Educators Mutual Insurance Association

Thank you for the opportunity to respondWe have been in contact with the dental provider and received notes and additional information Although the service provided was related to implants which aren't covered under the dental plan based on the confusion created by the the dental provider and the summary regarding abutments we are willing to cover the service up to the allowed amount for the service provided and as long as the annual maximum has not been exhausted The claim is being reprocessed If you would like to discuss it further please fill free to call Lisa Tat EMI Health

Thank you for the opportunity to respond A member of the EMI Health staff has reached out to [redacted] directly and has worked with her to resolve her concerns

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 Sincerely, [redacted]

According to the complaint the two dependents of the insured are still in braces currently. We have reviewed all of the information that we have received from the insured and the provider. According to the information received: *** had a month treatment plan starting 8/6/-
4/6/from DrCasey W***.*** had month treatment plan 8/25/- 8/25/from DrCasey W***.The insured changed dental plans from a $1,benefit to a $2,on 1/1/2017. Only services that occur after 1/1/would be eligible for the increased benefit. At this time we haven't received any information to confirm that there have been services after 1/1/2017. According to the treatment plan for *** we understand that the treatment plan may have included services after 1/1/but we have yet to receive any updated information from the insured or provider showing services.We would be happy to review any new information

Hello ***,We were able to find based on information we received from Warren Orthodontics that there were unpaid services from where we were still waiting for the proper documentation. Those additional services have now been paid according to the policy. For the plan year could you please provide evidence that you were told by an EMI Health employee that you would receive $benefit for each child if you showed that they had braces this year? All calls from you to EMI Health have been reviewed and we were unable to find any statements from an EMI Health employee that you would receive a $benefit if your child still has braces. We were able to find one call where you stated that your HR had told you that you would receive $benefit if your child still had braces but there was no mention of you being told that by an EMI Health employee. Benefits can only be paid for services that occur after the plan is in effect. In this case any dates of service prior to 1/1/would not be eligible for the new plan benefits that started on 1/1/17. Based on the information we received from Warren Orthodontics there were two dates of service for your daughter that occurred after 1/1/and those dates of service will be paid according to the plan.You do have the right to appeal any decision as outlined in your policy. Please contact me at 801-270-if you have any questions

Per the policy that governs the claims that are at issue in this complaint the individual has the right to appeal any claim decision We are considering this complaint an appeal that will be reviewed by the appeals committee which will meet next Thursday Thank you for the opportunity to
address the concerns of this member

Sorry for the delay in responding, I was traveling for business. Attached is breakdown of the claims similar to what was attached by Ms***. There are two claims that are separated at the bottom because those two claims are for infertility and do not accumulate towards the out of pocket maximum. The infertility benefit is listed on the benefit summary showing that claims for infertility do not accumulate towards the out of pocket maximum. Ms*** does have the right to appeal under the terms of her plan document

Revdex.com:Thank you for clarifying.
Sincerely,
*** ***

Hello,Thank you for the opportunity to respond to the concerns of Ms***. We have fully reviewed her claims for to ensure the correct amount of her out of pocket accumulation. As of today Ms*** has paid a total of $towards her out of pocket maximumI believe the
confusion is related to two claims that based on the benefit of her plan do not count towards her out of pocket maximum. The two claims total $485.89. Please let me know if there are any additional questionsWe can provide more specific details including a breakdown of the claims if we receive authorization from Ms***. She can also contact me directly at 801-270-

We appreciate the opportunity to respond to the concerns presented The individual contacted our company on December 13th to request copies of Explanations of Benefits(EOBs) EOBs detail the cost for the services, the provider of service such as the doctor, facility, or lab, etc
The individual was told that EOBs could be viewed and printed online The individual declined to use the online portal to access the EOBs and requested printed copies to be mailed The request was started but because there were more than EOBs the process was not initially completed before the individual called our company again to request the EOBs Again, the individual was told about the online portal where instant access was available The individual again declined using the online portal and requested the printed copies The research and printing was completed by January 6th and mailed first thing Monday January 9th

Complaint: ***
I am rejecting this response because:according to both your company and my HR department the benefits for each child should be paid in one lump sum not in monthly payments because I've paid the amount due in fullThere will be no bills this year since we finished paying for it last yearThere shouldn't be prorated amounts in each child and I was told that they would both have $paid if we showed that they had braces this year for any time period along with coordination of benefits.
Sincerely,
*** ***

Thank you for the opportunity to respond. We have been in contact with the dental provider and received notes and additional information.  Although the service provided was related to implants which aren't covered under the dental plan based on the confusion created by the the dental provider...

and the summary regarding abutments we are willing to cover the service up to the allowed amount for the service provided and as long as the annual maximum has not been exhausted.  The claim is being reprocessed.  If you would like to discuss it further please fill free to call Lisa T. at EMI Health.

The internal review process for the first level has been completed.  The urgent care center was recently purchased by a different company so the bill came in as the new company and not NEXTCARE.  The urgent care center claim will be paid as in-network up to the allowed amount.  The doctor claim was billed using a different tax ID that is not contracted with EMI Health.  However, this claim will also be paid as in-network up to the allowed amount.  Please let us know if there are any additional concerns.

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.
Sincerely,
[redacted]

After listening to all the calls with Mr. [redacted] and EMI Health customer service representatives it is clear that Mr. [redacted] is familiar with and has made attempts to use the online system to print his EOBs.  In this instance on Dec. 13th he requested all his EOBs be printed and mailed to him.  The representative that he spoke with told him she would send the EOBs but failed to complete the task.  Because of this failure we would be willing to reimburse Mr. [redacted] the requested $1000 in an effort to make the situation right.  If it is agreeable to Mr. [redacted] we can mail him a check.  Thank you again for a chance to respond to the concerns of our client.

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.
Sincerely,
[redacted]

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.
Sincerely,
[redacted]

Thank you for the opportunity to respond.  A member of the EMI Health staff has reached out to [redacted] directly and has worked with her to resolve her concerns.