Discovery Benefits, Inc.

I am rejecting this response because: never did a discovery benefit customer service speak with me or attempt to explain reason for multiple denialsClarissa supervisor agreed to extend benefits till march of 2015-therefore other medical claims were placed. Multiple attempts and contacts have been made with poor communication and lack of responseIt was discussed via phone and supervisor clarissa that claisms would be processed under Generic letter from 2/6/15 stated inability to process claim because it was not accompanied by appropriate form, letter, or notification. Hundreds of calls placed with no response. These extended dental claims were from services 1/22/Eyeglasses from 2/2015. Jumping through hoops to get this hard earned money returnedThey were well aware with sufficient documentation that this should be taken from remaining accountThis was only realized when I went to claim my money after ***(spouse) had ER visits
I have copies of multiple receipts for drug, office visits, I have medical condition polycystic ovary disease and require electrolysis that was denied as well as receipts for chiropractic dietary care all denied

The claim in question was filed on August 8, and the documentation supporting the claim was processed on August 9, The documentation provided did not include the year of service, only the month and dayAs a result, Discovery Benefits was unable to approve the claim as the full date
of service is required to ensure the services were incurred in the appropriate plan yearThe statement date is not used as the statement could potentially include services from the prior plan year The participant uploaded the same documentation for the claim on August 11, and the claim was again denied on August 15, as there was not a year included with the date of service The participant uploaded an explanation of benefits (EOB) on August 15, The portion of the claim supported by the EOB is being processed on August 17, so the participant will receive the funds by August 19,

Discovery Benefits is a third party administrator that provides COBRA administrative services on behalf of employers pursuant to service contracts with the employer. Discovery Benefits did not receive the participant’s payment within the grace period for the payment and COBRA was terminated in
accordance with applicable COBRA payment timeframes Discovery Benefits adheres to the “postmark” ruleA payment postmarked by the end of the grace period will be accepted even though it may not be received until after the end of the grace period. Monthly payment coupons are provided for participants to make payments by mailParticipants also have the option to pay online making a one-time payment by debit card, credit card or ACH during the grace period and may set up recurring ACH payments through the member portalPayments are not accepted over the phone.The participant attempted to make the September premium payment online on October 2, As the 30-day grace period expired on October 1, 2017, the account was in a terminated status and an online payment could not be appliedBecause October 1, was a Sunday, Discovery Benefits’ standard process does allow for an additional grace period day accepting September payments postmarked October 2, 2017. The participant first contacted Discovery Benefits regarding the September premium after 6:p.mCentral Time on October 2, During the call, the participant was advised that the payment had to be postmarked that day in order for the payment to be accepted An overnight courier label showing the October 2, date would also have been accepted During the initial call the Discovery Benefits representative assisted by trying to find couriers in the participant’s area that were open later in the dayAt no time during the call did Discovery Benefits state that sending payments via overnight courier were against federal law

The participant filed a claim for $Of this amount, Discovery Benefits received the necessary substantiation documentation for $360.00, which has been reimbursed
The remaining $from this claim may be resubmitted with additional supporting documentation for services
incurred between January 1, and March 29,

Initial Business Response /* (1000, 5, 2015/05/07) */
Upon review of this participant's account, we found that three claims submitted in had been denied or partially denied in error
In one situation, a portion of the claim had been denied in error and was corrected two days after
originally processedThe other portion of this claim was denied correctly as we needed to clarify with the participant an abbreviation on the submitted documentationOnce the clarification was received, the claim was approved
In another situation where the claim was denied in error we did have everything we neededOnce we were aware of the error, the claim was reprocessed and approved in full
Each of these incorrect denials was done by the same Discovery Benefits employee, who is no longer with the company
A third claim received was denied correctly due to it being a duplicate expense
The fourth claim filed by the participant was denied as needing a prescription that is required for over-the-counter medicines under the IRS regulationsHowever, nasal sprays are an exception and are eligible for reimbursement without a prescriptionThis claim is currently pending reimbursement for the amount deniedWe have taken steps to provide additional training and education internally on this particular type of expense so this does not happen in the future
As of today, all claims for this participant have been approved and reimbursed or are in the process of being reimbursed
We apologize to this participant for the frustration these incorrect denials has causedWe have also shared her input with our Client Services team so they are aware of her input from the employer perspective
Initial Consumer Rebuttal /* (3000, 7, 2015/05/08) */
(The consumer indicated he/she DID NOT accept the response from the business.)
The 3rd denied claim that DBI states was a duplicate is incorrectThis claim was originally denied by DBI when first submitted saying I needed to have it authorized for as medically necessary by getting a form completed and then resubmitting itI turned around and go the EOB for this copay and resubmitted it and in the mean time, after speak w/***, the spvsr, she got the original claim paid because it was denied in errorI didn't need any such form to prove that visit was medically necessaryBut I had to waste my time getting the EOB and resubmitting it to get the copay paidIn reference to declining the nasal spray (which is posted on their website that it doesn't need a prescription) their cust svc reps should obviously know what is covered and what is not or a least look it up before declining it (just as I did before submitting it)I don't see any mention of DBI saying they will make an effort to review other participants claims in general to make sure no one was declined in error (I am sure I was not just one person out of many to have this problem)I think that is Something that should be done, especially since 1/1/
Final Business Response /* (4000, 13, 2015/05/19) */
At the time of the first response, Discovery Benefits had received four claims from this participant
A portion of the claim filed by the participant on January 21, was denied in errorThis was corrected two days after the claim was originally processedAs indicated in the first response, clarification of an item was required for the remainder of this claimUpon receipt of the necessary clarification, the claim was reprocessed and paid
A claim filed by the participant for services received on January 21, was received and denied in part on January 30, The denial was in error and the claim was reprocessed on February 2, and approved in full
A third claim filed by the participant on February 2, was a duplicate submission for the services received on January 21, Because the claim was already being reprocessed and approved, this claim was denied appropriately as a duplicate claim
A fourth claim filed by the participant on May 4, was denied in error and has subsequently been approved
As indicated in our previous response, the information supplied by this participant has been reviewed internally by Discovery Benefits and steps taken to ensure the appropriate processing of reimbursement claims

Discovery Benefits is a third party administrator that provides COBRA administrative services on behalf of employers pursuant to service contracts with the employerDiscovery Benefits is not an insurance carrier and does not have access to or control of the records or processes of insurance
carriers. Discovery Benefits notified the carriers of the reinstatement of coverage for this participant the day after his enrollmentUpon notification of his coverage being inactive, Discovery Benefits contacted the carriers with urgent update requests on October 30, 2017, December 12, and January 4, 2018.Discovery Benefits received confirmation from the dental and vision carriers of the reinstatement of coverage for this participant effective October 1, on January 5, and is currently awaiting confirmation of coverage from the medical carrierA Discovery Benefits customer service representative will reach out to the qualified beneficiary by phone upon receipt of this confirmation

The situation was not caused by a Discovery Benefits error or lack of procedures. A letter is in the mail to the participant today that provides the participant with background and information related to her account

I am rejecting this response because:
They claim to have notified us by mail and yet have no proof that this happenedWe never recievedany notificationDiscovery claims non payment was the issue and still some how managed to cash the check for the amount we did send, which as far as we knew was the proper amountThey took our money and canceled our plan anywayAt the intervention of our former employer they were eventually persuaded to correct their errorHow ever it has taken a mo th to get them to do so and in the mean time I am suffering medical complications, pain, emotional suffering and loss of workThey did not notify us or Anthem that they had canceled the plan in a timely mannerI continued to undergo medical care and obtain prior authorizations for two months that I would not have done otherwise because of their negligence

The plan in which this participant is enrolled is an employer-sponsored plan governed by various IRS regulations along with plan rules that are defined in the employer’s plan document and summary plan description Discovery Benefits provides administrative services on behalf of employers
pursuant to service agreements with the employer The customer service representatives with whom the participant spoke are not responsible for the adjudication of participant claimsRather, their role is to respond to participant questions, including why a claim was not approved. Even though IRS Publication states that medical expenses include temporary storage of eggs and sperm, the IRS Office of Chief Counsel commented in May that “temporary” is undefined and that in order for reimbursement to be made from a cafeteria plan flexible spending account for temporary storage expenses, the eggs or sperm would need to be used within the same plan year.Upon review of the calls and emails the participant made and sent to Discovery Benefits, we have found the participant was treated with courtesy and respect throughout. Any funds that may remain in a participant’s account after the end of the plan year are forfeited to the employer-sponsored plan and are not retained by Discovery Benefits

The plan in which this participant is enrolled is an employer-sponsored plan governed by IRS regulations and plan rules as defined in the employer’s plan document and summary plan description Discovery Benefits provides administrative services on behalf of employers pursuant to service
contracts with the employer IRS rules governing substantiation requirements for the flexible spending accounts require that all claims must be substantiated, even those paid using the debit cardSee 1.125-6(b)(2) and 1.125-6(3)(i) All expenses must be substantiated by information from a third party that is independent of the employee and the employee’s spouse and dependentsThe independent third party must provide information describing the type of service or product, the date of the service or sale, and the amount Medical history is never requested or required.Claims are typically processed within two business days with reimbursement sent out on the third business day If reimbursement is made by check, there will be additional US Post Office mailing time, which can be anywhere between two to eight business days If reimbursement is made via direct deposit, depending on how quickly each bank receives and posts funds, typically reimbursement is in the participant’s account within three to five business days.Any funds that may remain in a participant’s account after the end of the plan year are forfeited to the employer-sponsored plan and are not retained by Discovery Benefits

Initial Business Response /* (1000, 10, 2015/12/04) */
The participant used her debit card to pay for a service on August 14, Discovery Benefits emailed a Request for Substantiation Notice to the participant on December 10, and a Denial Letter with Repayment on December 26,
The
participant used her debit card to pay for a service on August 22, Discovery Benefits emailed a Denial Letter with Repayment for this expense on January 4,
The participant contacted Discovery Benefits by phone on November 17, regarding these two claimsThe participant's email address was confirmed at this timeDiscovery Benefits received documentation from the participant for these expenses on November 19, The documentation received was a treatment plan and did not indicate the services were actually incurredThe documentation also did not include a form or claim number and there was a delay in processingThe claims were processed and denied on November 30, as being outside of the 180-day appeal periodThe final date to appeal the claim for the August 14, claim was June 23, and the final date to appeal the claim for the August 22, claim was July 2,
Initial Consumer Rebuttal /* (3000, 12, 2015/12/17) */
(The consumer indicated he/she DID NOT accept the response from the business.)
I have yet to receive any direct form of communication from the company I have attempted via email, phone calls, fax, and log in to accountI have yet to receive any responseProper documentation has been summit yet they are refusing to cooperateThe use of the funds were for medical reasonsThey were given payment directly from my pay check weekly before the use of the card and they continue to demand fundsThey have been paid twice for the use of the cardTo this day access to the company portal is denied
Final Business Response /* (4000, 14, 2015/12/21) */
Discovery Benefits notified the participant twice via email of the denied claim; on December 26, and again on January 1,
The participant contacted Discovery Benefits by phone twice on November 17, She was advised during both of those calls of the denial of the claim due to the expiration of the final filing dateThe participant's email address was also confirmed during each of these calls and the customer service representatives advised the participant of the online portal available to plan participants to manage their accounts and view notificationsDuring the first call, the participant was provided with a temporary password in order to log in to the portal
Based on the participant's request, a supervisor placed a call to the participant on November 17, The participant was unavailable so a voice message was left for her
Discovery Benefits received documentation from the participant for these expenses on November 19, The documentation received was a treatment plan and did not indicate the services were actually incurredThe documentation also did not include a form or claim number and there was a delay in processingThe claims were processed and denied on November 30, as being outside of the 180-day appeal periodThe final date to appeal the claim for the August 14, claim was June 23, and the final date to appeal the claim for the August 22, claim was July 2,
Discovery Benefits has no record of further communication with the participant via email or phone and the participant has not logged into the portal

Discovery Benefits is a third party administrator that provides COBRA administrative services on behalf of employers pursuant to service contracts with the employerDiscovery Benefits does not sell directly to individuals and does not have individual service agreements with employees, participants
or qualified beneficiaries Discovery Benefits is not an insurance carrier and does not have access to or control of the records or processes of insurance carriers Discovery Benefits does not retain premiums remitted by participantsAll premiums are forwarded by Discovery Benefits monthly based on the agreement between Discovery Benefits and the employer Discovery Benefits reached out to the carrier for this participant on May 25, and again on August 7, after the participant contacted Discovery BenefitsThe carrier confirmed reinstatement of coverage effective June 1, on August 28, Discovery Benefits is working directly with the employer and carrier to confirm the correct plan for this participant and will contact the participant upon resolution

I am rejecting this response because:I was in contact with both aetna and the city of east orange in which they provided proof that I already had insuranceat that time and did not have to pay cobra at allMy aetna insurance was terminated on 1/1/So, it was an error on all partied to have me pay the cobraI have documentation stating the above that I attachedDiscovery cashed my premium and I was told by both aetna and city of east orange that it is on them to provide my premium refundI could only attach images, but I also have the remaining from aetna that shows coverage for the rest of us

The plans in which this participant is enrolled are employer-sponsored plans governed by IRS regulations and plan rules as defined in the employer’s plan document and summary plan description Discovery Benefits provides administrative services on behalf of employers pursuant to service
contracts with the employer The customer service representatives with whom the participant spoke are not responsible for the adjudication of participant claimsRather, their role is to respond to participant questions, including why a claim was not approvedUnfortunately, there were circumstances that caused this situation to be confusing. The participant first submitted the documentation on May 10, As the documentation was a credit card/payment receipt only, it did not include the date of service or type of service and was denied.The participant submitted additional documentation for this claim twice on May 16, using two different methodsThe documentation uploaded through the portal was processed first and resulted in an approvalThe documentation that was emailed was not eligible, as it did not include the date of service or type of serviceThis caused the claim to be denied on the same day, which caused the confusion. The participant submitted documentation for this claim on May 18, This claim is being reprocessed and the status will be updated to approved.Discovery Benefits apologizes for the confusion regarding this claim. Even though debit card transactions may be denied due to lack of or insufficient documentation, the merchant remains paid In addition, any funds that may remain in a participant’s account after the end of the plan year are forfeited to the plan and are not retained by Discovery Benefits.While a participant’s debit card may be placed on hold, the participant may continue to file claims for reimbursement via the mobile app, or online through the member portal

Discovery Benefits is a third party administrator that provides COBRA administrative services on behalf of employers pursuant to service contracts with the employerDiscovery Benefits does not sell directly to individuals and does not have individual service agreements with employees, participants
or qualified beneficiaries. Discovery Benefits is not an insurance carrier and does not have access to or control of the records or processes of insurance carriers. Discovery Benefits will send a letter directly to the participant in response to this complaint

Discovery Benefits is a third party administrator that provides COBRA administrative services on behalf of employers pursuant to service contracts with the employerDiscovery Benefits is not an insurance carrier and does not have access to or control of the records or processes of insurance
carriers. The participant does have the correct phone number but may have been selecting the wrong options to get through to customer service teamA Discovery Benefits customer service representative reached out to this participant by phone on March 12, to offer assistance and answer her questions

Discovery Benefits is a third party administrator that provides COBRA administrative services on behalf of employers pursuant to service contracts with the employer. Discovery Benefits is not an insurance carrier, does not process insurance claims and does not have access to or control of the
records or processes of insurance carriers It is the responsibility of the carriers to issue medical cards to their members.Discovery Benefits notified the carrier of this participant’s coverage continuation on December 18, 2017, January 16, and January 22, When contacted by the participant, Discovery Benefits reached out to the carrier again on February 8, with an urgent update request. Discovery Benefits reached out to the carrier again on February 15, and was advised by the carrier a branch code provided was incorrectDiscovery Benefits followed up with the client on February 16, and confirmed the branch code was indeed correct and that branch codes were not used by the client The carrier was contacted again on February 20, with this informationDiscovery Benefits received from the carrier confirmation of coverage for this participant effective January 1, on February 20,

The web portal where ACH information is entered by participants clearly states in two places during the setup process: “Please be sure to confirm when your ACH payments will begin before stopping other payment methods to ensure you remain current in your premium payments.” The statement is provided when the banking information is entered and again as part of the summary of the recurring payment information entered It is the participant's responsibility to ensure timely premium payments are made The participant did not contact DBI nor did he log into his account to verify whether or not his February payment was pulled from his bank account

I am rejecting this response because: The information relayed is not totally accurate. They told us where the post office was but all places referred were closed and could not postmark on day in question. Furthermore, Discovery Benefits does NOT have a physical address so a npostal service courier cannot deliver. They will not accept online payments during the COBRA mandated grace period. This policy has no other practical reason except to make it difficult to make payment and considering many people do not have paper checks, it's premeditated and a predatory practiceWe offered to overnight the following day so it would be received ASAP (before a postmarked letter) however they said the federal guidelines prohibit them from accepting payments after the deadlineThis inaccurate information was given to us on a 2nd call by a service agent named Evan on the same day. When asked, "who told you it was against federal regulations?", he finally stated his training at Discovery Benefits was the source. While it was last minute, we made every attempt to get the payment in. We even went as far as to have our in-laws on the west coast make the postmark cutoff which was 4:45pm. As the respondent mentioned, they do not accept payments by phone. In 2017, alternative methods of payments are accepted worldwide but not Discovery Benefits (a large company processing vast amounts of payments). Most companies who want to retain customers will provide an overnight address if they don't have online/phone payment. We had already paid approximately $and were simply trying to pay the remaining ~ $payment. Their policies are predatory because they make it difficult to make a payment and they point to federal regulation guidelines/laws when there is no such guideline in their ability to accept payments. These minimum standards unduly lead to more people losing benefits. They do not offer solutions to customers and fall on deaf ears

Discovery Benefits is a third party administrator that provides pre-tax reimbursement account administrative services on behalf of employers pursuant to service contracts with the employer
According to the terms of the employer’s plan, the participant’s final date to incur services was July 6,
and the final date to file claims incurred up to July 6, was October 5,
We are able to see that the participant logged into her account on September 20, However, there is no record of a claim ever being filed or documentation being uploaded to the Dashboard or Expense TrackerSince it is now past the final filing date of the plan, we are no longer able to accept new claims for reimbursement unless the participant can provide proof of the attempt to file a claim prior to the final filing date