attempts and failures to have Blue Cross/ Blue Shield complete review of my prior authorization in a timely manner, I currently possess zero faith that they will be able to complete the review without being encouraged to do so through this complaint process. ,Desired Settlement: I am requesting three responses for this issue. The first is that a senior authoritative member of the relevant department of Blue Cross/ Blue Shield personally insure that my prior authorization has been processed fully and justly. My second request is that this senior member contact me personally by phone as soon as possible to confirm that my prior authorization has been processed fully and justly. The third request is that I receive, in written form, an official explanation and apology by Blue Cross/Blue Shield of Arizona explaining why they first lost my paperwork and then failed to live up to their contractual obligations to process my prior authorization in a reasonably timely manner.

Business

Response:

On behalf of Blue Cross Blue Shield of Arizona (BCBSAZ), I am responding to the 3/13/14 Revdex.com case# [redacted], filed by BCBSAZ member [redacted], concerning the processing of his prescription claims. I hope this information is helpful. Our records do not document a release, authorizing us to share specific protected information with your agency; however, I can tell you that when we received Mr. [redacted]’s concern, we initiated a priority review. As a result, the necessary precertification was obtained, the claim was resubmitted and reimbursement will be made for any direct RX purchases obtained during this process. BCBSAZ also acknowledges the confusion Mr. [redacted] noted and has corresponded directly with Mr. [redacted] via telephone call, email and a follow up written response from our Vice President of Pharmacy Management on 3/13/14 to apologize for any confusion and confirm our resolution to this matter. We believe resolution to this issue has been achieved with our member and will continue to communicate directly with him to address further questions he may have. If you have additional questions, please feel free to contact me. Please note that my new email is: [redacted].[redacted].com Sincerely, [redacted]Corporate OmbudsmanOffice of the PresidentBlue Cross® Blue Shield® of Arizona

Consumer

Response:

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

Regards,

Review: On May 2nd, 2013 I went to the emergency room at [redacted] hospital located on [redacted] and the [redacted] freeway to be seen for tachycardia. I used my Blue Cross Blue Shield of Arizona health insurance card (member number [redacted]) that specifically states that there is a $150 dollars copay for the ER visit. After a month I receive three bills for my 30 minutes spent in the hospital. The first bill was for $608 from the hospital,$757 from the physician Dr [redacted], and $13 from the Xray lab. When I called Blue Cross Blue Shield of Arizona, a customer service representative called [redacted] told me that the reason why my insurance did not cover my bills is because there is a deductible of $3000 and I only met $752.18. According to them I got to pay the physician because she is an out-of network provider which in that case I did not have the option to choose who would see me. The representative [redacted] told me that BCBSaz will not cover for my bills because I did not meet my deductible. The thing is that nobody explained to me that a deductible of $3000 has to be met before you do not pay the full amount of the bill and that it is now my responsibility to pay for it. I wished I a representative explained that to me before I even enrolled in the service they offer. What I understood from the card is that I am only responsible for the $150 visit to the ER. These bills are causing financial harship for my family since I am the only one working right now and making $1800 per month. I have a new born at home that requires from my income for her care and I am also a full time [redacted] student.Desired Settlement: I need BCBSaz to pay for the bills that I was not expecting to receive.

Business

Response:

On behalf of Blue Cross Blue Shield of Arizona (BCBSAZ), I am responding to the Revdex.com’s (Revdex.com) complaint #[redacted], filed by BCBSAZ member [redacted] and sent to BCBSAZ on Saturday, 8/24/13. I hope this information is helpful.

Our records do not document receipt from the member authorizing us to disclose specific information with your agency, which limits the information I am able to share. I can tell you however, that when we received the concern noted above on Monday, August 26, the member grievance process was initiated. A letter acknowledging receipt and the initiation of this grievance review was mailed to Mr. [redacted] on August 27, 2013. The correspondence received from your office will be included for consideration in this review. As outlined in the BCBSAZ Health Coverage Appeal process, BCBSAZ will complete its review of Mr. [redacted]’s request and send a written response advising of the decision directly to him.

We will continue to communicate directly with Mr. [redacted] in response to his request. We do appreciate the opportunity to review this situation and thank you for bringing it to our attention. If you or Mr. [redacted] have questions, you are welcome to contact me.

Sincerely,

Corporate Ombudsman

Office of the President

Blue Cross® Blue Shield® of Arizona

Consumer

Response:

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 the action requested by me in my original complaint (refund) and, if it does, will consider this complaint resolved.

Regards,

Review: I received notice this month that I am not allowed to keep my health insurance plan. Under ACA a policy is grandfathered if you had it in effect when the ACA law was passed in 2010. My policy was in effect but I have been told by Blue Cross Blue Shield of Arizona (BCBS) that I am not grandfathered because of a policy change made in 2011. This change was suggested by the BCBS representative to keep my yearly premium increase to around 5%. I was not informed that any changes to my plan would cause a loss of my grandfathered status. I believe that the BCBS representative purposely avoided disclosing this information. I made it very clear that the reason for the call was to ensure I could afford to continue my insurance policy.

My current monthly plan costs approximately $120. BCBS is currently quoting me a rate of $497 per month for 2014. This now seems like a bait and switch in order to get me to pay 300% more in monthly premiums.Desired Settlement: I am requesting my plan retain its grandfathered status.

Business

Response:

On behalf of Blue Cross Blue Shield of Arizona (BCBSAZ), I am responding to the Revdex.com’s complaint case# [redacted], filed by BCBSAZ member [redacted], concerning changes he requested to his Individual BCBSAZ coverage plan. I hope this information is helpful.

When your correspondence was received, we initiated a priority review of the concerns Mr. [redacted] brings to your attention. This will also confirm that Mr. [redacted] contacted BCBSAZ directly and we will be communicating our findings directly with him.

Our records do not document our receipt of a release from Mr. [redacted], authorizing us to share protected information with your agency, therefore, due to privacy considerations, it is necessary that we correspond directly with our member regarding the details related to his concerns regarding his plan. I can tell you that BCBSAZ has been diligent in its efforts to make sure our members received information about the new Affordable Care Act regulations and plan requirements.

I hope this information is helpful. We do appreciate the opportunity to review this situation for our member and thank you for bringing it to our attention. If you have additional questions or information regarding this situation, please feel free to contact me.

Sincerely,

Corporate Ombudsman

Office of the President

Blue Cross Blue Shield of Arizona

ph: ###-###-####

Consumer

Response:

I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that this proposed action would not resolve my complaint. For your reference, details of the offer I reviewed appear below.

I have not received communcations from Blue Cross and Blue Shield of Arizona on this matter. My initial contact requested a review and documentation which I have not received. I was promised documention. Thus a Revdex.com complaint was filed. I am still waiting for a review and subsequent call from Blue Cross and Blue Shield of Arizona.

I am still waiting.....

Regards,

Review: I went to the emergency room on 4/8/13 [redacted] Claim # 0[redacted] . It clearly states on my blue cross medical card that there is a $150 copay for an emergency visit. [redacted] I was hit with $2000 in medical bills that bcbs refused to pay for this emergency visit.Desired Settlement: pay my bills

Business

Response:

On behalf of Blue Cross Blue Shield of Arizona (BCBSAZ), I am responding to the Revdex.com’s complaint case#[redacted], filed by BCBSAZ member[redacted], concerning the processing of claims under her BCBSAZ Individual benefit plan. I hope this information is helpful. Our records do not document our receipt of a release from the member, authorizing us to share specific protected information with your agency, therefore, due to privacy considerations, it is necessary that we correspond directly with our member regarding her BCBSAZ claims. This will confirm however, that our records confirm that the claims in question were processed correctly and in accordance with the member’s benefit plan, which includes a calendar year deductible, coinsurance and emergency room access fees. This will also confirm that a detailed explanation has been mailed directly to Ms. [redacted]. We regret that this may not be the answer hoped for, but we are required to administer all aspects of our benefit plans, including those related to member cost share in a consistent manner for all BCBSAZ members. If you have additional questions, you are always welcome to contact me.Sincerely, [redacted]Corporate OmbudsmanOffice of the PresidentBlue Cross® Blue Shield® of Arizona[redacted]

Business

Response:

On behalf of Blue Cross Blue Shield of Arizona (BCBSAZ), I am responding to the follow up request dated 7/26/13, submitted by BCBSAZ member[redacted], to the Revdex.com’s case#[redacted]. As noted previously, our initial review shows that the claims in question processed correctly and in accordance with the benefit plan purchased by the member, which includes a calendar year deductible, member coinsurance as well as applicable the emergency room access fee. This will also confirm that based on the stated concerns, the member grievance process has been initiated. A letter of acknowledgement has been mailed directly to the member and as outlined in the BCBSAZ Health Coverage Appeal and Grievance process, BCBSAZ will complete this review and also provide written communication of the determination directly to the member. If you or Ms. [redacted] have additional questions, please contact me.Sincerely,[redacted]Corporate OmbudsmanOffice of the PresidentBlue Cross® Blue Shield® of Arizona[redacted]

Consumer

Response:

I have reviewed the response made by the business in reference to complaint ID[redacted], and have determined that this proposed action would not resolve my complaint. For your reference, details of the offer I reviewed appear below.[redacted]

Attached is a screenshot of my account on your website that clearly states that the copay for an ER visit is $150, yet we have been charged over $1500 for our ER visit.

Regards,

Review: Blue Cross changed my insurance plan from [redacted] to [redacted] without my knowledge. They blamed the discrepancy on [redacted] although BCBS has been difficult to work with from the beginning.

My son was born on January 23rd 2014 and we attempted to add him to my coverage plan. It took many calls to accomplish this and the frustration level on my family's part was very high during this process.

In my opinion BCBS purposely made the process difficult because I bought the policy on the [redacted] site.

I was told in late October that the insurance card I have been using all year was not correct and now I have a billing discrepancy of $358.

I am very disappointed with the conduct of BCBS and even though they admitted that I never authorized them to change my plan, they insist on blaming the situation on [redacted].

I am needing BCBS to pay my claims because they changed my healthcare plan without my knowledge or permission.Desired Settlement: I am needing BCBS to pay physician claims of:

$130 to [redacted] (two claims of $85)

$268 to [redacted]

Business

Response:

On behalf of Blue Cross Blue Shield of Arizona (BCBSAZ), I am responding to theRevdex.com’s complaint case# [redacted], filed by [redacted], concerning a change made to his BCBSAZ coverage plan and subsequentclaims that have been processed. This will confirm that [redacted] has alsocontacted the Federal Facilitated Marketplace and BCBSAZ has been in directcontact with him regarding this concern. It may be helpful to first clarify that BCBSAZ must follow certain direction providedby the Marketplace when a consumer purchases coverage On the Exchange. This will also confirm that BCBSAZ received notice from the Marketplace on November10, 2014 authorizing BCBSAZ to correct a coverage plan change inadvertently madeby the Marketplace when [redacted] communicated a change in his plan’s dependentstatus earlier this year. BCBSAZ has been in contact with [redacted] and hisproviders to confirm the necessary corrections are in process. All affected claimsfor services will be adjusted to process according to the corrected benefitplan’s specifications. We will continue to communicate directly with [redacted] on this process. We do appreciate the opportunity to review and resolve this situation with ourmember and thank you for bringing it to our attention. If you have additional questions, please feelfree to call me.Sincerely,[redacted]

Corporate OmbudsmanOffice of the PresidentBlue Cross® Blue Shield®of Arizona[redacted]

(please note - my email has changed)

Review: I have been a member of Blue Cross Blue Shield for many years and have never had to use my insurance but the one time I do, and NOBODY is available (either through email or phone) to help me get care. I work during the only hours when you can call Blue Cross Blue Shield to ask for help in getting care and when I do take a break from work to call them I get put on hold. The website does not let me set up an online account with them and my emails don't get sent. I will be making a complaint with the regulatory body that oversees the health insurance industry as well.

In September, I received a letter that I could stay on the grandfathered plan that I have if I did not respond to the letter or I could look for another plan covered under the Affordable Car Act. I didn't respond to the letter, and while my increased premiums have been continually taken from my account, I have yet to receive an updated member card. I am feeling ill now, and went to a doctor in the network and was told a physical would cost me $170 while my understanding is I can make three doctor visits a year for $25 a visit. I am now confused and without a member card (even though I am paying). I NEED AN ANSWER.

Once again, I AM ILL, so a prompt response would be appreciated. And I will be filing a complaint with the regulatory agency that oversees the insurance industry.Desired Settlement: Simply put........AN ANSWER......and answer for all the premiums I have been paying you folks.

Business

Response:

On behalf of Blue Cross Blue Shield of Arizona (BCBSAZ), I am responding to the Revdex.com’s 1/26/15 complaint case# [redacted], filed by BCBSAZ member [redacted], regarding his concerns related to contacting BCBSAZ. I hope this information is helpful.When your correspondence was received, we initiated a priority review of the concerns [redacted] brings to your attention. [redacted] also contacted BCBSAZ via email. Although attempts to reach him by phone were unsuccessful, our records confirm we have been communicating with [redacted] via email to address his questions, including confirming his address to ensure receipt of his identification cards and plan information as well as those related to the benefits provided under his BCBSAZ plan. Our records reflect email communication on 1/24/15, 1/26/15 and 1/28/15. We will continue to correspond directly with [redacted] to address any questions he may have. I hope this information is helpful. We do appreciate the opportunity to review this situation for our member and thank you for bringing it to our attention. If you or [redacted] have additional questions, you are also welcome to contact me.Sincerely, [redacted]Corporate OmbudsmanOffice of the President Blue Cross® Blue Shield® of Arizona[redacted]

Consumer

Response:

I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that this proposed action would not resolve my complaint. For your reference, details of the offer I reviewed appear below.

[redacted],I have been a Blue Cross Blue Shield customer for many years now. Every month, I faithfully pay my premium, without having been late on a payment once, NOT ONCE. I make sure of this by having them automatically take my premium from my account every month on the same day of the month. I have faithfully made sure that every month on that day, the funds are in the account whether I have had a good month, financially, or not. I have continued being a customer with them through the years despite the annual premium increases. I have never made a medical claim since being a customer, and the one time ...the one time in all these years I have been ill, after having been a faithful paying customer, I can't reach anybody....NOBODY. The number to call for assistance is only available from 8 to 4 Monday through Friday, so any normal gainfully employed person will have a hard time reaching them. I called them the Friday before I entered the Revdex.com complaint and was put on a hold and had to almost go without lunch that day because it's only time I had to make a call at work. On Saturday, the next day, I went to their site and the only.....ONLY....phone number where you could reach anyone was to the sales department. So on a Saturday, I can be sick and dying without any hope of reaching anybody for help with my policy but I can sure as hell buy a new policy if I wanted to. [redacted], I feel robbed. I feel like all my years of paying premiums were for naught. After making an emailed complaint to Blue Cross Blue Shield on that very same Saturday I did receive an email response the next day. Fortunately my sickness didn't put me in the hospital where a day might have been a day too late, but I still feel robbed. If Blue Cross Blue Shield operated with any good faith towards their customers they would at the very least have their customer service department operate with the same hours of operation as their sales department does. It's really a damned shame that the Affordable Car Act has now made us hostages to the whims of these greedy [redacted] insurance companies.[redacted]

Review: Around January of this year, I spoke with an insurance salesman about a blue cross blue shield health insurance policy. I am covered by Health Net and was at the time as well (and have been without any lapse in coverage). The salesman told me that I should fill out the application for the policy in case I did decide to go with BCBS. I did want to consider other options but was not sure that I would change health insurance providers. I made the decision to stay with Health Net in February and I did notify the insurance salesman to let him know that I had decided to stay with Health Net. I recently found that BCBS of AZ has been debiting my checking account for $254 a month since March 2015. I never authorized this transaction.Desired Settlement: I would like all of the money that BCBS of AZ took from me back.

Business

Response:

On behalf of Blue Cross Blue Shield of Arizona (BCBSAZ), I am responding to the Revdex.com’s complaint case# [redacted], filed by [redacted], concerning the issuance of an Individual BCBSAZ coverage plan. We hope this information is helpful.Our records do not indicate receipt of a release authorizing BCBSAZ to disclose specific information with your agency. I can tell you however, that when your correspondence was received, a priority review was initiated to assess the concerns Mr. [redacted] brings to your attention. Our review showed that both Mr. [redacted] and the broker associated with this coverage plan recently contacted BCBSAZ and review of this concern was already in process. Although review of BCBSAZ records does confirm receipt of a completed enrollment request, which was processed appropriately in accordance with BCBSAZ standard procedure, it is the contention of both Mr. [redacted] and the agent of record that there was no intention of submitting this application. Based on these findings, BCBSAZ has agreed to cancel this coverage plan as though it were never in effect and refund all premiums paid. An outreach call was made to Mr. [redacted] on July 22, 2015 to confirm this action and he indicated his approval. Again, I hope this information is helpful. We do appreciate the opportunity to review this situation. If you have additional questions regarding this situation, please feel free to contact me.Sincerely,[redacted]Corporate OmbudsmanOffice of the PresidentBlue Cross® Blue Shield® of Arizona

Review: I submitted a pharmacy reimbursement to blue cross of arizona and sent all forms I was told to fill out plus the copies of the pharmacy slips from rite aid.

I received a letter from [redacted] showing that no reimbursement was issued. All that was on the single piece of papers was a list of the amounts requested and zeros for amount reimbursed. There was no explanation of why the reimbursement was denied. I then called blue cross of arizona and inquired about it. The employee there told me that they did not show any insurance for myself. I then gave her the info on my primary insurance which is blue cross of [redacted] blue cross of arizona is my wifes primary and my secondary.

I was then transfered to [redacted] at ###-###-####. After about 20 minutes I was told that the claim was being escalated and that I would need to call back in 4 days (october 22nd)

and ask what the status was. I called today and was transfered twice and no one could tell me why the claim was denied or if infact it was denied.

I have hit dead end after dead end between blue cross of arizona and [redacted].Desired Settlement: I want my reiembursement claim of $100.13 to be paid asap or I would like to have our insurance with blue cross of arizona canceled and all our premiums paid to date refunded.

I have not been even clos to satisfied with this companies service so far. I don't understand how blue cross of [redacted] can provide such great service and handle there own pharmacy claims and arizona blue cross farms it out.

Business

Response:

Dear Ms. [redacted]:

On behalf of Blue Cross Blue Shield of Arizona (BCBSAZ), I am responding to the 10/23/13 Revdex.com’s case# [redacted] filed by BCBSAZ member [redacted], concerning the processing of prescription claims. I hope this information is helpful.

Our records do not document a release, authorizing us to share specific protected information with your agency, which limits the information we are able to share. It may be helpful however, to first note that as Mr. [redacted] mentions, he is covered as a dependent under his wife’s BCBSAZ employer group benefit plan as his secondary coverage. It appears that the claims in question were already processed by Mr. [redacted]’s primary coverage plan, which is not based with BCBSAZ. This will also confirm that an outreach to Mr. [redacted] is being made in an effort to discuss his concerns in further detail and answer any questions he may have about the claims.

It may also help to note that we are required to administer all aspects of our benefit plans, including those related to prescription claims processing in a consistent manner for all BCBSAZ members. If you or Mr. [redacted] have additional questions, you are always welcome to contact me.

Sincerely,

Corporate Ombudsman

Office of the President

Blue Cross® Blue Shield® of Arizona

###-###-#### |

fax: ###-###-####

[redacted] | [redacted]

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: On September 7th 2012 I visited [redacted] Family Medicine (Dr. [redacted]). Dr. [redacted] requested a series of tests on my behalf, one of them being "[redacted]" test, which was submitted to [redacted]. During my visit, neither Dr. [redacted] nor his staff disclosed that I would be taking part in "experimental testing" that traditional insurance does not cover.

Unfortunately, I wouldn't find out until much too late that Blue Cross Blue Shield of Arizona did not cover this type of test. Needless to say Blue Cross Blue Shield of Arizona summarily denied the claim from [redacted] who then proceeded to bill their customer directly.

On September 15th 2012 my wife called and spoke with David from [redacted] who advised that the test was denied because it was not medically necessary.

Why would my physician order a test that was not medically necessary?

As a follow up my wife contacted [redacted] from Blue Cross Blue Shield of Arizona who advised that a new code would have to be submitted to obtain coverage for the test.

Why would a new code change the fact that the test wasn’t medically necessary in my case?

Regardless, my wife did as she was asked and contacted [redacted] from [redacted] Family Medicine to have new codes submitted to Blue Cross Blue Shield on October 16th 2012, which [redacted] failed to send according to Blue Cross Blue Shield. After numerous calls by my wife to [redacted] Family Medicine, [redacted] finally found the time to talk with Dr. [redacted] on November 27th 2012 to ask why he had ordered an experimental test on a patient and submitted a different code to the insurance company.

Two months later on February 27th 2013 [redacted] from Blue Cross Blue Shield of Arizona advised my wife that the claim was still being denied since it “didn’t meet the criteria for approval” but [redacted] was unable to provide my wife necessary detail to fix the issue. At this point [redacted] asked my wife to have my full medical records forwarded to them for review.

Around March 2013 I called [redacted] Family Medicine to have my medical records faxed and was informed that I would need to submit a release request form, which I submitted relatively soon after. To date we have not received the copy of our medical records despite my wife’s numerous attempts to contact [redacted] Family Medicine on this subject. At this point [redacted] won’t even return phone calls or return messages repeatedly left by my wife, and is of no help at all.

At the base of this complaint, for the life of me, I can’t even figure out why I’m being impacted by this.

1) I didn’t order the test, my Dr. [redacted] did.

2) I didn’t administer the test, [redacted] did.

3) I didn’t submit the test for coverage through my insurance, [redacted] Family Medicine and [redacted] did.

4) I didn’t fail to pay the bill, Blue Cross Blue Shield of Arizona did.

From my perspective this debacle has nothing to do with the customer at all. This is simply some bureaucratic financial dance that should be settled between the Physician’s office, the lab and the insurance company. I simply went to, and trusted my physician knowing that I had paid my insurance premiums in full and therefore should be covered for the procedures that my medical professional deems necessary. I would hope that the relatively insignificant dollar amount of $202.28 can be settled on the business side keeping the customer out of it.

At this point, [redacted] is threatening to send me to collections over this ridiculous issue. If that happens I will be forced to escalate this issue past the Revdex.com. Please do the right thing here.Desired Settlement: Work out the billing with Blue Cross Blue Shield of Arizona and [redacted] or simply pay the claim.

Business

Response:

On behalf of Blue Cross Blue Shield of Arizona (BCBSAZ), I am responding to the Revdex.com’s complaint ID#: [redacted], filed by BCBSAZ member [redacted], concerning the processing of his claims under his wife's BCBSAZ employer group plan. I hope this information is helpful.

Our records do not document our receipt of the member’s authorization allowing us to disclose specific information with your agency, which limits the information that I am able to share. I can tell you however, that Mr. [redacted] also sent a copy of his concern noted above to BCBSAZ. Our review shows that when this correspondence was received, the member’s appeal process was initiated. A letter acknowledging receipt and the initiation of this appeal was mailed to Mr. [redacted] on June 24, 2013. As outlined in the BCBSAZ Health Coverage Appeal process, BCBSAZ will complete its review of Mr. [redacted]’ request and send a written decision within 30 days.

We will continue to communicate directly with Mr. [redacted] in response to his request. We do appreciate the opportunity to review this situation and thank you for bringing it to our attention. If you have additional questions, please feel free to contact me.

Sincerely,

Corporate Ombudsman

Office of the President

Blue Cross® Blue Shield® of Arizona

Consumer

Response:

I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that this proposed action would not resolve my complaint. For your reference, details of the offer I reviewed appear below.

Regards,

We will file a grievance form, but I don't agree that I have a grievance at all.. I believe that [redacted] and ultimately [redacted] Family Medicine has a grievance and should be taking the appropriate steps to reconcile that grievance. It is a vastly unprofessional practice to involve mutual customers in billing issues generated by business to business practices.

That being said, if Blue Cross Blue Shield of Arizona can prove that I have made an error as the customer.. I would be more than happy to pay the bill in full with any penalties or fees associated with it.

Business

Response:

On behalf of Blue Cross Blue Shield of Arizona (BCBSAZ) I am responding to the reply dated 7/9/13, referencing The Revdex.com’s case #[redacted], which was filed by BCBSAZ member [redacted].

This will confirm that the correspondence mentioned above will be included for consideration in the current review noted in our response of 6/27/13. BCBSAZ will complete its review of this case and will communicate the decision in writing to Mr. [redacted] within the time frame as outlined in the established grievance and appeals process.

Thank you for forwarding this information on to BCBSAZ. If you or Mr. [redacted] have any questions, you are always welcome to contact me direct.

Sincerely,

Corporate Ombudsman

Office of the President

Blue Cross® Blue Shield® of Arizona

Consumer

Response:

I have reviewed the response made by the business in reference to complaint ID [redacted], and have determined that this proposed action would not resolve my complaint. For your reference, details of the offer I reviewed appear below.

Regards,

Still waiting on resolution

BCBS has the WORST customer service organization I have ever seen. I have had to call you each day for the last 3 days, to solve the same problem. Why is it you can get it you can fix my start date of Feb. 1st fixed, and stay fixed. Your phone system is the worst. When I log onto your web site, it tells me to call (602)864-4115, but you can't, because it is always busy. I am then forced to call the (855) 818-0240, but each time, I am kept on hold for over 45 minutes. Your system sucks. FIX IT

Review: BC/BS has me on 2 contracts as an active member. ID # are [redacted] which ended 12/31/2015 and was overpaid and [redacted] which is active since 01/01/2016 and is paid on time and in full. Now BC/BS sends me a notice of "Holding Your Claims" for # [redacted] and refuses to pay for medical bills. About a month ago I talked to a supervisor of BC/BS and was promised(and I quote) " to clean up this mess and send deduct the overpay from the 2015 plan to the 2016 plan. Nothing happened!!!!!! BC/BS is almost impossible to reach by phone and my call back requests have been ignored. I do not owe anything to BC/BS and this issue needs to be fixed on a higher management level.Desired Settlement: BC/BS needs to sort this out and adjust the billing. Also there are medical bills of around [redacted] dollars for lab work and ultra sound procedures that need to be paid immediately.

Business

Response:

On behalf of Blue Cross Blue Shield of Arizona (BCBSAZ), I am responding to the 2/8/16 Revdex.com’s case# [redacted] filed by BCBSAZ member [redacted], concerning duplicate enrollment with BCBSAZ in an Individual ON Exchange Medical plan. Because our records do not indicate receipt of a release from the member authorizing BCBSAZ to disclose specific information with your agency, I am limited in the information I am able to share. I can tell you however, that when your correspondence was received, a priority review was initiated to assess the concerns Mr. [redacted] brings to your attention. It may be helpful to first note that when a medical plan is purchased ON Exchange, BCBSAZ is required to follow directive as received from the Marketplace. I hope the following information is helpful. Our records confirm Mr. [redacted]’s comments regarding confusion with regard to receipt and BCBSAZ’s handling of his 2016 BCBSAZ enrollment, which resulted in the issuance of a duplicate identification (ID) number. BCBSAZ acknowledges the confusion noted above and this will confirm that our Membership Services office contacted Mr. [redacted] directly via telephone call on 2/10/16 to apologize and confirm our resolution in his ID number assignment. This will also confirm that premiums are being credited to the appropriate benefit plan and claims for services are being adjusted accordingly. We do believe an agreeable resolution to this issue has been met and will continue to communicate directly with Mr. [redacted] to address any questions that may arise. Again, we hope this information is helpful and sincerely apologize for any confusion or inconvenience that may have resulted. If you or Mr. [redacted] have questions, you are also always welcome to contact me. Sincerely, [redacted]

Consumer

Response:

Hello, I just checked what BC/BS did to FIX the problem. I received a call from them, telling me that I do not owe any money to BC/BS and they wanted to deactivate the old plan [redacted] and apply the overpayment to the active plan [redacted]. Now the plan [redacted] (ended 12/31/2015) shows an open balance of [redacted]. This plan was always paid in full, actually overpaid by $ [redacted] which should be credited to my active plan [redacted]. The 2016 plan is correct, except the credit of the [redacted]So they did not what they said they do and I still have 2 active plans in their system. It is actually an easy fix, BC/BS should really get somebody with common sense on that case and it could be resolved in minutes. Zero out plan [redacted] and deactivate it and apply the 13.58$ credit to my account[redacted]. DONE!I am really upset, because BC/BS makes it look like I did not pay, and I am very particular with my payments. My bills get normally paid about 2 weeks before they are due. Well, I hope this helps to clean up this mess and I hope I never have a real complicated case with BC/BS Arizona. Respectfully [redacted]

Business

Response:

On behalf of Blue Cross Blue Shield of Arizona (BCBSAZ), I am responding to the Revdex.com’s (Revdex.com) second submission of case#[redacted] had previously expressed concern with the handling of a duplicate enrollment situation that occurred with his Individual ON Exchange medical plan through the Federal Marketplace. Please refer to BCBSAZ’s response dated 2/11/16 to the initial Revdex.com case #[redacted] with acknowledgement and apology for the initial confusion related to Mr. [redacted]’s concern. I hope this information is helpful. BCBSAZ had initially contacted Mr. [redacted] on 2/10/16 to acknowledge our awareness of this situation regarding the duplicate enrollment situation and to advise of the initiation of correction efforts. Upon receipt of the second Revdex.com notice, additional member outreach was conducted. On 2/16/16, Mr. [redacted] was contacted again by phone to apologize for remaining confusion and to explain that full resolution of this situation, which impacted his premium and claims requires a multi-day correction process. Additional communication on the status of this effort was provided on 2/18/16. We are very sorry for the delay associated with this correction process and will remain in direct contact with Mr. [redacted] to ensure all questions are addressed and final resolution of this matter. Sincerely, [redacted] Blue Cross® Blue Shield® of Arizona (602) 864-4448 | cell: (602) 320-7229 fax: (602) 864-4376 [email protected]

Review: On August 20, 2012, I terminated my employment with the Federal Government and secured other employment. Since my departure date from the government, I have had two other jobs and insurance providers. In December 2014, I received a notice from Blue Cross/Blue Shield Federal Employee Program(FEP) indicating that I was responsible for the cost of five prescriptions filled at a retail Pharmacy between February 2013 and September 2013 that were incorrectly filed under FEP. I have reached out to Blue Cross via fax to inquire about the timeliness of this discovery and why they continued to process claims on a policy that was terminated and not paid for since August 20, 2012. The only response that I received was a letter with canned language stating that their refund recovery request was valid and that cardholders are responsible for any charges incurred in error by any members listed on the contract. I am not sure why Im responsible for Blue Cross processing claims on terminated accounts; which is equivalent to a credit card company allowing charges to process on a closed credit card. At the time the five prescriptions were filled, I was (and still am) covered under [redacted]. I have made claim with them to cover the prescriptions and was advised that they only honor requests made within 12 months of the prescription being filled. It is fundamentally wrong for a customer to be responsible for over $700 in prescriptions when I was insured with another provider and this was a process issue with the retail pharmacy as well as an audit issue with Blue Cross FEP.Desired Settlement: Due to Blue Cross error in processing claims on a terminated policy and their excessive delay in sending a notification to recover funds from their error, I am respectfully requesting that these charges be submitted directly to my insurance provider at the time the five prescriptions were filled or that Blue Cross consider this a loss for their negligence in processing claims on a policy that was cancelled on August 2012. (My last payroll check from the federal government was dated September 2012 so at the latest, September 2012 should have been the last time Blue Cross received any payment on this policy).

Business

Response:

On behalf of Blue Cross Blue Shield of Arizona (BCBSAZ), I am responding to the Revdex.com’s complaint case# [redacted], filed by previous BCBSAZ Federal Employee Program (FEP) member [redacted] expresses concern regarding the request for the return of reimbursement made for prescriptions obtained after her BCBSAZ coverage termination date. We hope this information is helpful. It is very important to understand that the Federal Employee Program eligibility requirements are established by the Office of Personnel Management (OPM.) BCBSAZ is limited in the action we are able to take in this type of situation. When this notice was received from the Revdex.com, BCBSAZ contacted OPM and have been advised that they did not receive the standard documentation from [redacted] HR department, therefor the member is responsible for any claims submitted to BCBSAZ after the termination date of the plan. It may also help to understand that BCBSAZ is unable to provide benefits for services obtained after the termination date of coverage. There are no benefits available on and after the date coverage ends. Additionally, based on this review, we are unable to discontinue the collection process. If the member disagrees, they may wish to directly contact the OPM to discuss further. BCBSAZ also reached out to [redacted] on January 22, 2015 to explain this. I realize that this is not the answer [redacted] was hoping for, but hope that it is beneficial in providing an additional understanding of the basis for this request. Sincerely, [redacted]Corporate OmbudsmanOffice of the President Blue Cross® Blue Shield® of Arizona[redacted]

Review: We have already sent our communication to [redacted] in your customer service department. Our INITIAL email is below. Today is March 18th, and we do not have a resolution to this matter.

We really do hope that you will give our matter your fullest attention at this time, as we feel that we have exhausted all our options in dealing directly with your company.

Original Email SENT 3/9 at 5:17pm to [redacted]

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To Whom It May Concern,

I have had Blue Cross Blue Shield for many years and have always found that it was a great company to hold my health insurance. They covered my preferred physicians that I have seen for many years, and I never once had any problems with coverage or customer service.

In January of 2015, I began research on new health insurance benefits. I recently got married, and was forced to find a new plan under [redacted] because the plan that I had with Blue Cross was not "grandfathered in" with the new health laws.

After researching the different plans and companies, I chose to move forward with Blue Cross Blue Shield of Arizona because of my previous positive experiences with the company. I researched the different plans available to me on your website, and ensured that my doctors were listed in the plan I chose. After extensive research, I didnt see a difference between the networks because our doctor was listed as covered in both, and simply applied and paid for one of them, not having any idea that we had chosen incorrectly (see video: [redacted]).

I was approved and was shipped my insurance card, I have attached a photo copy (see attachment). A few weeks later, I was shipped a letter and a new insurance card stating that the plan was listed incorrectly on the first one I had received (listed as a PPO saver instead of HMO). I didnt think anything of it, and took my new insurance card and put it in my wallet (see attachment).

Mid-February of 2015, my husband and I discovered that we were pregnant. Upon finding this out, I immediately double checked my in-network providers VIA the iPhone app "Blue Finder" to ensure that my doctor was listed, and they were according to the app, and then made a prenatal appointment

(see video: 0[redacted]). They asked what insurance I had, and told them it was Blue Cross Blue Shield, and they told me it was accepted.

Upon arrival and inspection of my insurance card, I was told by the office administrator that my visit would not likely be covered because my member prefix was listed as "XBT".

You can imagine my sincere frustration and disappointment to hear this news when Im standing in the doctors office waiting to get a check up on myself and on my unborn child. I am not an unprepared person, and when making large decisions, I never jump in to anything without doing research. You can imagine my disappointment and embarrassment as I stood in the office and again used the app to show the office administrator that the practice and the physician were listed. She called billing but was unable to get a hold of her billing manager, and advised that I continue with my appointment and we would figure it out at a later time.

My husband and I returned home from our appointment with a positive pregnancy test, and unnecessary stress because we had done a lot of research on my new plan in the event that this moment arose, and now we are faced with the idea that I may have to find a new doctor that I am not comfortable with because we were misled about our network.

We did further research and found that it wasnt the plan that was the problem, but instead it was the incorrect network. I was enrolled in the "Alliance" Network and should have been enrolled in the "Select" network. My OB/GYN does not take the prefix "XBT" but does accept the prefixes "XBI" and "XBJ". This all could have been avoided had we not been misled via our research methods on your website. Being sent the wrong insurance card with incorrect information listed is testament to the fact that there are flaws in the Blue Cross Blue Shield system.

I called your customer service number, and Kimberlee was very helpful. She advised me to write this letter explaining what happened and to include all the processes that we went through to choose my insurance plan.

I am emailing because I am expecting that my network be changed based on the argument that I was misinformed regarding my network choices. Had I known definitively that Alliance would not cover my doctor, I NEVER would have chosen the plan in the first place. The cost and benefits between Alliance and Select networks are the EXACT same. I never would have chosen the network that my doctors were not covered in if the benefits and costs were the same. I dont believe this is a difficult request, as it does not change my plan or my monthly premium, but simply allows me to continue seeing the doctors that I trust. I have gone to Goodman and Partridge for over 6 years now.

I am expecting this matter to be resolved by March 17, 2015. My next doctors appointment is set for March 19th and I need a definitive resolution in time for that. If not, I will be reporting this situation to the Arizona Department of Insurance, the Revdex.com and the local news stations. I have faith that Blue Cross Blue Shield will do the right thing and provide me with the coverage that I thought that I was getting.

Respectfully, [redacted]Desired Settlement: Our "network" to be switched to the correct network that covers our doctor, as we were lead to believe we were enrolling in.

Business

Response:

On behalf of Blue Cross Blue Shield of Arizona (BCBSAZ), I am responding to the Revdex.com’s complaint case# 10538151, filed by [redacted] concerning the processing of her BCBSAZ Individual coverage plan. I hope this information is helpful. Because our records do not document receipt of a release from the member, authorizing us to share specific protected information with your agency, I am limited in the detail I am able to share. I can however, confirm to you that BCBSAZ’s review of our records shows that Ms. [redacted] purchased a Portfolio Alliance 6300 OFF Exchange plan effective 2/1/15. BCBSAZ also recognizes that confusion may have existed within the application and the verification processes confirming the contracting status of her providers in this case. Because of this, administrative approval has been made to allow Ms. [redacted] to change her plan from the Portfolio Alliance 6300 to the Portfolio Select 6300 plan as of her original effective date of 2/1/15. Any affected claims will be adjusted to process in accordance with the Select plan and premium will be applied accordingly. Our attempts to reach Ms. [redacted] by phone to confirm have been unsuccessful, so written confirmation of this action is also being mailed. We do appreciate the opportunity to review and resolve this situation and thank you for bringing it to our attention. If you or Ms. [redacted] have additional questions, please feel free to contact me. Sincerely, Anne KennedyCorporate OmbudsmanOffice of the President Blue Cross® Blue Shield® of Arizona[redacted]

Review: I unfortunately must complain about my experience with Blue Cross Blue Shield of Arizona. I feel I was told one over the phone by a sales representative and then found out very bad news in regards to my insurance plan later on.

I was originally told that my current plan would cover services at [redacted] once the out of network deductible was met. However, I've talked with [redacted] and they claim that Blue Cross Blue Shield of Az is completely NOT acceptable. I would not have purchased this plan when I was shopping around back in November if I new this.

In addition, I am now stuck with this plan until the new enrollment period thanks to the new healthcare act. Very dissatisfied and I wish I was informed all of the information necessary to make the right decisionDesired Settlement: I'm not writing this because I would like a refund. I'm writing this because I feel I was deceived when I originally purchased my plan. I am now stuck with this plan for the rest of the year. I also have recordings of my conversations with Blue Cross Blue Shield. Thanks for your time.

Business

Response:

On behalf of Blue Cross Blue Shield of Arizona (BCBSAZ), I am responding to the 5/2/15 Revdex.com’s case# [redacted], filed by BCBSAZ member [redacted], concerning his purchase of an Individual Off Exchange Medical plan and benefits provided for services obtained at an out of network provider. Because our records do not indicate receipt of a release from the member authorizing BCBSAZ to disclose specific information with your agency, I am limited in the information I am able to share. I can tell you however, that when your correspondence was received, a priority review was initiated to assess the concerns Mr. [redacted] brings to your attention. I hope this information is helpful. Our review determined several documented discussions with Mr. [redacted] in which out of network benefits, specifically referencing the contracting status of [redacted] were discussed. This included an initial discussion during his plan purchase on 10/6/14, as well as several subsequent conversations. Although there is no evidence of inaccuracy or miscommunication noted in these conversations, BCBSAZ recognizes that there may have been confusion and because of this, although under no obligation to do so, BCBSAZ contacted Mr. [redacted] on 5/11/15 in an effort to review additional OFF Exchange plan options. During this call, Mr. [redacted] chose a plan that he believes better met his current needs. It is important to note that this plan change will not affect provider contracting status or the plan’s out of network benefits. This decision is based on the specific circumstances related to this situation only. It reflects our desire to make every attempt to work with our customers and does not in any way imply BCBSAZ has made an error in this case. If you or Mr. [redacted] have additional questions, you are always welcome to contact me. Sincerely, Anne K[redacted] Corporate Ombudsman Office of the President Blue Cross® Blue Shield® of Arizona [redacted]