Blue Shield of California

Review: My deductible was withdrawn out of my acct. on the 15th of every month in the amt of $154.50 from Blue Shield. Starting Feb. 2015, my new deductible was to be $140.40. on March 15th, they pymt was not taken out of my acct. A few days later, I recvd a letter dated 3/12/15, that $239.84 would be withdrawn from my acct. on 3/25/15. I immediately called the phone number provided in the letter (###-###-####) to question why this was there a huge jump in my deductible. Had to call back 3 x's as the phone call kept getting dropped. Finally, spk with a rep. who attempted to assist me but out of all 3 reps, not one of them could explain to me why the change of amt. My automatic pymts was deactivated until this situation could get resolved. Was told that my case will be forwarded to the "Resolution Team" and I should recv a call back from them within 72 hrs. No call back so I contacted them. Recvd another rep who attempted to help who also could not tell me why the change in my deductible. Was told again that my case would be frwd to the eligibility dept since I did not recv a rtrn call from the other dept. Still NOTHING! No call, No letter of explanation or anything. For 2 months I was given the run around. Out of the blue, on 4/24/14, Blue Shield took $392.55 out of my acct. without any warning, my knowledge or permission. I called immediately. No one could tell me the reason why after 2 months and a deactivated automatic pymt option, what the breakdown of the amt and why is was taken. I spoke to someone who claimed to be a "SUPERVISOR" who assured me that I would be getting a refund but would not be able to tell me when. Trying to get this matter resolved, I was on the phone for over 50 min in which 45 of those mins. were on hold. On 4/29/15 still no refund so I called back and spoke w/"[redacted]". It was at that time that I was told that I would not be getting a refund but that I still owed them $17. Customer service with this company is beyond AWFUL!!!Desired Settlement: I want them to get the deductible amt of $140.40 CORRECT!. I want them to cancel the additional vision that they keep billing me for and is $21/mo as it is on my policy I already have with the Silver 70 PPO plan. I owe them $280.80 ($140.40 for March and April 2015). They took $392.55 from my acct. I want them to send me a refund of $111.75 ($392.55-$280.80 = $111.75).

Review: Can't get several issues resolved

In 2014 I had a Blue Shield of CA Silver PPO Plan. I wanted to updgrade, so in early December 2013 I applied to upgrade to Platinum PPO from Blue Shield. There was no break in service. Newplan was to begin 1/1/15. By 1/9/15 I had no information and the payment submitted hadn't been taken from my account. I needed to make Dr appts so I called. They had no clue about the upgrade and couldn't help me log in online. They had no information about my new plan and promised to have someone call me. No one called. On 1/12/15 I see that money was deducted from my account of $1,134.39 which was my monthly premium, so I called and was told they didn't have any information for me on my plan as far as Group # or ID# was concerned. I was unable to log in online and they couldn't either so they said they would have someone call back. No one called. Again. I had to get a prescription so I paid the old amount from the 2014 plan. Finally on 1/20/15 I received the information for my new ID# and Group# so that I could actually pick up prescriptions and make needed DR appts. My complaint is that for 20 days of the month of Jan I was unable to use the plan I chose and paid for however Blue Shield seems to think it's appropriate for them to keep the entire premium amount. I have have asked for it to be pro-rated but have been denied. I was told they were so busy during the enrollment period, which I understand, but that is not my fault. I applied on time and paid the full month premium, of which I was only able to use 11 days of. As of today I am STILL unable to log in. I spoke with another lady a couple of days ago who told me I needed to create another online account to be able to see the updated information on my new plan. I tried that and AGAIN it didn't work! I also tried to change my HMO dentist because the one I have no longer accepts the Blue Shield HMO as of 1/1/15, which I found out while trying to make my kids' dental appts I am really frustrated as I can't seem to get anyone to really be able to help me!Desired Settlement: I would like a pro-rated amount of the Jan monthly premium to be for the time I was actually able to use the plan. I didn't get any new plan info until 1/20/15 so for 20 days I was unable to use what I had paid for.

I would also like someone to contact me about my online account. Several ppl have tried, but no success.

I also need a new dentist! I cannot log in online, so I am not able to figure out how to get a new one.

Business

Response:

This letter is in reference to the correspondence received by Blue Shield of California (Blue Shield) on February 18, 2015, concerning a Blue Shield enrollee by the name of [redacted]. The information provided by the Revdex.com included a consumer complaint against Blue Shield.We thank you for forwarding these concerns to Blue Shield for review and would like to inform you that Steve Ms. [redacted] has not completed the grievance process with the plan. We are initiating a grievance to address the concerns raised in the correspondence submitted. Please be advised that, grievances are resolved within 30 days of the receipt date. A response to the review will be sent directly to Ms. [redacted], and a copy of the resolution letter will be sent to the Revdex.com as we received a signed release of information with the correspondence submitted by the Revdex.com.If you have additional questions regarding this matter, please contact me directly at the telephone number listed below.Sincerely,[redacted] Regulatory CoordinatorGrievance Department([redacted]

Consumer

Response:

I am rejecting this response because: I have gotten no correspondence from Blue Shield besides a faxed email telling me to contact customer service, which I have ALREADY done several times and have gotten no where which is why I finally filed a complaint. This is NOT an appropriate response from them. I souls like someone to contact me that can help!! Otherwise I have gotten nothing from them. HELP!?!

Consumer

Response:

This has been resolved. They pro-rated the amount as requested. You can close as resolved.

Review: Covered CA & Blue Shield of CA erroneously cancelled my family's insurance. We have been fighting more than 3 months to reinstate and cover our bills.

Despite having subscribed to medical insurance for the entirety of 2015, payment of our medical bills is being denied by our insurance company, Blue Shield of California (BSC) and our good credit has been threatened. We ask your assistance in resolving this matter.

Sometime at the end of August, 2015, Covered California (CC) cancelled our families insurance, and thereby notified BSC, our selected insurance carrier through CC, to annul our insurance for the entirety of 2015. No notification was sent to us and we did not realize what had occurred until a visit to our doctor on October 1st, 2015 revealed that we were no longer being covered by insurance. The specific reasons for this cancellation are unknown to me although CC has admitted it to be an error on their part.

From the moment we realized we had been dropped, I have spent hours over 50 hours on phone calls, faxes and emails between myself, CC and BSC that continue until this day. We were able to get our insurance reinstated with CC reflecting no break in their records by November 17th. By December 16th, BSC finally issued a letter to say that we were erroneously dropped and they would reinstate our insurance. Although they have reinstated our family's insurance from December, they refuse to pay medical claims incurred during the period that we were mistakenly dropped.

It is January 4th, 2016 and Blue Shield has been extremely slow in helping me and my family. What seemed like a simple issue, has become a convoluted. I have been shuffled around from department to department, been put on hold for hours and hours, explained my family's situation over and over again in attempts to get help. BSC has made innumerable promises to expedite our issue and although each representative has been very nice, they eventually end up transferring me to another department or taking note of my situation and sending it down the line.

The problem has become pressing, as our medical bills incurred during this period of mistakenly dropped coverage, total in the thousands. I have called each medical office to explain our situation, trying to get an extension in time before our bill is due, to no avail. While BSC attempts to figure out the problem on their end, our bills have gone to 3rd party collection agencies and we have been forced to put a good portion of our expenses on credit cards that will be due in a matter of weeks. We do not have enough ready money to cover these upcoming expenses, and BSC shows no ready willingness to help us solve the financial situation they have put us in.

Additionally, BSC has miscalculated our bills and is now demanding that we pay them $4289.64 before they start to cover any of our doctor bills.

Although I started out with a good measure of patience and understanding, over the past 3 months I have become enraged and astonished that BSC has proved so difficult and incompetent in simply reinstating medical insurance that was, though no fault of ours, mistakenly cancelled by CC. I am frustrated at CC for initializing the problem, but far more frustrated at the way BSC is holding our family's finances hostage because they cannot take the time to seriously analyze and resolve a simple problem, instead kicking it from department to department. I am a part-time worker and stay-at-home mother, and have had to sacrifice much of the time that should have been devoted to the raising of my daughter and my family, instead working to resolve a problem that still seems unsolvable to BSC. I am reduced to seeking outside assistance in the form of formal complaints. I ask for your assistance in bringing attention to this matter.Desired Settlement: We ask Blue Shield of CA to pay all bills owed to our creditors immediately. We would also be happy if some amendment could be made for all the hours we've devoted to resolving this issue.

Review: Where do I begin. So due to the changes from the ACA, I saw my individual insurance go from about $140.00 to $240.00 per month. The sticker shock can be a bit rough, but we all saw this coming and that seems to be the new range for any individual plan these days.The problem I had is that my normal billing cycle is on the 30th of each month, that's how I plan my bills and make sure that my finances are in order to cover this payment. The problem I am having is that Blue Shield randomly charged me on the 21st for $240 and then charged me again for the same amount on the 28th of the same month. So I now have two charges of $240.00 within the same month. Sometimes these things happen, and my ultimate goal is to just get some clarification.Here is where the problem lies however, there is ABSOLUTELY NO WAY to contact customer service. They probably have up to ten different numbers you can call and they all lead to the same general call group. I have been trying to call their customer service for a whole week and have been unable to get a hold of a live person once. Most of the time you will call, go through all of the prompts to talk to customer service and then you will get a message that "the call volume is extremely high and that no agents are available to help you at this time", followed by a hang up tone. They literally don't even let you be placed on hold. They suggest you call earlier or later in the day, but it doesn't matter because you will get the same result regardless. On the off chance you actually get in the queue, which I have been able to do just once, you will be waiting for an indefinite period of time - the time I called I was on hold for 3 hours before finally giving up.If this is an indication of their customer service I can only imagine what a nightmare it would be if something more urgent or important was required of this company. Truly depressing.Desired Settlement: I would like to be contacted by a live customer service representative to address my questions and get this issue resolved.

Business

Response:

This letter is in reference to the correspondence submitted to Blue Shield of California (Blue Shield) dated February 12, 2014, concerning a Blue Shield enrollee by the name of [redacted]. The information provided by the Revdex.com included a consumer complaint against Blue Shield.

We thank you for forwarding these concerns to Blue Shield and would like to inform you that we have reviewed the concerns raised in the correspondence submitted. We have enclosed a copy of our resolution letter issued to the enrollee.

Dear Mr. [redacted]:

This is in response to your inquiry sent to the Revdex.com received on February 19, 2014.

Thank you for contacting Blue Shield regarding your concerns related to the changes in Blue Shield's health plan offerings effective January 1, 2014. While we anticipated and planned for increased customer service needs, the numerous last-minute changes to the enrollment, eligibility and payment timelines exploded the volume of year-end enrollments, which has impacted all major health plans. We are taking this matter very seriously and have put several measures in place to improve our customer service experience.

I understand you have been charged twice for your monthly premiums. Your concerns have been forwarded to our Appeals and Grievances Department for resolution.

The service expectations of our customers are very important to us, and we thank you for sharing your concerns with us. We understand that the health care industry is a complicated environment and strive to alleviate any unnecessary burden upon our members. Blue Shield uses the information we receive to continually improve the services we provide.

Consumer

Response:

I have reviewed the response made by the business in reference to complaint ID [redacted], and find that this resolution is satisfactory to me.

Sincerely,

Review: To Whom it may Concern,

I have notified [redacted] on three different occasions concerning the matter described in the paperwork enclosed. They first claimed they did not charge my mediation to Anthem but then I found the Rx numbers in question which showed co-pays that was payed and I did not have any co-pays with my [redacted] insurance but did have with Anthem so it pretty meant it was charged to Anthem.I have ask them to take care of this matter and at the time of the first e-mail I sent to them I still had Medi Cal insurance and they could have charged it to my [redacted] and refunded Anthem for what they charged them. They was given my insurance and told not to charge to Anthem because I am not longer had them and I was on [redacted] now. But as the paperwork shows they paid no mind to what they were told and went ahead and charged to Anthem. Now as the paperwork shows Anthem has turned me in to Collections to get money back for what they paid, but this money was not paid to me it was paid to El Portal Pharmacy.

I do not understand why Anthem has turned me into collections to get their money back when they should be going after EL Portal Pharmacy; they collected the money and the copays from me. They have refused to take care of the matter and they have been notified as you can see in the copy of the emails sent to them. The attachments to the emails are enclosed also so they received everything proving they did collect the money and even Anthem acknowledges that [redacted] was paid the money but still they are taking me to collections.

Please look over all the enclosed information and I would like to make a formal complaint against this company. Any help you can give me on this matter will be greatly appreciated.

Thank you,

Ronald W. Sliman

Desired Settlement: They was given my insurance and told not to charge to Anthem because I am not longer had them and I was on [redacted] now.

Review: I went to the chiropractor after reviewing my coverage and showed that I was allowed 12 visits in the calendar year. After I had several visits, I received my EOB and showed that the services were denied for reaching maximum number of visits allowed in the calendar year. I then contacted the insurance company customer service to ask how this is possible since I have not seeked chiropractic care in all of 2013. They explained that within the certificate of coverage it states I am limited to a maximum of 12 visits per insured, per calendar year, for Outpatient Rehabilitation (physical, occupational, speech, chiropractic and/or respiratory therapy. Now this wasn't displayed on their site under the coverage section for chiropractic care. So I filed a grievence, which they denied stating they were correct in denying my claims. I then filed a complaint with CA Department of Insurance who stated they would try to work with them on the coverage issue of adding and approving 3 additional visits. I was denied again by Blue Shield of CA. Not only was this company deceitful in its insurance practices, but now I have a bill with my chiropractor that I wouldn't have had to begin with since I wouldn't have seeked additional treatment had it been clear on their website for my coverage.Desired Settlement: I would like Blue Shield of CA to reprocess the denied claims and pay out their contractual portion to the chiropractor and my portion will be the copay, which I was prepared to be paying for in the first place.

Business

Response:

Enclosed please find a copy of the letter sent to Mr. [redacted] in response to a grievance which was filed by you, regarding the complaint against Blue Shield of California Life & Health Insurance Company (Blue Shield Life) and the combined rehabilitation services benefit for chiropractic services.

Dear Mr. [redacted]:

This is in response to the grievance submitted by Ms. [redacted], on your behalf, on February 19, 2014, to let us know about your experience provided to you by Blue Shield of California Life & Health Insurance company (Blue Shield Life). From the information provided, I understand your concerns to be regarding your combined rehabilitation services benefit for chiropractic services. As noted in the grievance, you stated that you would like Blue Shield Life to reprocess the denied claims for chiropractic services and pay out Blue Shield Life's contractual portion and your portion will be the copayment. In addition, you stated your benefits for outpatient rehabilitation for chiropractic services under the coverage section was not displayed on Blue Shield Life's website. You also stated you filed a complaint with California Department of Insurance to work with you on the coverage and approving three additional chiropractic visits. We appreciate you taking the time to share your experience with us, and regret that your experience did not meet your service expectations.

We would like to take this opportunity to advise you that the service expectations of our members are very important to us. Please be assured that all member concerns are tracked through our grievance process as Blue Shield Life uses the information received to continually improve the services we provide.

Your satisfaction is our primary concern. While we understand your concerns and frustration, you are enrolled in the Premier PPO 15. The benefits of your health plan can be found in your Certificate of Insurance (COI). It is important to carefully read all Blue Shield Life health plan materials immediately after you are enrolled so you understand how to use your benefits and how to minimize your out-of-pocket costs.

As indicated in your COI, benefits are limited to a combined visit maximum of 12 visits per Calendar Year for outpatient chiropractic, and outpatient rehabilitation (physical, occupational, and/or respiratory therapy). Whether these services are provided in an office location or a hospital's outpatient department, all visits count towards the Calendar Year visit maximum.

If your plan has a Calendar Year medical deductible, the number of visits starts counting toward the maximum when services are first provided even if the Calendar Year medical deductible has not been met.

Please note when a benefit specifies a benefit maximum and that benefit maximum has been reached, the Insured is responsible for any charges above the benefit maximums. Unfortunately, regardless of the medical necessity or whether a physician recommends extended treatment. Therefore, you are only allowed 12 combined visits per Calendar Year.

Please note for the 2013 Calendar Year you have 12 combined visits, after those visits have been satisfied no additional visits will be paid. You are fully responsible for all non-covered charges obtained.

Please be advise that the decision to proceed with a recommended treatment is solely the responsibility of the patient, their family and the attending physician. Blue Shield Life can provide benefits only for those items covered by the insured's policy.

It is important to understand that Blue Shield Life strives to meet the needs of all of its insured's. However, at the same time, we must follow a consistent administration of the benefit coverage as outlined in the insured materials and COI, so that we are fair and equitable to all insured in terms of benefit coverage issues.

While we understand the reason for your request, in view of the terms, conditions and limitations of your policy, we are unable to comply with your request to allow additional chiropractic benefits past your combined 12 visit maximum.

Based on this information, we will consider this matter resolved and no further action is necessary. We are therefore closing your case. We do apologize for the inconvenience this matter has caused you.

Consumer

Response:

I have reviewed the response made by the business in reference to complaint ID [redacted], and find that this resolution is satisfactory to me.

Sincerely,

Review: I lost my job 6/2/2014 and was calling blue shield to inquire about healthcare options when mine run out at the end of this month. I was told by a representative that I could possibly receive low cost healthcare. I told her that I currently had no income and she said that it was fine since if I filled out the application and sent her all my work documents coverage would not be until 8/1/2014, she had me give her my credit card for the future. Last week they withdrew $408.00 from my account I have been calling since last week to obtain a refund, since Im currently waiting for unemployments decision and have no other form of income. I was living off of that. I was transferred to countless different departments and even hung up on, but finally able to speak with a representative concerning an expedited refund, she told me that there is no way for her to cancel my claim or issue a refund because I don't have a policy number (application#[redacted]) she is not able to issue me a refund. I explained my desperate situation and how I don't want the paperwork continued. I demanded a refund and was denied. I don't know what else to do I don't qualify for general assistance because I have no kids and they cleaned out my account that would have helped me until a EDD kicks in and I obviously can't afford their health care, which is not in effect at this time, I wanted to cancel the future policy due to financial restraints. I was also told by them that this is new process for them since the new healthcare laws and they have never had anyone cancel a policy process and they have no process to stop it or return the funds no matter what. I really need my money back, can you help me?Desired Settlement: The entire amount of $408.00 taken out of my account. They are not covering me so their should be no reason for me not to obtain a refund.

Review: I wish to file a complaint with the Revdex.com against Blue Shield of CA Dental PPO PLan concerning the Following Issue.As of January 1, 2014 I wanted to disenroll in the Individual Dental PPOPlan. My Membership ID is [redacted]. I had originally signed up for auto pay which automatically deducts $43.50 a month as of january 1, 2014.I originally sent in a letter followed by calling two numbers - which are 888-256-3650 and 800.431.2809. when I tried calling these numbers you are told that because of extremly hugh call volume, that theyare unable to answer their call. Or they tell you that because of someweather condition or whatever their line from Arizona to CA is down.I think the latest excuse if that because of the affordable health careact they are too busy to answer or service your request.However, whatever their reason is or excuse I still want to disenroll from this individual plan. Also because of this inconvenience I am also going to have to request my credit union put a "STOP PAY" on all recurring transactions of $43.50 a month(premium payment ID: [redacted] - ACH ECC WEB) The charge for this is $10.00 involving all recurring transactions which is another irritant for me.

Product_Or_Service: Health- Dental Insurance

Account_Number: [redacted]Desired Settlement: DesiredSettlementID: Refund

would like Blue Shield of CA. to reimburse me the last $43.50 + the $10.00for the Stop Pay. (As of January 18, 2014).TY for your attention in this matter.

Review: I submitted a claim for reimbursement in August 2015 for services on 7/16/2015. I have been in contact with several of their representative for the period of five months and I received nothing but run around. last call I received was on 11/05/2015 for an assistant supervisor who told me that a check was being issued and I called again today and they are telling me that it in the process, but they will not tell be when the process time will be done and when a check will be issued. This must be against some government regulation. They must have a time frame to reimburse patient in a timely manner.Desired Settlement: To receive my reimbursement.

Business

Response:

This letter is in reference to the correspondence received by Blue Shield of California (Blue Shield) on December 18, 2015, concerning a Blue Shield enrollee by the name of [redacted]. The information provided by the Revdex.com included a consumer complaint against Blue Shield.We thank you for forwarding these concerns to Blue Shield for review and would like to inform you that we are currently reviewing the concerns raised in the correspondence submitted. A response will be sent directly to [redacted]. Our records do not reflect that a signed release of information was submitted with the correspondence sent by the Revdex.com. Unfortunately, without a signed release of information from [redacted], we are unable to provide a copy of the resolution to the Revdex.com. If [redacted] has signed a release of health information to the Revdex.com, you may send a copy to my attention via fax at [redacted] or by mail at:[redacted]If you have additional questions regarding this matter, please contact me directly at the telephone number listed below.Sincerely,[redacted], Executive Inquiry Coordinator[redacted]

Review: I am asking for help concerning Blue Shield of California [Subscriber #[redacted]]

On 9-11-15 I received my bill statement saying I had not paid 8th month and 9th month. I phoned Blue Shield of California. I then went down to my bank getting the checks (copies) of front and back. Faxed this to them not once but twice with reference numbers on Sept 18-15 [redacted]. Phoning them 4X and received a letter of canceled my insurance. Each time I phone same answer, looking into it will phone back.Desired Settlement: I have heard nothing up to October 9-15. I phoned them 9-8-15 still say they have not received 3 months payments. Blue Shield doesn’t seem to call. I hope you can help me. I am disabled due to stress seziures. Thank you so very much.

Consumer

Response:

ID # [redacted]This is concerning Blue Shield of CA. Blue Shield has credited my account, therefore this is resolved. Thank you very much [redacted]

Review: When comparing healthcare plans on Blue Shield website it states $70 to see a specialist for one of the plans that I chose. After seeing several specialists and getting billed hundreds of dollars I called Blue shield and they say "no it's $70 AFTER DEDUCTIBLE" and that I have to login to my account to find the details. It absolutely did not state "After deductible" when I compared plans side by side and decided to chose the plan and purchased it.. it said $70 for specialist. This is clearly deceptive and the rep at Blue Shield did not disagree when I complained. He had no excuse to give me when I told him that I chose the plan based on that side by side plan comparison and would not have chosen it had it not said that. He said he will bring it up to management... meanwhile I can't change plans as it is too late and I'm stuck with hundred of dollars in bills. I do not want to find out the fine print and details of a plan only AFTER I purchase the plan.Desired Settlement: I would like Blue shield to honor their deceptive advertising and reimburse me for the specialist bills I was charged. I would like to pay $70 to see a specialist in the year of 2015 as advertised as I can no longer change plans.

Business

Response:

This letter is in reference to the correspondence received by Blue Shield of California (Blue Shield) on March 13, 2015, concerning a Blue Shield enrollee by the name of [redacted]. The information provided by the Revdex.com including a consumer complaint against Blue Shield.We thank you for forwarding these concerns to Blue Shield for review and would like to inform you that [redacted] , has not completed the grievances process with the plan. We are initiating a grievance to address the concerns raised in the correspondence submitted. Please be advised that, grievances are resolved within 30 days of the receipt date. A response to the review will be sent directly to Ms. [redacted], and a copy of the resolution letter will be sent to the Revdex.com as we received a signed release of information with the correspondence submitted by the Revdex.com.If you have additional questions regarding this matter, please contact me directly at the telephone number listed below.Sincerely,[redacted], Executive Inquiries CoordinatorGrievance Department###-###-####

Consumer

Response:

I am rejecting this response because:Blue shield did not address the problem and misunderstood the complaint as they were not listening to what I am saying. They have already sent a letter of denial to the wrong issue. I originally signed up for this plan because it said $70 to see a specialist... It never said $70 "AFTER deductible". This was false advertising and misleading. I chose the plan because it was advertised as $70 to see a specialist and now they tell me it's $70 after the deductible and I can not change the plan. See attached advertised info. Next to "specialist" it says $70. I also talked to several reps before I purchased this plan and they confirmed that it was $70 to see a specialist and they did not say that it was only $70 after the deductible was met. Due to this false advertising I feel that my plan should be honored as advertised and all of my visits to see a specialist should be $70. Thank you,[redacted]

Business

Response:

This letter is in reference to the correspondence received by Blue Shield of California (Blue Shield) on April 20, 2015, concerning a Blue Shield enrollee by the name of [redacted]. The information provided by the Revdex.com included a consumer complaint against Blue Shield.We thank you for forwarding these concerns to Blue Shield for review and would like to inform you that [redacted], has completed our grievance process regarding this specific issue. A response letter was mailed directly to the member on April 3, 2015. The member now has the right to request an Independent Medical Review (IMR) through the Department of Managed Health Care (DMHC). If the complaint meets the criteria as determined by the DMHC, an independent review organization as selected by the DMHC will review the pertinent issue(s) and/or medical documentation. An IMR Application Form and addressed envelope was enclosed with the Blue Shield determination letter for the member's convenience. If the member chooses to pursue an IMR, the request must be submitted to the DMHC directly.If you have additional questions regarding this matter, please contact me directly at the telephone number listed below.Sincerely,[redacted], Executive Inquiries CoordinatorGrievance Deparmtnet###-###-####

Consumer

Response:

I have reviewed the response made by the business in reference to my concern, and find that this response is acceptable as it is being addressed by the California Department of Managed Healthcare (DMHC). While Blue Shield continues to have the false advertising on their website and will not honor the advertised price that lead to me choosing them vs Anthem, I have informed the DMHC and will continue the complaint with them. Blue shield informed DMHC that there was an asterisk after the $70 that referred to "after deductible" which is not true (see attached). I have several charts provided by Blue shield that have absolutely no asterisk. At this time there is no additional action that the Revdex.com can assist with. As you can see with the enclosed documents, when doing a plan comparison Blue Shield says $70 to see a specialist, while Anthem says $70 "after deductible". Anthem is being honest about their prices while Blue shield is not. Considering Anthem has a lower monthly premium I would have chosen them instead of Blue shield if the plan comparison had stated accurate information. I now have to wait for open enrollment which isn't until the end of the year. I am stuck and there is no accountability on Blue shield's part.Thank you,[redacted]

Review: On May 15, 2014 Blue Shield of California was issued check number [redacted] in the amount of $292.80 from my check account with Bank of America. The check cleared on May 21, 2014.Three weeks later, I noticed the funds had still not been credited to my account (#[redacted]) and so I contacted Bank of America (Case ID [redacted]) to seek assistance in resolving the matter. They contacted [redacted] at Blue Shield who confirmed payment was not posted to the account. Bank of America provided Blue Shield a copy of the check as proof of payment and Blue Shield advised them it would take at least two business days to research and post the payment.As of July 16, 2014, Blue Shield has been contacted twice more and have not resolved the matter nor communicated in any way about why the payment has not been posted.Desired Settlement: I would like the payment posted to my account to completely resolved the matter.

Review: My policy was terminated Dec 31st 2013 and Blue Shield withdrew January 2014 dues from my checking account. I was told a refund check would be mailed within two weeks however no check has arrived. I've called multiple times, and tried multiple phone numbers but I am put on hold for over an hour each time without pickup. There is no option for a call back or estimate of pickup time. They simply do not answer phones. Additionally, I've made two online requests for resolution with a guaranteed return contact within 2-5 business days but still nothing. I can not contact them in any manner to resolve this issue.Desired Settlement: Timely refund of dues and direct contact with a representative at Blue Shield.

Review: The worst customer Service. You can not reach a supervisor, get a straight answer or reach a complaint department.

Trying to get help on billing heath plans is one of the worst experience ever. I had to get 3 separate accounts. 1 for wife and I and 1 each for each child. When I setup 2 child accounts I put down a debit card to pay for the 2 accounts and setup automated payment. The Sales lady set it up. Each kid were paid for the 1st month. When the 2nd month comes I get a threat that accounts will be closed if not payed. So I went in to pay the 2 accounts separately. the next day the automated payment goes through. but instead of splitting it. It paid for 2 months to 1 account. when I called . I got the runaround with staged answers and no common sense. After going around for an hour. he finally talks to someone and says it will be taken care of but you will not see it on the website. I then ask to talk to a supervisor and he said we can not do that. If you have a complaint you can file it with me. SO now I have to file a complaint with the person I am complaining about. then the next month get a call that 1 account will be cancelled hit 0 to talk to someone. Of course it cuts me off. Knowing that it was taken care of and that the rep told me it would not show up right away. I think I am fine. Only to find a few days later they cancelled the 1 account. I call to talk to a supervisor and they give me the runaround again. put me on hold and repeat the things I know. says I cannot talk to anyone in billing. that I have to go through them. So again I am getting the runaround without talking to anybody that makes sense. Both reps were of foreign language and a waste of my time. So I am still waiting 40 min. into cal and cant get a supervisor even though that is what I asked for from the beginning. Insurance companies do not have our best interest. they are money making criminals.Desired Settlement: All I want is to talk to someone in billing that can get my account set up correctly

Business

Response:

Dear This letter is in reference to the correspondence received by Blue Shield of California (Blue Shield) on July 16, 2015, concerning a Blue Shield enrollee by the name of [redacted]. The information provided by the Revdex.com included a consumer complaint against Blue Shield.We thank you for forwarding these concerns to Blue Shield for review and would like to inform you that we are currently reviewing the concerns raised in the correspondence submitted. A response will be sent directly to [redacted]. Our records do not reflect that a signed release of information was submitted with the correspondence signed by the Revdex.com. Unfortunately, without a signed release of information from [redacted], we are unable to provide a copy of the resolution to the Revdex.com. If [redacted] has signed a release of health information to the Revdex.com, you may send a copy to my attention via fax at 916-350-7405 or mail at:P.O. Box 5588El Dorado Hills, CA, 95762If you have any additional questions regarding this matter, please contact me directly at the telephone number listed below. Sincerely,[redacted], Executive Inquiry Coordinator

Review: I received a letter from Blue Cross of California, dated May 19, 2014, telling me that they made an incorrect payment of $333.68. This payment, which covered August 04-August 28, was not sent to the provider, but to me instead.They are now requesting, after a seven month period between their mistake and the date of the letter, that I refund the $333.68 within 30 days. I have also received three additional letters, dated June 18, July 17, and August 15. They are all saying that I must refund the $333.68 back to them.The most recent letter says that they must either receive the refund within 20 days or initiate an automatic offset against future claims.My complaint is why should I have to repay them for a mistake made by them? I also would like to know why they waited so long (from September 19, 2013 until May 19, 2014) to even notify me of their mistake?Desired Settlement: I would simply want them to disregard the letters that they have been sending me and accept the fact that this is a mistake that they made. I should not be held responsible for their mistake of sending the payment to the wrong location. The check I received for the $333.68 was addressed to me with my name shown as the person being paid.I also do not feel that they should discontinue providing insurance coverage simply because I have not refunded the amount that I was paid by them.

Business

Response:

This letter is in reference to the correspondence received by Blue Shield of California (Blue Shield) on October 10. 2014, concerning o Blue Shield enrollee by the name of [redacted]. The information provided by the Revdex.com included a consumer complaint against Blue Shield.

We thank you for forwarding these concerns to Blue Shield for review and would like to inform you that Mr. [redacted] has not completed the grievance process with the plan. We are initiating a grievance to address the concerns raised in the correspondence submitted. Please be advised that, grievances ore resolved within 30 days of the receipt date. A response to the review will be sent directly to Mr. [redacted], and a copy of the resolution letter will be sent to the Revdex.com as we received a signed release of information with the correspondence submitted by the Revdex.com.

If you have additional questions regarding this matter, please contact me directly at the telephone number listed below.

Review: Paid for first installment of insurance premium, but have not received member ID number. Representatives do not have a member number when I call for my plan.Desired Settlement: Need new policy number!

Business

Response:

Company states they will give the consumer a call in regards to the member ID.

Review: My husband saw his physician for annual physical and had routine lab test taken the day prior. Bill for preventive blood test unpaid by Blue Shield.

In November 2012 my husband's physician ordered routine blood tests for annual evaluation. Husband was busy and didn't go for blood test until 8/12/13, the day prior to his routine physical exam on 8/13/13Desired Settlement: In November 2012 my husband's primary physician (a Preferred Blue Shield Provider) ordered annual routine blood tests. My husband was busy and had labs taken on 8/12/13, the day prior to annual physical exam. The exam was 8/13/13 and he was feeling well and had no specific complaints. He was planning to see the physician in November 2012 and had delayed his annual physical due to his work schedule.

He does have a strong family history of cardiac disease (his father and 3 paternal uncles had heart attacks before age 40), diabetes (maternal and paternal), xanthomas (paternal), hyperlipidemia (maternal), and hypertension (maternal). Due to the familial risk factors, his physician monitors lipid panel and glucose including glycosylated hemoglobin and C-reactive protein and kidney function closely. Due to the statins he is taking, he also monitors AST and CPK and diabetes. These are preventive blood tests in an asymptomatic patient for early diagnosis of disease. His last set of blood tests were in 2011 and were covered. According to the Blue Shield plan book, preventive health benefits are paid at 100% for early detection of disease when no symptoms are present.

I received the first bill 8/2/13 and was told that I owed $0 balance. I received a second bill on 10/29/13 and was told Palo Alto Medical Foundation coded the bill as preventive. Blue Shield has denied the request due to the diagnosis code of soft tissue pain culled from the medical records. My husband mentioned muscle pain after exercise two years ago so his physician checked for low magnesium and other possible causes. He hasn't had any muscle pain in two years. The physician was being thorough in checking for low magnesium and cpk (as myopathy is a possible side effect of medication) that could uncover an early problem. The physician monitors lipid, glucose, kidney function, liver function, etc. regularly as part of his wellness physicial exam and monitors for side effects of the medication. The preventive lab tests in the asymptomatic patient, especially ordered 9-10 months in advance of the visit, should be covered by insurance at 100%. I request that Blue Shield of California PPO cover all the lab expenses as a preventive benefit.

Business

Response:

This letter is in reference to the correspondence submitted to Blue Shield of California (Blue Shield) dated November 27, 2013, concerning a Blue Shield enrollee by the name of [redacted]. The information provided by the Revdex.com included a consumer complaint against Blue Shield.

We thank you for forwarding these concerns to Blue Shield and would like to inform you that we have reviewed the concerns raised in the correspondence submitted. We have enclosed a copy of our resolution letter issued to the enrollee.

--------------------------------------------------

This is in response to the grievance received by Blue Shield of California (Blue Shield) on October 19, 2013, regarding services provided on August 12, 2013, by Palo Alto Medical Foundation, for the total billed amount of $142.00. In your appeal you stated you believed these services would be covered under your Preventive Care Benefits. You are requesting Blue Shield process these claims as preventive services and make payment according to your Preventive Care Benefits.

Your request has been denied for the following reasons:

* According to our records you are enrolled in an employer sponsored Preferred Provider Organization (PPO) Plan. With the Blue Shield PPO Plan you have the opportunity to be an active participant in your own health care. The choices you make at the time you need medical care will determine your out of pocket costs.

* The Benefit Booklet for your plan identifies claims for preventive care as those primary preventive medical services provided by a Physician for the early detection of disease when no symptoms are present.

* Benefits are provided for routine laboratory services based on Blue Shield's Preventive Health Guidelines. These guidelines are derived from the most recent version with all updates of the Guide to Preventive Services of the US Preventive Services Task Fore as convened by the US Public Health Service.

* In review of your appeal we have determined the claims has processed correctly as the services done do not match the Blue Shield's Preventive Health Guidelines.

* The benefits of your health plan are detailed in your Benefit Booklet. The decision to proceed with a recommended treatment is solely the responsibility of the patient, their family and the attending physician. Blue Shield can provide benefits only for those items covered by the member's health plan and at the appropriate benefit level the patient has chosen.

* Blue Shield strives to meet the needs of all its members. However, at the same time, we must follow a consistent administration of the benefit coverage as outlined in the Benefit Booklet, so that we are fair and equitable to all members in terms of benefit coverage issues. While we understand the reason for your request, in view of the terms, conditions, and limitations of your health plan, we are unable to comply with your request.

* This request was reviewed by a grievance coordinator who is knowledgeable about your plan's benefits and coverage. The Benefit Booklet for the health plan you are enrolled in supports the above determination. Please refer to your Benefit Booklet for your plan as provided by your employer. Should you not have a Benefit Booklet, please contact your employer's Human Resource Department.

Review: I have had a Blue Shield Health Insurance policy since July 2013. In December 2013, I received a letter from the insurance saying that my insurance policy would be terminated due to the [redacted] Insurance, therefore the company directed me to different plans that would be available. I decided to choose a new plan through Blue Shield and made the initial first month payment. Later on, I received a bill to pay my second month's payment from Blue Shield. The payment amount was different from what I had initially paid, so I called the company. Upon calling, I found out that I have 2 health insurance policies that are active with Blue Shield. My previous policy from last year had not been terminated. Instead Blue Shield had carried it through. At this point, I was very frustrated as to why Blue Shield has given misinformation about the old policy being terminated on December 31, 2013. The representative on the phone apologized for the confusion and assured me that she will terminate the old policy, so that I only have one active policy. A few weeks passed, and I decided to call Blue Shield, since I received no update or mail from them. The representative informed me that the wrong policy had been cancelled. I asked him to file a grievance to reverse this cancellation, so that the correct policy can be reinstated. I received a letter in the mail with my grievance/inquiry number. The later stated that this grievance would be resolved in one month from the date the grievance was filed March 26, 2014. I called Blue Shield again last week (5/2/2014) to see if this issue had been resolved. I was told both my policies had been cancelled. I left a voicemail to the grievance dept, and have yet to receive a call back. I called BlueShield on 5/9/2014. I asked to speak to the supervisor for the Grievance Dept, but I was not given a phone number/email address where I could contact this person. It's been over a month since this grievance was filed, and there has been no resolution/reinstatement of my policy.Desired Settlement: 1. I would like to reinstate the appropriate policy immediately.2. I would like to receive a phone call from someone higher in ranks, who can address this problem quickly and effectively. 3. I would like to receive written acknowledgment that I am effectively covered for my medical/dental through blue shield. 4. I tried to get temporary insurance while this problem was being resolved. [redacted] informed me that I am actively covered by Blue Shield, which contradicts what blueshield is saying.

Business

Response:

This is in response to the grievance received by Blue Shield of California (Blue Shield) on March 26, 2014, regarding the cancellation of your health plan. You are requesting that we reinstate your health plan under identification number [redacted] without lapse in coverage and terminate the coverage under identification number [redacted].

Your request has been approved. The information has been forwarded to the appropriate department for processing.

The appeal review was conducted by a Blue Shield Grievance Coordinator with training and experience in processing member grievances.

If you have any questions regarding this letter, please contact me directly. If you have questions regarding your health plan benefits, please contact your Customer Service Department at ###-###-####.

[redacted] ###-###-####

Consumer

Response:

I have reviewed the response made by the business in reference to my concern, and find that this resolution is satisfactory to me.

Review: I make my payments electronically through my bank. Two times now Blue Shield's systems have "lost" my payment. This last time they actually cancelled my coverage through I have made payments through next month so I am a month ahead on my payments. The first time this happened they told me that the payment had gone to their old system and hadn't been transferred over to their new system yet. This time they said that I need to give my bank a billing ID number instead of my account number but my bank's system won't take the billing ID number as they want the account number. Blue Shield said they have that problem with a number of banks. If that is the case, they need to fix the issue instead of letting it continue. The only option they have offered me so far is to set up auto payment through Blue Shield, which I do not want to do.Desired Settlement: I want to be able to pay Blue Shield through my bank and have Blue Shield's systems give me credit for the payments they have received instead of cancelling my coverage! I also want to make sure they aren't reporting this to a credit reporting agency in a way that negatively impacts my credit score.

Business

Response:

This letter is in reference to the correspondence received by Blue Shield of California (Blue Shield) on September 8, 2015, concerning a Blue Shield enrollee by the name of [redacted] (Ms. [redacted]). The information provided by the Revdex.com included a consumer complaint against Blue Shield.We thank you for forwarding these concerns to Blue Shield for review and would like to inform you that Ms. [redacted], has completed our grievance process regarding this specific issue. A response letter was mailed directly to the member on August 27, 2015. If the member is dissatisfied with the grievance resolution, she may contact the Department of Managed Health Care for additional assistance. The department has a toll-free telephone number (1-88-688-9891) for the hearing and speech impaired. The department's Internet Web site http://www.hmohelp.ca.gov has complaint forms, IMR application forms and instructions online. If you have additional questions regarding this matter, please contact me directly at the telephone number listed below.Sincerely,[redacted], Executive Inquiries CoordinatorGrievance Department(916) 350-7885

Review: Blue Shield are sending me up to three demanding letters for payment each week: I am no longer covered by Blue Shield. I left a year ago.

I left Blue Shield, canceled my coverage, only to find they were charging me for dental coverage long after I left. (The old Switcheroo: I didn't make it clear enough when I called to cancel 'all my coverage', that I mean't dental too) I tried to fight them but ran out of resources. Still the letters come, so long after I left Blue Shield-- more than a year. Threatening letters talking about collection activity...THREE A WEEK SOMETIMES....I am sick of it. It is affecting my health. I am now seeking legal advice to sue for harrassment, and I am also contacting the media.

This week's mail bag includes letters with these codes:

[redacted] A

MAKE IT STOPDesired Settlement: Please, Blue Shield, leave me alone.

Business

Response:

This letter is in reference to the correspondence received by Blue Shield of California (Blue Shield) on July 20, 2015, concerning a Blue Shield) on July 20, 2015, concerning a Blue Shield enrollee by the name of [redacted]. The information provided by the Revdex.com included a consumer complaint against Blue Shield. We thank you for forwarding these concerns to Blue Shield for review and would like to inform you that we are currently reviewing the concerns raised in the correspondence submitted. A response will be sent directly to [redacted]. Our records do not reflect that a signed release of information was submitted with the correspondence sent by the Revdex.com. Unfortunately, without a signed release of information from [redacted], we are unable to provide a copy of the resolution to the Revdex.com. If [redacted] has signed a release of health information to the Revdex.com, you may send a copy to my attention via fax at [redacted] or by mail at: [redacted] El Dorado Hills, CA 95762If you have any additional questions regarding this matter, please contact me directly at the telephone number listed below.Sincerely, [redacted]Executive Inquiry Coordinator[redacted]