City of Pittsburg

RE: Complainant: [redacted] I i " ID #: [redacted] *Member Number: [redacted] Dear [redacted] : _This letter is in response to your inquiry dated February 12, to Kaiser FoundationHealth Plan of the Mid-Atlantic States, Inc(Health Plan) on behalf of [redacted] .*** [redacted] stated that his credit card was charged $for his January 2018premium on January 1, for the Catastrophic 7350/0/Dental Plan ( [redacted] )that was canceled effective December 31, [redacted] is requesting that theHealth Plan refund his credit card $for the overpayment.A refund of $was refunded to the *** Card ending In On February 20, 'Z018.If you and/or [redacted] have any additional questions, p ease ¢0l1me at ###-###-####.Sincerely,

This letter is in response to your inquiry dated April 11, 2016, to Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc(Health Plan), submitted by the complainant, Mr [redacted] * [redacted] .Mr [redacted] indicated in his complaint that effective February 1, he enrolled with the Health Plan through the Marketplace and setup automatic deduction of payment of his monthly premiumsIn August 2015, Mr [redacted] learned that his policy was terminated for non-payment of his monthly premiums as of May 31, Mr [redacted] also indicated that he quickly sent a payment of $1,by check to the Health Plan to prevent his account from being cancelledMr [redacted] ' policy was not reinstated and he did not receive a refund of payments applied to his monthly premiumTherefore, Mr [redacted] is requesting from the Health Plan to refund payment of $1,045.36.As a result of our research, it was determined that Mr [redacted] ' refund premium payments totaling $1,was processedA check for payment was mailed on May 3, 2016, to Mr [redacted] ' home address on file as of May 3, He should expect to receive payment on or before May 17, If you and/or Mr [redacted] have any additional questions or concerns regarding this matter, please contact Enia Walker at ###-###-####.Sincerely,Cynthia W [redacted] Manager, Appeals and Correspondence

This letter is in response to your inquiry dated September 13, to Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc(Health Plan) on behalf of [redacted] *** [redacted] [redacted] received a copy of the Health Plan's response letter dated September 8, 2016; however he rejected the response [redacted] rejected the response because he believes that he has not received adequate treatment; therefore, he should not be responsible for his Copayments.As previously stated, a copy of [redacted] 's letter was also forwarded to the Physician Chief of the Northern Virginia Service Area, DrCheryl K [redacted] for review.A team of Patient Safety experts and physicians have met, thoroughly investigated and discussed this caseTheir findings revealed that the medical care provided to [redacted] was appropriateHealth Plan has a clear plan of action and recommendations for his continued care in place and have communicated that to [redacted] .Section 3-Benefits of [redacted] 's Evidence of Coverage states the following; In addition to Premium Payments, you may be required to pay a Cost Share for some ServicesThe Cost Share is the Copayment, and Coinsurance, if any in the Summary of Cost SharesYou are responsible for payment of all Cost SharesCopayments are due at the time you receive a ServiceYou will be billed for any Coinsurance you owe." If [redacted] continues to dispute the cost share for the medical services provided to him, he may submit a written appeal to:Appeals and Correspondence [redacted] *** Rockville, MD [redacted] FAX: [redacted] Please note that [redacted] 's appeal request must be filed in writing within days from the date of receipt of the original denial notice (Explanation of Benefit statement).If you and/or [redacted] have any additional questions, please contact Keyla W [redacted] at ###-###-####.Sincerely,Daisy S [redacted] Manager, Appeals and Correspondence

October 3, OCT [redacted] Revdex.com of Metro Washington DC and Eastern Pennsylvania K StNW, 10th Floor Washington, DC 20005-3404RE: Complainant: [redacted] ***ID #: [redacted] Member Number [redacted] Dear [redacted] ***:This letter is in response to your inquiry to Kaiser Foundation Health Plan of the MidAtlantic States, Inc(Health Plan) on behalf of [redacted] ***The inquiry was received on September 28, [redacted] stated in her complaint that her premium was increased without noticeTherefore, she is requesting that the Health Plan refund her $[redacted] ***'s was enrolled into a Kaiser Permanente Silver $6000/30/idental plan on November 22, with a premium of $On January 24, 2017, the Health Plan was notified by the exchange to enroll [redacted] into a Silver Plan $2750.00/20%/HSA/Dental Plan with a premium of $The Health Plan senta plan change letter to the members address on January 24, The Health Plan also sent monthly statements of account to [redacted] ***s home address which included her monthly premiumA warning letter was sent to [redacted] ***s home address on March 7, and a termination letter was sent on April 5, Enclosed for your review are the members notifications and monthly statements.We regret that we are unable to refund [redacted] $because she was covered under her exchange policy from January 1, to April 1, If [redacted] would like to appeal her enrollment into the Silver Plan, she may dispute her enrollment though the Maryland Health Connection [redacted] may appeal by mail, by email or by phone.By Mail: Complete the Request for Case Review form or write a request to:Maryland Health Connection P.OBOX Lanham, MD 20703-0857O: Office of Administrative Hearings Gilroy Road Hunt Valley, MD 21031By Email: Complete and SCan the Request for Case Review form and send an email to: MHBE.Appeals (Gmaryland.govBy Phone: Call Maryland Health Connection at [redacted] (TTY ###-###-####)If you and/or [redacted] have any additional questions, please contact Evral M [redacted] at ###-###-####

[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.] 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 Regards, [redacted]

September 2, 2016Dear [redacted] :This letter is in response to your inquiry to Kaiser Foundation Health Plan dated August 12, of the Mid-Atlantic States, Inc(Health Plan) from [redacted] regarding his mother, [redacted] ***Your correspondence was received in our office on August 25, [redacted] submitted a complaint stating that he had requested an investigation and responses to his questions and concerns regarding the care his mother, [redacted] received at the [redacted] Nursing Center in Silver Spring.Given [redacted] ***' concerns, a copy of his concerns was forwarded to the staff in our Quality Management Department for reviewThis review may involve staff and doctors from Kaiser Permanente and the particular medical specialty involvedThe quality review findings help Kaiser Permanente continue to improve the way we deliver care and service to all members.This review is performed under special provisions of the Federal Health Care Quality Improvement Act (HCQIA) §11137, and state laws, which encourage physicians to participate in identifying issues and improving care for patients[redacted] ***' concerns and questions were also referred to the Kaiser Permanente Service Chief Of Continuing Care (Skilled Nursing Facilities and Palliative Care Programs).We were informed that as a part of the investigation the Service Chief met with the executive leaders of [redacted] Nursing FacilityMultiple attempts and messages were left for [redacted] and no callbacks were received.Please refer to the chronology of the calls below;•The Center Nurse Executive, Michelle D [redacted] , called the office, home and cell phone numbers on file for [redacted] in the afternoon of June 9thShe left a message informing him that we knew of his concerns and wished to discuss them with him to answer any questions he might have, and asked that he return her call.•Michelle D [redacted] called again at 5:40pm on June 9th, and left her cell phone number at that time.•Finally, she called again on June 10th and left another message.•Elliot R***, Center Executive Director also called [redacted] on his cell phone at 8:30pm on June 9th and left a message as well, explaining that we were following up on his concerns regarding his mother's stay at [redacted] CenterMrR [redacted] informed him that Michelle D [redacted] had left messages and that if he was willing to speak with us to give her a call on the number she leftFinally MrRoth said that if he could not reach Michelle D [redacted] to contact him.I have spoken with MrR [redacted] and he still looks forward to the opportunity to talk with [redacted] Please inform [redacted] that he can contact Elliot Roth or Michelle D [redacted] at ###-###-####.If you and/or [redacted] have additional questions regarding this complaint, please contact Ella L [redacted] at ###-###-####.Sincerely,Daisy S.Manager, Appeals and Correspondence

Kaiser Foundation Health Plan of the Mid-Atlantic States - East Jefferson Street - Rockville, Maryland 20852January 22, [redacted] Revdex.com of Metro W [redacted] DC and Eastern Pennsylvania K StNW, 10th Floor Washington, DC 20005-3404RE: Complainant: [redacted] [redacted] ID #: [redacted] Patient: [redacted] Member Number: [redacted] Dear [redacted] ***:This letter is in response to your inquiry dated January 11, to Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc(Health Plan) on behalf of [redacted] , authorized representative for her daughter, [redacted] The inquiry was received on January 14, [redacted] stated in her complaint that she received a bill in the amount of $57,for a nipple shield that she received on October 30, [redacted] believes that that nipple shield should cost $She indicated that she paid the bill to avoid collections.The claim in question was forwarded to the Patient Financial Services Department to be reviewed by the Billing and Collections AuditorOnce the review has been completed, [redacted] will receive a corrected billIf the charges for date of service October 30, are incorrect, the claim will be reprocessedIf there is an overpayment on [redacted] 's account, she may be due a refund.If you and/or [redacted] have any additional questions, please contact Keyla W [redacted] at ###-###-####Sincerely,Cheryl T [redacted] Director, Appeals and Correspondence

This letter is in response to your inquiry dated September 21, to Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc(Health Plan) on behalf of [redacted] The inquiry was received on September 27, 2016.The [redacted] stated in her complaint that she was enrolled with the Health Plan from January through March However, she received a billing statement after her termination date [redacted] is requesting that the Health Plan terminate her coverage effective March 31, and cease all premium billing statements after that date.MsJackson's concern was escalated to the Client Services Department to process her termination request effective March 31, Any outstanding premium balance after March 31st will be adjusted.If you and/or [redacted] have any additional questions, please contact Keyla W [redacted] at [redacted] .Sincerely,Däisy S [redacted] Manager, Appeals and Correspondence

July 14, 2015Dear [redacted] :This letter is in response to your inquiry dated June 29,to Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc(Health Plan) on behalf of [redacted] The inquiry was received on July 6, [redacted] stated in his complaint that he received a delinquent notice for his monthly premium prior to receipt of his welcome letter.On behalf of the Health Plan, I apologize for the inconvenience this situation has caused [redacted] [redacted] is enrolled in the VA Silver 1500/Dental Plan which became effective February 1, 2015.On February 7, the Health Plan sent [redacted] a warning letter informing him that the first month's premium payment was still outstandingThe delinquent notices are used to inform members of arrearsThe February premium payment was subsequently received on March 5,2015.On February 11, the Health Plan sent [redacted] a "welcome letter" advising him of his plan coverage, effective date, and medical record number[redacted] also stated that the Health Plan enrolled him in the automatic monthly premium payment debit program without his consent or knowledge.On the initial enrollment application, [redacted] completed the automatic monthly payment section authorizing the Health Plan to automatically debit his credit card for his monthly premiumsExhibit A contains a copy of the applicationPlease see page of the application for the automatic monthly payment information.If [redacted] would like to discontinue the automatic monthly premium payments, he must submit a letter to the Health Plan requesting cancellation of the automatic monthly paymentsThe notice may be sent to the following address and/or fax number:Kaiser Permanente Attn: Membership Administration/Direct Pay Unit PO Box Rockville, MD 20852-Fax: ###-###-####Once the automatic monthly premium payment debit program has been cancelled, [redacted] may use the Health Plan's online premium payment system to pay his monthly premiums.If you and/or [redacted] have any additional questions, please contact Keyla W [redacted] at ###-###-####.Sincerely,Daisy SSenior Manager, Member Services

This letter is in response to your inquiry dated December 16, to Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc(Health Plan) on behalf of Mr [redacted] ***The inquiry was received on December 20, 2016.Mr [redacted] stated that on December 11, he refilled his medication through the Health Plan's website and was promised a 2-day delivery timeframeHe stated that he contacted the customer service department, and was advised that the medication would take 10-days for deliveryMr [redacted] is requesting a $refund for the mail order medication.According to the Health Plan's records, Mr [redacted] ordered his medication on December 14, at 2:23pm via kp.orgThe delivery time for mail order medication is up to daysOn December 20, the Health Plan delivered Mr***'s medication to his home address, Mr [redacted] declined the delivery.Mr [redacted] obtained his medication from the [redacted] Center's Pharmacy DepartmentHealth Plan will process a refund in the amount of $for the mail order medication that was declined by Mr***.If you and/or Mr [redacted] have any additional questions, please contact Keyla Washington at ###-###-####.Sincerely,Daisy S [redacted] Manager, Appeals and Correspondence

Dear [redacted] :This letter is in response to your inquiry dated August 26, to Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc(Health Plan) on behalf of [redacted] The inquiry was received on August 30, [redacted] expressed his dissatisfaction with the services that he received from DrsPaul M [redacted] , Brian H [redacted] , Sweta V***, Humira S [redacted] , Anuj T [redacted] and Frank G***.Providing quality medical care is one of our most important valuesA copy of [redacted] 's letter was forwarded to the staff in the Quality Management Department for reviewThis review may involve staff and doctors from Kaiser Permanente and the particular medical specialty involvedThe quality review process helps Kaiser Permanente Continue to improve the way we deliver care and service to our members.Our review is performed under special provisions of the federal Health Care Quality Improvement Act (HCOIA) [redacted] , and state lawsThese laws encourage physicians to participate in identifying issues and improving care for patientsThese laws also guarantee confidentiality to physicians or providers that take part in the quality review processAs a result, Our goal is to balance your need for information and the need to follow these lawsTo find this balance, Kaiser Permanente has developed a process to look into member concernsThis process is described belowA copy of [redacted] 's letter was also forwarded to the Physician Chief of the Northern Virginia Service Area, DrCheryl K [redacted] for review.A team of Patient Safety experts and physicians have met, thoroughly investigated and discussed this caseTheir findings revealed that the medical care provided to [redacted] was appropriateHealth Plan has a clear plan of action and recommendations for his continued care in place and have Communicated that to [redacted] .If you and/or [redacted] have any additional questions, please contact Keyla W [redacted] at ###-###-####.Sincerely,Daisy S

This letter is in response to your inquiry dated November 29, to Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc(Health Plan) on behalf of MsAshley ***The inquiry was received on December 8, 2016. Ms*** Stated in her complaint that she has been billed
erroneously for her monthly premiums, and as a result, her coverage terminated.Ms***'s coverage has been reinstated with no break in coverageMs*** has been working directly with the Health Plan and the Maryland Insurance Administration to resolve this issue.Please note that the Health Plan has not received Ms***'s renewal information from the Maryland Exchange for the contract yearHer coverage will terminate effective December 31, 2016, Ms*** should contact the Maryland Exchange if she wishes to renew her health insurance coverage for 2017.If you and/or Ms*** have any additional questions, please contact Keyla W*** at ###-###-####.Sincerely,Daisy S*Manager, Appeals and Correspondence

This letter is in response to your inquiry to Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc(Health Plan) dated September 8, from *** *** ** ***Your request for additional information was received in our office on September 9, 2016.*** *** is requesting that a response Comes from Kaiser Permanente Staff/investigator pertaining to the care his Mother received on February 27, at the *** *** Nursing CenterHe also stated that he did not wish to discuss his Concerns or questions with the Executive staff at the Nursing Center.Given *** ***' specific request for a response from Kaiser Permanente staff, Lynette H***, RN, BSN, Manager, Inpatient Continuing Care, called and spoke with *** *** *** on September 19, and again on September 20, Lynette H*** discussed with *** *** the outcome of the investigation*** *** had some additional questions, to which MsH*** recommended that he contact the Director of Nursing, Michelle D*** and/or the Executive Director, Elliot R*** at *** *** Nursing Center*** *** agreed.If you and/or *** *** have additional questions regarding this complaint, please contact Ella L*** at ###-###-####.Sincerely,Daisy S*Manager, Appeals and Correspondence

[To assist us in bringing this matter to a close, you must give us a reason why you are rejecting the responseIf no reason is received your complaint will be closed as Answered]
Complaint: ***
I am rejecting this response because:
I have not yet received any update on this complaintWe have had to go through many different channels and still have not received a reimbursement on our breast pump we were forced to purchase due to Kaiser telling us that our plan did not cover breast pumpsPlease advise the status of our reimbursement
Regards,
*** ***

This letter is in response to your inquiry dated April 1, to Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc(Health Plan) on behalf the complainant Mr*** ***The inquiry was received on April 8, 2016.Mr*** *** stated in his complaint that he made an
appointment for an annual health checkHe subsequently received a bill from Kaiser Permanente Patient Financial Services Department (guarantor account #***) for a copayment of $for the office visit on date of service December 28, Mr*** *** disputes the $copayment for the office visit on December 28, 2015.Please be advised that this issue was referred to our Patient Financial Services Specialist for research and resolutionOur Patient Financial Services Specialist informed us that the $20,copayment for date of service December 28, was applied correctly, Additionally, Mr*** *** received an annual exam on February 23, for which no copayment was charged.I have enclosed a copy of Mr*** ***'s Federal Employees Health Benefit Program Brochure explaining the “Preventive Care, Adult Benefit" for your reference (see page 29)The information contained under this section indicates that this specific benefit is allowed at no cost once per calendar year for adults age and older.Additionally, Mr*** *** has not exhausted the Internal Grievance Process.Therefore, he may request an appealAppeals should be submitted to the department and address reflected below:Kaiser Permanente Attn: Appeals Department *** *** *** *** Rockville, MD 20849If you and/or Mr*** have any additional questions, please contact Ella L*** at ###-###-####.Sincerely,Cynthia W*** Manager, Appeals and Correspondence

August 26, 2015Dear *** ***:This letter is in response to your inquiry dated August 17, to Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc(Health Plan) on behalf of *** *** ***This inquiry was received on August 18, 2015.*** *** stated in his complaint that he is
being billed for services that were not performedHe also stated that he was not told about the fees prior to receiving the Services.*** *** is covered under a High Deductible HMO Plan through an employer group, According to the Summary of Services and Cost Share Section of *** ***'s Evidence of Coverage (EOC), he is responsible for a $1,individual deductible, or a $2,family deductible per contract year*** *** must first meet the stated deductible before Health Plan will begin to pay for covered services that he receivesAfter meeting the deductible, *** *** is financially responsible to pay 20% of the allowable charges for behavioral health servicesExhibit A contains a copy of the relevant pages of *** ***'s EOC.• On April 14, the Health Plan received a claim for date of service April 10, from *** ***, LCSW, The claim was denied on April 21, due to lack of authorizationExhibit B contains copies of the claims and Explanation of Benefits (EOBs).• On April 18, the Health Plan received a claim for date of service April 17, The claim was processed on April 21, and $was applied towards *** ***'s deductibleExhibit B contains copies of the claims and Explanation of Benefits (EOBs).• On May 29, the Health Plan received a claim for date of service May 28, The claim was processed on June 1, and $was applied towards *** ***'s deductibleExhibit B contains copies of the claims and Explanation of Benefits (EOBs).If you and/or *** *** have additional questions regarding this concern, please contact Keyla W*** at ###-###-####.Sincerely,Daisy S.Senior Manager, Member Services

This letter is in response to your Inquiry dated May 11, to Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc(Health Plan) on behalf the complainant Ms*** ** ***The inquiry was received on May 16, 2016.*** *** stated in her complaint that her coverage terminated with
the Health Plan as of November Additionally, she requested that the records be updated to reflect that Kaiser Permanente is not her crossover secondary insurance to Medicare.Please be advised that this issue was referred to our Medicare Benefits Coordinator for research and resolution, Our Medicare Benefits Coordinator informed us that *** ***'s records have been updated and Kaiser Permanente has been removed and no longer reflects as her Medicare crossover secondary insurance.We have also attached a copy of our response letter to *** *** dated May 13, for your referenceExhibit A contains a copy of this letterThis response letter informed *** *** that this issue had been resolvedIf you and/or *** *** have any additional questions, please contact Ella L*** at ###-###-####.Sincerely, Cynthia W*** Manager, Appeals and CorrespondenceMay 13, 2016*** ** *** *** *** *** *** * Bethesda, MD ***RE: Medical Record Number: ***Dear *** ***:Thank you for your correspondence received on April 8, 2016, in the Member Services Department of Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc(Health Plan)You indicated that you dis-enrolled from Health Plan since November 30, 2014, however, Medicare still has your information showing Kaiser Permanente as your secondary payer.Upon receipt of your concern, we contacted our Medicare Benefits Coordination & Recovery Center for your information to be updated in our systemI am pleased to inform you that the Medicare Crossover information to Medicare has been ceased and you are no longer showing Kaiser Permanente as your secondary payer.*** ***, on behalf of the Health Plan, please accept my apology that your experience with the Health Plan did not meet your expectationsOur goal is to provide Kaiser Permanente members with quality service, and it is never our intention for a member to be disappointed with the service they receive from the Health Plan>As of May 13, 2016, we have completed our review of your inquiry within the grievance processIf you have any questions regarding this letter or the review process you may call me Monday through Friday from 8:a.mto 5:p.mat ###-###-####.In addition, you may call Member Services from 8:am to 5:pm Monday through Friday, at ###-###-#### (toll free) with general questions or for help with benefits or coverage issuesFor TTY users, please call ###-###-#### (toll free) 8:am to 8:pm, Seven days a week.*** *** *** *** ***] We appreciate your giving us the opportunity to respond to your concernsWe value your membership and look forward to serving your future health care needs,Sincerely,Mariama A*** Appeals and Resolution SpecialistKaiser Permanente is a Cost plan with a Medicare contractEnrollment in Kaiser Permanente depends on contract renewal.*** *** *** *** ***

Revdex.com:
I have reviewed the response made by the business in reference to complaint ID ***, and find that this partial resolution is satisfactory to me. The billing issues remain open and for that reason I cannot fully accept the response, however I do accept the steps taken thus far and the plan of action to close out the complaint
Regards,
*** ***

[To assist us in bringing this matter to a close, you must give us a reason why you are rejecting the responseIf no reason is received your complaint will be closed as Answered]
Complaint: ***
I am rejecting this response because: The business' response was not a responseIt was a deflection and indicated no attempts for remediation.
Regards,
*** ***

This responds to your inquiry on behalf of *** *** *** dated 07/21/2016, received on 08/05/by Kaiser Foundation Health Plan of the Mid-Atlantic States, Inc(Health Plan)Unfortunately, under Federal and state privacy laws, without an authorization from *** *** to release
protected health information to the Revdex.com, Health Plan is unable to respond to the concerns raised in your inquiry.Although we are unable to discuss *** ***'s specific concerns, we are disappointed that *** *** is dissatisfied with the service she has received from Health PlanWe encourage her to continue to work with Health Plan staff to resolve her concernsIn addition, depending upon how *** *** obtains her coverage, Federal or state law provide her with an avenue for review of her concerns by the appropriate insurance regulator.Again, we regret that we are unable to address the concerns raised in the 07/21/inquiryIf you and/or *** *** have any additional questions, please Cynthia W*** at ###-###-####.Sincerely,Cheryl T*** Director, Appeals and Correspondence