Colorado Health Insurance Cooperative, Inc.

Complaint: ***
I am rejecting this response because: I was not told by Colorado HealthOp that *** Hospital was contracted with them, but ***'s ER doctors were not contracted Colorado HealthOP did not tell me to beware of Emergency Medical Specialist as they do not have a contract with Colorado HealthOp If Colorado HealthOp would have told me that the ER doctors who work for *** hospital were not contracted with them, then I would have gone elsewhere Colorado HealthOp should not have said I could go to *** Hospital emergency room unless I was fully covered by every department Colorado HealthOP should have told me to ask for a contracted ER doctor (if there was such as person) In any case, Colorado HealthOP must prove to me that they made the people who were insured by them, aware that the doctor they may see in the ER at *** Hospital, may not be contracted with Colorado HealthOP even though *** Hospital was, and that their insured participants would have to pay that portion of the bill in full So, I still hold Colorado HealthOp responsible for this mess
Sincerely,
*** *** ***

Under the terms of the policy it is your responsibility to choose the type of care you receive and the provider that renders that treatment.The Certificate of Coverage states, in pertinent part: Choose Your Physician It is Your responsibility to select the health care professionals who will deliver care to You Provider Network We arrange for health care providers to participate in a NetworkNetwork Providers are independent practitionersThey are not Our employeesIt is Your responsibility to select Your provider Our credentialing process confirms public information about the providers' licenses and other credentials, but does not assure the quality of the services provided Before obtaining services, You should always verify the Network status of a providerA provider's status may change.That being said, most Emergency Room physicians do not contract with any Insurance Carrier. In addition, when patients present to the emergency room they are not afforded the opportunity to select a contracted Emergency Room physician. This is why in our response resolution, we advised that the claim in question had initially been processed incorrectly and that we had re-priced the claim to allow 100% of billed charges and had reprocessed the claim at the in network benefit level. However, even though we allowed 100% of the charges the claim did not issue a paymentThe charges were applied to your deductible because you had not yet satisfied your annual in network deductible.The Certificate of Coverage states, in pertinent part: Annual Deductible - the amount You must pay towards any Allowed Amounts for Covered Health Services incurred in a calendar year, before We will begin paying for BenefitsHospital expenses are incurred on the date of admissionMedical expenses are incurred on the date that services are renderedThe amount that is applied to the Annual Deductible is calculated on the basis of Allowed AmountThe Annual Deductible does not include any amount that exceeds the Allowed Amount.The claim in question has been processed correctly and no additional benefits are payable.We realize that this is not the answer you were seeking, but trust you understand that we are bound by the provisions of the policy.Sincerely,Jolene CoffmanDirector of Compliance Operations

Final Consumer Response /* (2000, 6, 2015/05/04) */
This situation has been resolved. The bill was changed to show the correct sign up period of May 1st.

Our records indicate [redacted] was enrolled with her husband, [redacted], on the Bison HSA EPO plan effective 8/1/15.  This plan has an aggregate family deductible of $4100.00.The office visit for 9/10/15 was received on 9/17/15 and was processed the same date.  The...

provider did not bill the charges as preventive services.  The charges were billed as the treatment of a medical condition.  For this reason charges are not covered at the preventive benefit level.The total allowable charges were $177.02 which was applied to the member's in network deductible.  The difference of $52.98 is the EPO discount and may not be billed to the member.  The member is financially responsible for paying the $177.02 to the provider.  The claim has been processed correctly and no additional benefits are payable.The Certificate of Coverage, states in pertinent part:     "The Annual Deductible must be met before covered charges for these services will be reimbursed."We realize that this is not the answer you were seeking but trust you understand that we are bound by the provisions of the policy.  If you have any further questions, please feel free to contact member services at 866-915-6619.Sincerely, Jolene CoffmanDirector of Compliance Operations.

Although this member sought emergency medical treatment at a contracted hospital facility, the Emergency Room physician, Dr. [redacted], was not contracted.  Dr. [redacted]'s claim was reduced to the reasonable and customary rate and was processed at the In Network Benefit Level applying $506.70 to...

the member's in network deductible.That being said, the charges should not have been reduced to the reasonable and customary rate but should have been allowed at 100% of billed charges.  The claim has been reprocessed but because the member's in network deductible had not been met, the full billed amount of $869.00 has been applied to the members in network deductible.Under the terms of the policy the member's deductible must be satisfied before charges are payable.  It is the member's financial responsibility to pay the $869.00 owed to this provider.If the member has any further questions she can contact member services at 866-915-6619. Sincerely,Jolene CoffmanDirector of Compliance Operations

Initial Business Response /* (1000, 6, 2015/09/22) */
This letter is in response to the complaint you filed with the Revdex.com in which you advised that member services informed you on two separate occasions that pre-natal care was covered but that charges for services rendered were...

not paid.
In researching this matter we find that you are enrolled under the Bear EPO health plan that has a $6500 individual deductible.
The Certificate of Coverage states, in pertinent part:
The Annual Deductible must be met before covered charges for these services will be reimbursed.
Our records indicate that you contacted member services on 4/24/15 and were informed that pre-natal care, labor and delivery were covered at 100% after the calendar year deductible had been satisfied.
Our records also indicate that you received services on 5/4/15. The physician billed an office visit, ultrasound and a lab fee. These services are all subject to your annual deductible as defined in the policy. It should be noted that the office visit portion of the visit was denied as incidental to the ultrasound, but due to the clinical nature of the visit we have reprocessed that charge to be applied to your deductible. The total amount applied to your deductible is $313.72, which is your financial responsibility to your physician. You will be receiving a corrected Explanation of Benefits in the mail.
While we realize that this is not the answer you were seeking, we trust you understand that we are bound by the provisions of the policy.
If you have any further questions or concerns, please feel free to contact me.