Revdex.com:
I have reviewed the response made by the business in reference to complaint ID ***, and find that this resolution is satisfactory to me and the matter has been resolved
Sincerely,
*** ***
I would like to not have to go through the hassle, of every time I have a doctor's appointment or an MRI, CT Scan etc, that I have to contact the insurance company because I am constantly getting lost in their systemI would like to know that I am covered and going to be approved for procedures my
doctor deems necessaryI would like to know that when I call the insurance company to try to find out why I am lost in the system, or my procedure has been denied, or my prescription plan is not active, that I will actually talk to someone instead of being placed on hold for up to an hour
The Plan did receive a grievance from the member regarding preventative services that were rendered to her on 03/**/and alleging that the claim was processed incorrectly which showed that there was member liability. Upon receipt of the grievance, the case was assigned to an Appeals and
Grievances associated who reached out to the claims department regarding the members concerns. The Claims Department reviewed the claim and reprocessed the claim to pay as preventative care with no member liability. The member will also receive a written response to her grievance. Please see the response that was received from the Claims Department.Claim # *** has been backed out to reverse the member deductible which was incorrectly appliedNew Claim # *** paying in full nowClaim # *** has been backed out to reverse the member deductible which was incorrectly appliedNew claim # *** paying in full now.I trust that this has resolved the matter for the member. Thank you, Reugenia S***, Director of Appeals and Grievances
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID# ***, and have determined that my complaint has NOT been resolved because:
Affinity rejected every single claim related to my son *** *** when we were advised that the mother's insurance is sufficient
In order for the Revdex.com to appropriately process your response, you MUST answer the question above
Sincerely,
*** ***
Upon receipt of your concern, the Plan’s Enrollment Department was contacted and a representative from that department advised that your newborn was enrolled in a Qualified Health Plan (QHP) Platinum plan and that newborns are covered under the member’s QHP plan for days effective
their date of birthDue to an internal error that occurred with the Plan’s Enrollment vendor, invoices were generated with the incorrect premium amount. The representative further advised that you did speak with a supervisor on June *, who advised you that the he would reach out to the New York State Department of Health to correct the errorThe representative confirmed that the error has been corrected and the correct premium amount is $549.08.The Plan apologizes for any inconvenience this matter may have caused you. Reugenia S*Director Appeals and Grievances
Upon receipt of this complaint, an Enrollment Specialist was contact and advised that the Enrollment Departments records revealed that member ID cards and Handbooks were sent on 3/*/and again on 3/**/to: *** *** **
*** ** *** The Enrollment Specialist further
advised that she was successfully able to log into the members account using both the Affinity ID and Exchange ID number and access the area to print temporary ID cardsThe specialist also purposely entered an incorrect ID number to confirm that contact information is provided to users when they are experiencing difficulty logging in The Enrollment Specialist also confirmed that the departments return mail log was reviewed and she was unable locate any returned mail for this member Based on the Plan’s findings, the members request for reimbursement cannot be approved Copies of the member’s ID cards and Welcome letter have been attached to this response Sincerely, *** ***
*
*** ***
*** *** *** *** ***
*** *** *** *** ***
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID# ***, and have determined that my complaint has NOT been resolved because:
This is an explanation of what happened and I appreciate Affinity letting me know how the issue was causedI am more concerned with a solution to the issueI understand that I now have a credit for $which will be applied and used for the April premiumI am still concerned as to how I will receive the $refund for the doctor's fee that I had to pay out of pocket. As a suggestion, Affinity should notify customers about the issues that can arise when the premium has changedNo one notified me that the payment was due before the 1stAs usual I expected it to come out of the 10th as it has been for yearsIn addition this issue caused my children to not be insuredImagine if the issue of my son getting sick was more serious and he didn't have health coverageI wasn't notified in any way that he coverage was being cancelled due to my premium going up. I would like a final answer as to how and when I can expect my $refundIt is absurd that I have to go through the Revdex.com to get a valid response and I am still be given the run around.
In order for the Revdex.com to appropriately process your response, you MUST answer the question above
Sincerely,
*** ***
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID ***, and find that this resolution is satisfactory to me and the matter has been resolved
Sincerely,
*** ***
This member has already contacted the NYSDOFS regarding this matter. A favorable response was submitted to the State. the member should reach out to the state for the response
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID ***, and find that this resolution is satisfactory to me and the matter has been resolved
Sincerely,
*** ***
The New York State of health is responsible for providing members with the tax forms ([redacted]), not the individual health plans. We confirmed the dates this former member was active with us and requested a [redacted] statement be sent to her on her behalf.Should you have any questions, she can...
contact me toll free at ###-###-####.Tracey Purdue, R.N.Complaint, Grievance & Appeal Sr. Coordinator
Upon receipt of this complaint, the Plan’s Enrollment/Billing Department and vendor liaison were notified of the member’s request for her [redacted] form. It was discovered that due to an internal processing error, the vendor did not generate a [redacted] form for this member. On March ** , 2016, an urgent request was submitted to the vendor who was able to generate the [redacted] form for the member. The Director Complaints, Grievances and Appeals obtained a copy of the [redacted] form and emailed a copy via secure email to the member. Before emailing the form to Ms. Bell, the Director contacted the member to confirm her email address asked her to confirm when the form was received. The Director also apologized for the delay and inconvenience this matter may have caused. On March **, 2016 the Director called the member to confirm if the [redacted] form had been received. As the member was not available, a message was left. A copy of the requested [redacted] form has also been attached to this response. Sincerely, Reugenia S[redacted] Reugenia S[redacted]Director, Complaints Grievances and AppealsComplaint, Grievance and Appeal Unit
Affinity Health Plan (AHP) is in receipt of a complaint that was submitted on behalf of Donna Deming by the Revdex.com and was received on March **, 2016. The member states in her complaint that she and her spouse have been unable to access the dental benefit since...
enrolling in the Plan effective January *, 2016. Upon receipt of this complaint, the Director of the Plan’s Enrollment/Billing Department and vendor liaison were notified of the member’s inability to access their Dental Benefit. It was discovered that due to an internal processing error, the information required to add the member to the dental vendor’s eligibility file was not forwarded. As a result, the members did not appear as active in the DentaQuest system. On March **, 2016, an urgent request was submitted to DentaQuest to add the members to their system. On March **, 2016, DentaQuest confirmed that the required information was received and both members reflected as active in their system. The Plan extends an apology to the member for the inconvenience that this matter has caused.
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and find that this resolution is satisfactory to me and the matter has been resolved.
Sincerely,
[redacted]
Upon receipt of this complaint, the Directory of the Appeals and Grievances Department reached out to an Enrollment Specialist and the Manager of the Claims Department for assistance.
The Enrollment Specialist advised that the claims were denied because they were processed under the child’s...
account before the effective date of service. The claims were to have been processed under the parent as they were within a few days of the child’s birth this did not occur.
The Manager of the claims department confirmed that the 5 denied claims were reprocessed on Tuesday, October **, 2016.
Upon receipt of this complaint, the Director of the Appeals and Grievances Department reached out to an Enrollment Resolution Specialist who advised that this member was indeed MEDICAID active with during the Qualified Health Plan ([redacted]) date of service 10/*/2015.
Member’s 2015 [redacted]...
enrollment has cancelled and a refund will be issued to the member's VISA in the amount of $316.54. The member’s refund should be issued within 2-3 business days.
In order for the Plan to thoroughly investigate the allegations, the name of the insured child and member ID number is required. Please provide the requested information. Reugenia S[redacted]Director Appeals and Grievances
# [redacted] - Pays in full
# [redacted] - Pays in full
# [redacted] - Pays in full
# [redacted] - Duplicate to the cl # [redacted]
# [redacted] - Duplicate to the cl # [redacted]
# [redacted] - Pays in full
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID ***, and find that this resolution is satisfactory to me and the matter has been resolved
Sincerely,
*** ***
I would like to not have to go through the hassle, of every time I have a doctor's appointment or an MRI, CT Scan etc, that I have to contact the insurance company because I am constantly getting lost in their systemI would like to know that I am covered and going to be approved for procedures my
doctor deems necessaryI would like to know that when I call the insurance company to try to find out why I am lost in the system, or my procedure has been denied, or my prescription plan is not active, that I will actually talk to someone instead of being placed on hold for up to an hour
The Plan did receive a grievance from the member regarding preventative services that were rendered to her on 03/**/and alleging that the claim was processed incorrectly which showed that there was member liability. Upon receipt of the grievance, the case was assigned to an Appeals and
Grievances associated who reached out to the claims department regarding the members concerns. The Claims Department reviewed the claim and reprocessed the claim to pay as preventative care with no member liability. The member will also receive a written response to her grievance. Please see the response that was received from the Claims Department.Claim # *** has been backed out to reverse the member deductible which was incorrectly appliedNew Claim # *** paying in full nowClaim # *** has been backed out to reverse the member deductible which was incorrectly appliedNew claim # *** paying in full now.I trust that this has resolved the matter for the member. Thank you, Reugenia S***, Director of Appeals and Grievances
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID# ***, and have determined that my complaint has NOT been resolved because:
Affinity rejected every single claim related to my son *** *** when we were advised that the mother's insurance is sufficient
In order for the Revdex.com to appropriately process your response, you MUST answer the question above
Sincerely,
*** ***
Upon receipt of your concern, the Plan’s Enrollment Department was contacted and a representative from that department advised that your newborn was enrolled in a Qualified Health Plan (QHP) Platinum plan and that newborns are covered under the member’s QHP plan for days effective
*Director Appeals and Grievances
their date of birthDue to an internal error that occurred with the Plan’s Enrollment vendor, invoices were generated with the incorrect premium amount. The representative further advised that you did speak with a supervisor on June *, who advised you that the he would reach out to the New York State Department of Health to correct the errorThe representative confirmed that the error has been corrected and the correct premium amount is $549.08.The Plan apologizes for any inconvenience this matter may have caused you. Reugenia S
Upon receipt of this complaint, an Enrollment Specialist was contact and advised that the Enrollment Departments records revealed that member ID cards and Handbooks were sent on 3/*/and again on 3/**/to: *** *** **
*** ** *** The Enrollment Specialist further
advised that she was successfully able to log into the members account using both the Affinity ID and Exchange ID number and access the area to print temporary ID cardsThe specialist also purposely entered an incorrect ID number to confirm that contact information is provided to users when they are experiencing difficulty logging in The Enrollment Specialist also confirmed that the departments return mail log was reviewed and she was unable locate any returned mail for this member Based on the Plan’s findings, the members request for reimbursement cannot be approved Copies of the member’s ID cards and Welcome letter have been attached to this response Sincerely, *** ***
*
*** ***
*** *** *** *** ***
*** *** *** *** ***
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID# ***, and have determined that my complaint has NOT been resolved because:
This is an explanation of what happened and I appreciate Affinity letting me know how the issue was causedI am more concerned with a solution to the issueI understand that I now have a credit for $which will be applied and used for the April premiumI am still concerned as to how I will receive the $refund for the doctor's fee that I had to pay out of pocket. As a suggestion, Affinity should notify customers about the issues that can arise when the premium has changedNo one notified me that the payment was due before the 1stAs usual I expected it to come out of the 10th as it has been for yearsIn addition this issue caused my children to not be insuredImagine if the issue of my son getting sick was more serious and he didn't have health coverageI wasn't notified in any way that he coverage was being cancelled due to my premium going up. I would like a final answer as to how and when I can expect my $refundIt is absurd that I have to go through the Revdex.com to get a valid response and I am still be given the run around.
In order for the Revdex.com to appropriately process your response, you MUST answer the question above
Sincerely,
*** ***
please see the excerpt from the members QHP contract regarding Mammograms and member responsibility
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID ***, and find that this resolution is satisfactory to me and the matter has been resolved
Sincerely,
*** ***
This member has already contacted the NYSDOFS regarding this matter. A favorable response was submitted to the State. the member should reach out to the state for the response
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID ***, and find that this resolution is satisfactory to me and the matter has been resolved
Sincerely,
*** ***
The New York State of health is responsible for providing members with the tax forms ([redacted]), not the individual health plans. We confirmed the dates this former member was active with us and requested a [redacted] statement be sent to her on her behalf.Should you have any questions, she can...
contact me toll free at ###-###-####.Tracey Purdue, R.N.Complaint, Grievance & Appeal Sr. Coordinator
Upon receipt of this complaint, the Plan’s Enrollment/Billing Department and vendor liaison were notified of the member’s request for her [redacted] form. It was discovered that due to an internal processing error, the vendor did not generate a [redacted] form for this member. On March ** , 2016, an urgent request was submitted to the vendor who was able to generate the [redacted] form for the member. The Director Complaints, Grievances and Appeals obtained a copy of the [redacted] form and emailed a copy via secure email to the member. Before emailing the form to Ms. Bell, the Director contacted the member to confirm her email address asked her to confirm when the form was received. The Director also apologized for the delay and inconvenience this matter may have caused. On March **, 2016 the Director called the member to confirm if the [redacted] form had been received. As the member was not available, a message was left. A copy of the requested [redacted] form has also been attached to this response. Sincerely, Reugenia S[redacted] Reugenia S[redacted]Director, Complaints Grievances and AppealsComplaint, Grievance and Appeal Unit
Affinity Health Plan (AHP) is in receipt of a complaint that was submitted on behalf of Donna Deming by the Revdex.com and was received on March **, 2016. The member states in her complaint that she and her spouse have been unable to access the dental benefit since...
enrolling in the Plan effective January *, 2016. Upon receipt of this complaint, the Director of the Plan’s Enrollment/Billing Department and vendor liaison were notified of the member’s inability to access their Dental Benefit. It was discovered that due to an internal processing error, the information required to add the member to the dental vendor’s eligibility file was not forwarded. As a result, the members did not appear as active in the DentaQuest system. On March **, 2016, an urgent request was submitted to DentaQuest to add the members to their system. On March **, 2016, DentaQuest confirmed that the required information was received and both members reflected as active in their system. The Plan extends an apology to the member for the inconvenience that this matter has caused.
Revdex.com:
I have reviewed the response made by the business in reference to complaint ID [redacted], and find that this resolution is satisfactory to me and the matter has been resolved.
Sincerely,
[redacted]
Upon receipt of this complaint, the Directory of the Appeals and Grievances Department reached out to an Enrollment Specialist and the Manager of the Claims Department for assistance.
The Enrollment Specialist advised that the claims were denied because they were processed under the child’s...
account before the effective date of service. The claims were to have been processed under the parent as they were within a few days of the child’s birth this did not occur.
The Manager of the claims department confirmed that the 5 denied claims were reprocessed on Tuesday, October **, 2016.
[redacted],
Director, Appeals and Grievances
Upon receipt of this complaint, the Director of the Appeals and Grievances Department reached out to an Enrollment Resolution Specialist who advised that this member was indeed MEDICAID active with during the Qualified Health Plan ([redacted]) date of service 10/*/2015.
Member’s 2015 [redacted]...
enrollment has cancelled and a refund will be issued to the member's VISA in the amount of $316.54. The member’s refund should be issued within 2-3 business days.
The provider will need to submit a claim to the Plan and refund the member less the applicable co-payment. the refund will not come from the Plan.
In order for the Plan to thoroughly investigate the allegations, the name of the insured child and member ID number is required. Please provide the requested information. Reugenia S[redacted]Director Appeals and Grievances
the following claim numbers were paid. the claim
# [redacted] - Pays in full
# [redacted] - Pays in full
# [redacted] - Pays in full
# [redacted] - Duplicate to the cl # [redacted]
# [redacted] - Duplicate to the cl # [redacted]
# [redacted] - Pays in full