Cole Farms Restaurant Diner

Re: ID # [redacted] Dear Dispute Resolution Consultant:I'm writing in response to your letter on behalf of an Avesis member who complained that she had been incorrectly reimbursed for an eye care claim for services received by her on October 8, We reviewed our records with respect to the details provided by the complainantShe did call our Customer Service department on October 20,regarding what she believed to be a claim that was processed in errorShe spoke with one of our Supervisors who told her she would research the issue, have the claim reprocessed if indicated, and call her back with an update in 7-business days; the claims processing time lineOur Claims department researched the issue on her behalf and found that the complainant had indeed paid for the eye care visit in full with zero balance remaining While it was being reprocessed, the complainant called again and asked for an updateShe was advised on October 30, that the claim was reprocessed and would be paid in that week's check run and that she should receive it in the mail within the next weekThe Customer Service Supervisor called her to follow up on the 13th, leaving a voice mail message, and was able to speak with her on October 16th , at which time the complainant reported that she had received her check for the correct reimbursementAs a matter of information, our claims processors have a 98% quality standard for correctly processing claims for reimbursement and frequent audits reveal that we are processing over percent of all claims correctlyIt is our policy and practice to provide the highest level of claims processing support and customer serviceI sincerely regret that the initial claims processing overlooked a copy of the receipt on the second page and incorrectly paid the claim Thank you for bringing this complaint to my attention.Sincerely,Mark B [redacted] / Senior Vice President, Operations

We have received the letter of complaint forwarded to us this morning One of our Provider Representatives will call on the complaintant and we will send a report of our findings back to you within days

This response is to let you know that due to an error in information that you received, Avesis will be re processing your request to pay the additional amount of to you directlyPlease allow days to receive paymentIf you fail to receive payment within days please contact Marc C*** at
###-###-#### directly to follow upThe payment will be mailed to the address on file Thank you and we apologize for the inconvenience Marc C***Director of Complaints/Appeals/Grievance with Avesis

This message is advising you that we have corrected your record in our systemAvesis did receive notification from Wellmark back in May that you wished to cancel but the request was never submitted in writingWe apologize for the inconvenience this has caused youWe have taken this complaint as
your written request to cancel your policy and the policy was canceledYou if you happen to receive any additional letters from Avesis in regards to a bill please contact me directly at ###-###-####In addition I left you a voicemail to explain this to you via the telephone Thank you Marc C***Director of Complaints/Appeals/Grievances

[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 *** and find that this resolution would be satisfactory to me. I will wait until for the business to perform this action and, if it does, will consider this complaint resolved
Regards,
*** ***

Good afternoon,Avesis has reprocessed the claim that was submitted by the member to pay the additional $450.00. The claim was original processed in error and upon the claim being reprocessed it was worked after 30 days from original receipt which subjects the claim to pay interest. The...

member will be receiving an additional payment of $450.00 plus an additional $45.00 due to the claim being processed outside of 30 days from the original receipt. If the member does not receive payment by 06/30/2017 please reach out to me personally at 602-603-6355 or [email protected] also left 3 voicemails for the member to contact me and I would like the opportunity to discuss in more detail if the member chooses. We thank you for your business and apologize for the inconvenience that this has caused. SincerelyMarc C[redacted]Director of Complaints/Appeals/Grievances

Re: ID # [redacted]Dear Dispute Resolution Consultant:I'm writing in response to your letter on behalf of an Avesis member who complained that she had been incorrectly reimbursed for an eye care claim for services received by her on October 8, 2015. We reviewed our records with respect to...

the details provided by the complainant. She did call our Customer Service department on October 20,2015 regarding what she believed to be a claim that was processed in error. She spoke with one of our Supervisors who told her she would research the issue, have the claim reprocessed if indicated, and call her back with an update in 7-10 business days; the claims processing time line. Our Claims department researched the issue on her behalf and found that the complainant had indeed paid for the eye care visit in full with zero balance remaining.  While it was being reprocessed, the complainant called again and asked for an update. She was advised on October 30, 2015 that the claim was reprocessed and would be paid in that week's check run and that she should receive it in the mail within the next week. The Customer Service Supervisor called her to follow up on the 13th, leaving a voice mail message, and was able to speak with her on October 16th , at which time the complainant reported that she had received her check for the correct reimbursement. As a matter of information, our claims processors have a 98% quality standard for correctly processing claims for reimbursement and frequent audits reveal that we are processing over 99 percent of all claims correctly. It is our policy and practice to provide the highest level of claims processing support and customer service. I sincerely regret that the initial claims processing overlooked a copy of the receipt on the second page and incorrectly paid the claim.  Thank you for bringing this complaint to my attention.Sincerely,Mark B[redacted] / Senior Vice President, Operations

Thank you for sharing this member's report with us.  We have conducted a review of her concern and also reached out to provider where she obtained services.  She is enrolled and has coverage through her employer for one of our vision plans.  On February 9, 2017, the...

member sought services for eyeglasses from [redacted] Optical, one of our participating provider locations.
The member utilized an in-store promotion which reduced her out of pocket
responsibility from $559.00 to $279.00. When Avesis members utilize an
in-store promotion, they can then submit their claim to Avesis and receive a
direct reimbursement for their vision plan benefit. The member ordered high
index progressive lenses with premium anti-reflective coating and edge polish.
Avesis processed her claim and, on April 19, 2017, she was
reimbursed, $45 for her frame and $40 for her progressive lenses. Upon reviewing her benefit summary, we found that an error was made in calculating the reimbursement; she should have been reimbursed up to $80 for her frame and up
to $50 for her progressive lenses. Consequently, our claims department is reprocessing the
claim to pay her the additional amount of $45. I appreciate you sharing this issue with me.  It is Avesis' policy to provide the very best services and support to our members and providers.  This matter is being used as an additional training point for our claims processors to ensure that we do not experience similar issues going forward. Sincerely, Mark B[redacted]Senior Vice President, OperationsAvesis Incorporated.

February 24, 2016I'm writing in response to your inquiry on behalf of a vision plan member regarding the amounts covered for services under her insurance plan.In an effort to be sure we would clearly address the member's concern, I called to speak with her and obtain more specifics about her...

complaint.  As of yesterday, we had only received a claim from her provider for a $35 office visit in December 2015, which was paid.  Following that conversation, we called to speak with her provider's office, clarified the services she apparently received in late January 2016, and reached an agreement with them regarding payment in full for the services she received.  The provider's office agreed to submit their claim today and will receive the agreed payment in full by next week.  I have followed up with the member to explain more fully the specifics regarding the claim and to ensure she understands that she will not be responsible for any other costs related to the services she received.  It was helpful to receive this inquiry because no claims had yet been received from the member's provider for the services provided her in January in order for us to be able to resolve this issue for her.Thank you,Mark B[redacted]Senior Vice President, OperationsAvesis Incorporated

I'm writing in response to your inquiry on behalf of a Vision plan member regarding reimbursement for his glasses obtained from an out of network provider.After researching the member's claim history in our files, we identified an oversight in how his out of network claim was processed.  That...

claim was reprocessed yesterday and he will receive the additional payment for his glasses in the next few days.  I called this morning and spoke with the member to inform his that he will receive the maximum allowed payment for the glasses he obtained, explained to him what the reimbursement would be, and apologized for the delay in payment and any dissatisfaction he experienced.  He seemed to be pleased with our response and thanked me for calling him.  Please be assured that it is Avesis' policy to provide the best possible services and support for all our members.  I wish to thank you for bringing this matter to our attention so that we could identify and resolve this issue for the member.  Sincerely,Mark B[redacted]Senior Vice President, OperationsAvesis Incorporated

We have received the letter of complaint forwarded to us this morning.  One of our Provider Representatives will call on the complaintant and we will send a report of our findings back to you within 7 days.